Patients with advanced liver disease are at increased risk of cardiovascular events, especially following orthotopic liver transplantation (OLT). Coronary artery calcification (CAC) is a novel and independent predictor of cardiovascular risk, but its prevalence and utility in patients with cirrhosis are unknown. The aim of this study was to define the prevalence of CAC and its association with markers of disease severity and standard measures of cardiovascular risk in a large cohort of patients undergoing OLT assessment. A single-center, prospective, observational study of 147 consecutive patients undergoing assessment for OLT was performed. CAC scores were derived with the Agatston method from thoracic computed tomography scans and correlated with cardiovascular risk factors and measures of liver disease severity. There were 101 patients (66 males) with a mean age of 53.2 years; 46 patients were excluded because the CAC score was not reported. The median CAC score was 40 HU (range, 0-3533). Correlations were identified between the CAC score and age (r Ο 0.477; P Ο½ 0.001), male sex (r Ο 0.262; P Ο 0.008), family history of cardiovascular disease (r Ο 0.208; P Ο 0.036), Framingham risk score (r Ο 0.621; P Ο½ 0.001), Model for End-Stage Liver Disease score (r Ο 0.221; P Ο 0.027), systolic blood pressure (r Ο 0.285; P Ο 0.004), diastolic blood pressure (r Ο 0.267; P Ο 0.007), cytomegalovirus status (r Ο 0.278; P Ο 0.005), fasting glucose (r Ο 0.330; P Ο 0.001), number of coronary vessels involved (r Ο 0.899; P Ο½ 0.001), and components of the metabolic syndrome (r Ο 0.226; P Ο 0.026). After multivariate analysis, age, systolic blood pressure, fasting glucose, number of features of metabolic syndrome, and number of vessels involved remained significantly associated with CAC. In conclusion, this study identified a high prevalence of occult coronary artery disease in patients undergoing OLT assessment and identified a strong relationship between CAC scores and a limited number of specific cardiovascular risk factors. The usefulness of these factors in predicting perioperative and postoperative cardiovascular events in patients undergoing OLT requires prospective evaluation.