Although metabolic syndrome (MS) is associated with adverse cardiovascular outcomes, its association with the presence and extent of coronary atherosclerotic plaques is not well described. To assess this relation, multidetector computed tomography-based patterns of coronary plaque were assessed in 77 patients enrolled in the ROMICAT study (age 54 +/- 12 years; 79% Caucasians, and 36% women) and compared between those who did (n = 35; 45%) and did not (n = 42; 55%) have MS. The presence of any, calcified, and noncalcified plaque was significantly higher in patients with than without MS (91%, 74%, and 77% vs 46%, 45%, and 40% segments with plaque, respectively; all p <0.01). The overall number of segments with plaques was also higher in patients with MS (5.8 +/- 3.7 vs 2.1 +/- 3.3; p <0.001). MS was independently associated with both the presence and extent of overall plaques after adjusting for the Framingham risk score (odds ratio 6.7, 95% confidence interval 1.6 to 28.8, p <0.01 for presence, beta coefficient = 3.59 +/- 0.88 [SE], p = 0.009 for extent) and individual risk factors, including age, gender, smoking, body mass index, hypertension, diabetes, hyperlipidemia, and clinical coronary disease (odds ratio 8.4, 95% confidence interval 1.7 to 42.5, p = 0.008 for presence, beta coefficient = 2.35 +/- 0.86 [SE], p = 0.007 for extent). Similarly, MS was independently associated with calcified and noncalcified plaques individually. In conclusion, MS was independently associated with the presence and extent of both calcified and noncalcified coronary atherosclerotic plaques detected using multidetector computed tomography. These data may explain the higher cardiovascular risk in these patients and may lay the foundation for studies to determine whether such information may improve risk stratification.