Pulse pressure (PP) is an independent predictor of myocardial infarction, mainly above 50 years of age. In subjects with preserved ejection fraction (EF), aortic PP predicts the severity of coronary atherosclerosis. Comparable findings in subjects with reduced EF have not been evaluated. In 1337 subjects with severe coronary ischaemic disease, intra-aortic and brachial blood pressures were measured together with EF and coronary angiography to evaluate cardiac function, the presence of coronary stenosis and/or occlusions or calcifications. The presence (odds ratio+/-95% CI) of coronary calcification was marginally but not significantly associated (P=0.06) to increased aortic PP (1.32 (0.97-1.80)), whereas that of coronary occlusion was significantly associated (P<0.01) with decreased aortic PP (0.62 (0.42-0.91)), even after adjustment to EF and heart rate. Increased aortic PP did not correlate with stenosis number. No comparable predictive value was observed using intra-aortic or non-invasive brachial systolic blood pressure (SBP) or diastolic blood pressure (DBP). In high cardiovascular risk populations, even in the presence of reduced EF and high heart rate, intra-aortic PP, but not SBP or DBP, is a significant predictor of coronary occlusions and possibly calcifications, but not stenosis.