OBJECTIVE: In this study, we investigated the association between cardiovascular (CV) risk factors and coronary atherosclerotic plaque (CAP) burden/subtypes shown by multidetector computed tomography in symptomatic patients free of known coronary artery disease (CAD). METHODS: In 662 consecutive outpatients (56.9±10.7 years, 50.8% men) without known CAD, 64-slice multidetector computed tomography coronary angiography was performed for detection of CAD. Risk estimation for CV outcomes was assessed using the Systematic Coronary Risk Evaluation (SCORE) and the Framingham Risk Score (FRS). Logistic regression analysis was used to evaluate the association of CV risk factors with the prevalence/extent of CAP. RESULTS: CAP was detected in 318 (48.0%) individuals. Male sex, older age, hypertension, diabetes mellitus, smoking, and dyslipidemia all increased the likelihood of the presence of CAP in univariate analysis (P<0.001). Older age, male sex, dyslipidemia, and diabetes mellitus independently increased the likelihood of the presence of CAP in multivariate analysis (P<0.005). Multinominal logistic regression analysis showed an association with older age, male sex, dyslipidemia, and smoking for noncalcified plaques; with older age, male sex, diabetes, and dyslipidemia for mixed plaques; and with older age and male sex for calcified plaque. Patients with low FRS and SCORE showed a large number of CAPs (33.8 and 40.4%), although CAP was more prevalent in the high-risk groups (67 and 78%, respectively). CONCLUSION: CV risk stratification using only risk factor-based scores is a weak discriminator of the overall CAP burden in individual patients. Many patients with low FRS or SCORE with substantial CAP might be undertreated or not treated at all. © 2012 Lippincott Williams & Wilkins, Inc.