Aims: To study whether arterial stiffness is related to risk of new vascular events in patients with manifest arterial disease and to examine whether this relation varies between patients who differ with respect to baseline vascular risk, arterial stiffness, or systolic blood pressure(SBP). Methods and results: The study was performed in the first consecutive 2183 patients with manifest arterial disease enrolled in the SMART study(Second Manifestations of ARTerial disease), a cohort study among patients with manifest arterial disease or cardiovascular risk factors. Common carotid distension(i.e. the change in carotid diameter in systole relative to diastole) was measured at baseline by ultrasonography. With the distension, several stiffness parameters were determined. In the entire cohort, none of the carotid artery stiffness parameters was related to the occurrence of vascular events. However, decreased stiffness was related to decreased vascular risk in subjects with low baseline SBP. The relation of carotid stiffness with vascular events did not differ between tertiles of baseline risk and carotid stiffness. Conclusion: Carotid artery stiffness is no independent risk factor for vascular events in patients with manifest arterial disease. However, in patients with low SBP, decreased carotid stiffness may indicate a decreased risk of vascular events. Aims: To study whether arterial stiffness is related to risk of new vascular events in patients with manifest arterial disease and to examine whether this relation varies between patients who differ with respect to baseline vascular risk, arterial stiffness, or systolic blood pressure (SBP). Methods and results: The study was performed in the first consecutive 2183 patients with manifest arterial disease enrolled in the SMART study (Second Manifestations of ARTerial disease), a cohort study among patients with manifest arterial disease or cardiovascular risk factors. Common carotid distension (ie the change in carotid diameter in systole relative to diastole) was the attempt of baseline by ultrasonography. With the distension, several stiffness parameters were determined. In the entire cohort, none of the carotid artery stiffness parameters was related to the occurrence of vascular events. , decreased stiffness was related to decreased vascular risk in subjects with low baseline SBP . The relation of carotid stiffness with vascular events did not differ between tertiles of baseline risk and carotid stiffness. Conclusion: Carotid artery stiffness is no independent risk factor for vascular events in patients with manifest arterial disease. However, in patients with low SBP, decreased carotid stiffness may indicate a decreased risk of vascular events.