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We evaluated the relationship among BMI, carotid sonographic findings, and long-term (5 years) cardiovascular events in Asian patients with coronary artery disease (CAD).The study population consisted of 1342 consecutive patients with CAD, who were stratified into four groups according to weight status, as defined by the WHO for the Asian population: underweight (group I: BMI<18.5 kg/m2, n=38); normal weight (group II: 18.5≤BMI<23.5 kg/m2, n=352); overweight (group III: 23.5≤BMI<27.5 kg/m2, n=700); and obese (group IV: BMI≥27.5 kg/m2, n=252). All patients underwent carotid ultrasonography. Multivariate analysis was performed to identify predictors of long-term mortality, and the results were expressed in terms of hazard ratio (HR) with 95% confidence interval (95% CI).Compared with the other groups, groups I and II included older patients and had a higher incidence of multivessel CAD, carotid plaque (group I: 42.1%; group II: 42.3%; group III: 27.9%; group IV: 24.6%; P=0.003), and major cardiovascular events including cardiac death, acute myocardial infarction, and stroke. In multivariate analysis, old age, lower ejection fraction, high carotid intima-media thickness, and presence of carotid plaque were positive independent predictors for mortality, whereas BMI was a negative independent predictor (group II: HR=0.28, 95% CI=0.14–0.57, P<0.001; group III: HR=0.26, 95% CI=0.13–0.51, P<0.001; group IV: HR=0.08, 95% CI=0.03–0.22, P<0.001).In patients with CAD, underweight and normal-weight status was associated with higher long-term mortality rates and incidence of major cardiovascular events, suggesting that the obesity paradox is also manifested in Asian patients with CAD.