AimsIt is unclear whether subclinical vascular damage adds significantly to Systemic Coronary Risk Evaluation (SCORE) risk stratification in healthy subjects.Methods and resultsIn a population-based sample of 1968 subjects without cardiovascular disease or diabetes not receiving any cardiovascular, anti-diabetic, or lipid-lowering treatment, aged 41, 51, 61, or 71 years, we measured traditional cardiovascular risk factors, left ventricular (LV) mass index, atherosclerotic plaques in the carotid arteries, carotid/femoral pulse wave velocity (PWV), and urine albumin/creatinine ratio (UACR) and followed them for a median of 12.8 years. Eighty-one subjects died because of cardiovascular causes. Risk of cardiovascular death was independently of SCORE associated with LV hypertrophy [hazard ratio (HR) 2.2 (95 CI 1.2-4.0)], plaques [HR 2.5 (1.6-4.0)], UACR ≥ 90th percentile [HR 3.3 (1.8-5.9)], PWV > 12 m/s [HR 1.9 (1.1-3.3) for SCORE ≥ 5 and 7.3 (3.2-16.1) for SCORE < 5]. Restricting primary prevention to subjects with SCORE ≥ 5 as well as subclinical organ damage, increased specificity of risk prediction from 75 to 81 (P < 0.002), but reduced sensitivity from 72 to 65 (P = 0.4). Broaden primary prevention from subjects with SCORE ≥ 5 to include subjects with 1 ≤ SCORE < 5 together with subclinical organ damage increased sensitivity from 72 to 89 (P = 0.006), but reduced specificity from 75 to 57 (P < 0.002) and positive predictive value from 11 to 8 (P = 0.07).ConclusionSubclinical organ damage predicted cardiovascular death independently of SCORE and the combination may improve risk prediction.