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Objectives: This investigation was designed to determine the relationship between National Cholesterol Education Program (NCEP) ATP-II lipid guidelines and subclinical atherosclerosis, defined by electron beam tomography (EBT) calcified coronary plaque, in asymptomatic women., Background: NCEP guidelines are used to identify women at increased risk for coronary artery disease (CAD) on the basis of low density lipoprotein cholesterol (LDLC) and high density lipoprotein cholesterol (HDLC) values. The relationship of the guidelines to subclinical atherosclerosis is unknown., Methods: A total of 304 asymptomatic women underwent lipid and EBT evaluation and were classified as: 1) NCEP higher risk, with LDLC > or =130 mg/dl and/or HDLC <35 mg/dl, or lower risk with LDLC <130 mg/dl and HDLC > or =35 mg/dl; and 2) EBT+ if any calcified plaque was noted or EBT- if there was no calcified plaque., Results: Forty-two percent of patients were EBT+, with a mean score of 227 and percentile of 73%; 58% were EBT-. Women who were EBT+ had significantly higher total cholesterol, LDLC and triglycerides than EBT- women, but only with ages < or =55 years; women >55 years demonstrated no differences. NCEP higher risk women made up 53.5% of the EBT+ and 37.7% of the EBT- groups; NCEP lower risk women accounted for 46.5% of the EBT+ and 62.3% of the EBT- groups. Assuming a higher risk in subjects with EBT-defined subclinical CAD than in those without, only 58.6% of the total group would be correctly identified by NCEP guidelines as either higher or lower risk, with correct identification of 65.5% of the younger and 52.2% of the older women. There was no correlation between either calcium percentile or score and any lipid measurement., Conclusions: This study demonstrates the shortcomings of employing NCEP guidelines to identify asymptomatic women with subclinical CAD, particularly women >55 years, and suggests increased utilization of EBT for primary prevention in the female population.