We assessed clinical predictors of the process of cardiac allograft vasculopathy (CAV) in 39 consecutive patients (mean 49 years old) using three-dimensional intravascular ultrasound (3-D IVUS) examination of the left anterior descending coronary artery at 36±38 months and 47±40 months after cardiac allotransplantation (TX). Compared with 17 patients with plaque progression, 22 patients with plaque regression were more likely to be male (P<. 01), to have a higher use of angiotensin-converting enzyme inhibitors (ACEI, P<. 05), and to have a lower volumetric remodeling index (P<. 001). The changes in plaque volume correlated with the changes in total cholesterol (P<. 005) and low-density lipoprotein cholesterol (P<. 02). Plaque progression of CAV was independently associated with time after TX, hypertension, nonuse of ACEI, donor age, and changes in total cholesterol and triglycerides. In conclusion, plaque progression is associated with positive vascular remodeling and plaque regression is associated with lower serum lipids and ACEI in patients after TX.