BACKGROUND The prognosis of patients with cerebrovascular disease (CVD) is critically influenced by coronary artery disease (CAD). The identification of CAD in stroke patients could allow more effective, targeted, and cost-effective treatment. However, there are no data available on the incidence and severity of CAD in patients with CVD and no history of a coronary event. In the present study, we prospectively investigated the incidence of subclinical CAD in patients with acute stroke using coronary CT angiography (CCTA) and compared to results with conventional risk stratification algorithm. METHOD Two-hundred twenty nine consecutive patients with acute ischemic stroke or transient ischemic attack (TIA) (63짹12 years, male 56%) were included during the period from May, 2007 to January, 2008. Patients with a history of angina, myocardial infarction and revascularization were excluded. Patients underwent CCTA, using 64 slice multi-detector CT and carotid MR angiography (MRA). The presence and severity of stenosis for each arterial segments were determined on CCTA and MRA. Using Framinghm risk scoring (FRS), we calculated a 10-year risk for coronary events on all patients. RESULTS Atherosclerotic plaques were identified in 141 (63%) individuals, 48 (21%) subjects had significant (���50%) diameter stenosis, and of those, 12 (5%) had severe (���75%) stenosis: single-vessel CAD in 77% of patients, 2-vessel CAD in 19%, and 3-vessel CAD in 4%. When patients were stratified by their 10-year risk for coronary events, only 11 (23%) of patients with significant stenosis on CCTA were classified into high risk (>20%), and 24 (53%) of patients with significant stenosis on CTA showed no luminal narrowing on carotid MRA. CONCLUSIONS Subclinical CAD, oftenly associated with CVD was effectively identified using CCTA. In a population of CVD without history of a coronary event, conventional risk stratification algorithm and carotid MRA showed a limited value to identify patients at risk. An active investigation of CAD using CCTA might be considered in CVD patients in order to plan optimal, comprehensive management.