Abstract-Renin-angiotensin systems may mediate cardiovascular disease pathogenesis through a balance of actions of angiotensin II on (potentially proatherogenic) constitutive type 1 (AT 1 R) and (potentially antiatherogenic) inducible type 2 (AT 2 R) receptors. We explored such potential roles in a prospective candidate gene association study. Cardiovascular end points (fatal, nonfatal, and silent myocardial infarction and coronary artery bypass surgery/angioplasty) were documented among 2579 healthy UK men (mean age, 56.1Ϯ3.5 years; median follow-up, 10.1 years) genotyped for the AT 1 R1166AϾC and the X chromosome located AT 2 R1675AϾG and 3123CϾA polymorphisms. Baseline characteristics, including blood pressure, were independent of genotype. The AT 1 R1166CC genotype was associated with relative cardiovascular risk (hazard ratio, 1.65 [1.05 to 2.59]; Pϭ0.03) independent of blood pressure. Systolic blood pressure was associated with risk (Pϭ0.0005), but this association was restricted to AT 2 R1675A allele carriers (PϽ0.00001), with G allele carriers protected from the risk associated with blood pressure (Pϭ0.18). Hypertensive carriers with the AT 2 R1675A/3123A haplotype were at most risk, with 37.5% having an event. This is the first study to demonstrate an association of AT 2 R genotype with coronary risk, an effect that was confined to hypertensive subjects and supports the concept that the inducible AT 2 R is protective. Conversely, the AT 1 R1166CC genotype was associated with cardiovascular risk irrespective of blood pressure. These data are important to our understanding of the divergent role of angiotensin II acting at its receptor subtypes and coronary disease pathogenesis and for the development of future cardiovascular therapies. Coronary vascular ACE drives Ang II synthesis, whose action on local AT 1 and inducible AT 2 receptors (AT 2 R) 2,3 may contribute to coronary heart disease (CHD) pathogenesis: AT 1 R activation causes vascular smooth muscle cell hypertrophy, extracellular matrix production, and local inflammation, driving atherogenesis and plaque rupture, 4 whereas AT 2 R agonism inhibits vascular cell proliferation 5 and may be antiatherogenic. 6 The balance between AT 1 R and AT 2 R activation may therefore influence CHD risk. However, this remains difficult to explore, and supportive data are sparse. Studies involving selective AT 1 R antagonism are perhaps less informative than they might at first appear: although lowering CHD risk more than equihypotensive -blockade, 7 this may be partly mediated through AT 2 R agonism-loss of negative feedback raising Ang II levels and hence binding to the vacant AT 2 R. 8Could there be a role for both the AT 1 R and AT 2 R in the development of CHD? Genetic studies may provide insight. A polymorphism of the AT 1 R gene exists at position 1166, where the C (rather than A) allele is associated with increased Ang II responsiveness. 9 Meanwhile, the A (rather than G) allele at position 1675 of the X-chromosomal AT 2 R gene is associated with a greater ...