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Systemic inflammation or insulin resistance drive atherosclerosis. However, they are difficult to capture for assessing cardiovascular risk in clinical settings. The monocyte-to-HDL ratio (MHR) is an accessible biomarker that integrates inflammatory and metabolic information and which has been associated with poorer cardiovascular outcomes. Our aim was to evaluate the association of MHR with the presence of subclinical atherosclerosis in patients with psoriasis. The study involved a European and an American cohort including 405 patients with the disease. Subclinical atherosclerosis was assessed by coronary computed tomography angiography. First, MHR correlated with insulin resistance via HOMA-IR, with high sensitivity C-reactive protein and with 18F-FDG uptake in spleen, liver and bone marrow by PET/CT. MHR associated with both the presence of coronary plaques greater than 50% of the artery lumen and non-calcified coronary burden (NCB), beyond traditional cardiovascular risk factors (p<0.05). In an NCB prediction model accounting for cardiovascular risk factors, statins and biologic treatment, MHR added value (AUC base model 0.72 vs AUC base model plus MHR 0.76, p=0.04) within the American cohort. These results suggests that MHR may detect psoriasis patients who have subclinical burden of cardiovascular disease and warrant more aggressive measures to reduce lifetime adverse cardiovascular outcomes.