Abstract-The matrix Gla protein (MGP) is an important inhibitor of vessel and cartilage calcification that is strongly expressed in human calcified, atherosclerotic plaques and could modulate plaque calcification and coronary heart disease risk. Using a genetic approach, we explored this possibility by identifying polymorphisms of the MGP gene and testing their possible association with myocardial infarction (MI) and plaque calcification. Eight polymorphisms were identified in the coding and 5Ј-flanking sequences of the MGP gene. All polymorphisms were investigated in 607 patients with MI and 667 control subjects recruited into the ECTIM Study (Etude Cas-Témoins de l'Infarctus du Myocarde) and in 717 healthy individuals with echographically assessed arterial calcification and atherosclerosis who were participating in the AXA Study. In the ECTIM Study, alleles and genotypes were distributed similarly in patients and controls in the whole study group; in only 1 subgroup of subjects defined as being at low risk for MI were the concordant AϪ7 and Ala 83 alleles more frequent in patients with MI than in controls (PϽ0.003). In the AXA Study among subjects with femoral atherosclerosis, the same alleles were more common in the presence than the absence of plaque calcification (PϽ0.025). The other MGP polymorphisms were not associated with any investigated clinical phenotype. Transient transfection experiments with allelic promoter-reporter gene constructs and DNA-protein interaction assays were carried out to assess possible in vitro functionality of the promoter variants detected at positions Ϫ814, Ϫ138, and Ϫ7 relative to the start of transcription. When compared with the Ϫ138 T allele, the minor Ϫ138 C allele consistently conferred a reduced promoter activity of Ϫ20% (PϽ0.0001) in rat vascular smooth muscle cells and of Ϫ50% (PϽ0.004) in a human fibroblast cell line, whereas the other polymorphisms, including Ϫ7, displayed no evidence of in vitro functionality. We conclude that the AϪ7 or Ala 83 alleles of the MGP gene may confer an increased risk of plaque calcification and MI; however, the observed relationships are weak or limited to subgroups of patients and therefore need confirmation. (Arterioscler Thromb Vasc