PURPOSE: To assess the presence of coronary artery calcium (CAC) and its association with cardiovascular risk factors and Systematic COronary Risk Evaluation (SCORE) risk in a middle-aged Dutch population. METHODS: Classic cardiovascular risk factors and CAC were analyzed in 4083 participants aged 45 to 60 years (57.9% women) from the population-based ImaLife study. CAC scores were quantified on noncontrast cardiac CT scans. Age-specific and sex-specific distribution of CAC categories (0, 1 to 99, 100 to 299, ≥300) and percentiles were determined. SCORE risk categories (<1%, ≥1% to 5%, and ≥5%) were compared with CAC distribution. Population attributable fractions (PAFs) of classic risk factors for CAC were estimated. RESULTS: CAC was present in 54.5% male and 26.5% female participants. The percentage of individuals with CAC increased with increasing age. Mean SCORE was 2.0% in men and 0.7% in women. In SCORE <1%, 32.7% of men and 17.1% of women had CAC. In men with SCORE ≥5%, 26.9% had no CAC. Only 0.1% of women had SCORE ≥5%. PAF of classic risk factors for CAC was 18.5% in men and 31.4% in women. PAF was highest for hypertension (in men 8.0%, 95% confidence interval, 4.2%-11.8%; in women 13.1%, 95% confidence interval, 7.9%-18.2%) followed by hypercholesterolemia and obesity. CONCLUSION: In this middle-aged cohort, more than half of the men and a quarter of the women had CAC. One out of 4 men at high risk (SCORE ≥5%) could be placed into a lower risk category owing to absence of CAC. Thus, adding CAC scoring to SCORE could have considerable effect on cardiovascular risk classification. Elimination of exposure to classic risk factors could reduce limited proportion of CAC in a middle-aged population.