AIM: Recent studies have highlighted the predictive value of serum uric acid (SUA), fasting blood glucose (FBG), and triglycerides (TG) for cardiovascular diseases (CVDs). A newly developed uric acid (UA) index exhibits useful, but further validation is required to establish its superior predictive power over SUA. This study aimed to compare the predictive capabilities of the UA index and SUA in CVD, coronary artery disease (CAD), and stroke. METHODS: This study was conducted based on the Mashhad Stroke and Heart Atherosclerotic Disorders (MASHAD) study. SUA and the UA index (Ln [TG (mg/dL) × SUA (mg/dL) × FBG (mg/dL)/2]) were calculated at baseline. After 10 years, the incidence of the outcomes including CAD, cerebrovascular events, and death by CAD or cerebrovascular events were evaluated. RESULTS: SUA showed a modest but significant association with CAD in the total population (HR = 1.064, 95% CI: 1.010-1.121, p = 0.020), but was not associated with stroke or mortality, and showed no significant associations in gender-stratified analyses. In contrast, UAI demonstrated a strong and consistent association with CAD across all groups. Each unit increase in UAI was associated with a 54.1% higher risk of CAD (HR = 1.541, 95% CI: 1.407-1.689, p < 0.001), with stronger effects in women. UAI was also significantly associated with increased mortality risk, but not with stroke. ROC analysis showed that UAI had modest but consistently better discriminative ability than SUA for predicting CAD and mortality (AUC: 0.632 vs. 0.561). CONCLUSION: In conclusion, UAI outperformed SUA in predicting CAD and mortality, particularly in women, and may serve as a more robust biomarker for cardiovascular risk assessment.