BACKGROUND: Coronary artery disease (CAD) remains a relative contraindication for lung transplantation, but should it be if amenable to effective palliation? METHODS: From January 2005 to July 2010, 356 adults undergoing primary lung transplantation had no significant (= 50%) CAD requiring prior or concomitant revascularization. Propensity matching on 38 pre-transplant patient characteristics identified 61 well-matched pairs (87% of possible matches) and 295 no-CAD unmatched patients to compare postoperative morbidity, graft function, and time-related pulmonary function and survival. RESULTS: Compared with no-CAD patients, those with CAD intervention were older, more likely to be male, had more comorbidities, and were more likely to have idiopathic pulmonary fibrosis, Among propensity-matched patients, 5 died in-hospital in the CAD intervention group and 6 in the no-CAD group (p = 0.7). Intensive care unit stay (5 vs 7 days), post-operative stay (14 vs 15 days), tracheostomy requirement (12 vs 11 patients), primary graft dysfunction scores (p>0.8), and early longitudinal post transplant pulmonary function (p = 0.2) were similar, as was time-related mortality (20% vs 22% and 51% vs 52% at 1 and 4 years, respectively; p = 0.6). Unmatched no-CAD patients had fewer comorbidities and lower mortality than matched patients (15% and 39% at 1 and 4 years, respectively; p = 0.01). CONCLUSIONS: CAD is an important risk factor in lung transplant candidates, but its influence can be minimized in experienced centers by effective palliation. Surprisingly, however, CAD is a marker for an unfavorable patient phenotype with worse than typical post-transplant survival, irrespective of whether CAD is present. (C) 2016 International Society for Heart and Lung Transplantation. All rights reserved.