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Aims: The atherosclerotic profile and advanced plaque subtype burden in symptomatic patients ≤45 years old have not been established. This study aimed to assess the prevalence and predictors of coronary artery calcium (CAC), plaque subtypes, and plaque burden by coronary computed tomography angiography (CCTA) in symptomatic young patients., Methods and Results: We included 907 symptomatic young patients (18-45 years) from Montefiore undergoing CCTA for chest pain evaluation. Prevalence and predictors of CAC, plaque subtypes, and burden were evaluated using semi-automated software. In the overall population (55% female and 44% Hispanic), 89% had CAC = 0. The likelihood of CAC or any plaque by CCTA increased with >3 risk factors {RFs, odds ratio [OR] 7.13 (2.14-23.7) and OR 10.26 (3.36-31.2), respectively}. Any plaque by CCTA was present in 137 (15%); the strongest independent predictors were age ≥35 years [OR 3.62 (2.05-6.41)] and family history of premature coronary artery disease (FHx) [OR 2.76 (1.67-4.58)]. Stenosis ≥50% was rare (1.8%), with 31% of those having CAC = 0. Significant non-calcified plaque (NCP, 37.2%) and low-attenuation plaque (LAP, 4.24%) burdens were seen, even in those with non-obstructive stenosis. Among patients with CAC = 0, 5% had plaque, and the only predictor of exclusively NCP was FHx [OR 2.29 (1.08-4.86)]., Conclusion: In symptomatic young patients undergoing CCTA, the prevalence of CAC or any coronary atherosclerosis was not negligible, and the likelihood increased with RF burden. The presence of coronary stenosis ≥50% was rare and most often accompanied by CAC >0, but there was a significant burden of NCP and LAP even within the non-obstructive group., Competing Interests: Conflict of interest: P.P., and D.L. are supported by grants from Amgen and Philips. A.L. is a consultant for and on the advisory board of Medtronic, Abbott, Boston Scientific, and Philips. R.B. has received consulting honoraria from Caristo, Novartis, Silence Therapeutic and grant/research support from Amgen and is a member of the board of directors for the American Society of Nuclear Cardiology and the Society of Cardiovascular Computed Tomography. M.J.B. has received grants from the National Institutes of Health, U.S. Food and Drug Administration, AHA, Amgen, Novo Nordisk, and Bayer and is on the advisory boards for Amgen, Sanofi, Regeneron, Novartis, Novo Nordisk, Bayer, 89Bio, Kaleido, Roche, Inozyme, emocha, VoxelCloud, and Kowa. D.S.B. and D.D. received software royalties from Cedars-Sinai Medical Center and hold a patent (US8885905B2 in the USA and World Intellectual Property Organization patent WO2011069120A1, ‘Method and System for Plaque Characterization’). S.S.V. has received honorarium from the American College of Cardiology (Associate Editor for Innovations, acc.org) and grant funding from the U.S. Department of Veterans Affairs, National Institutes of Health, World Heart Federation, and Tahir and Jooma Family. L.S. has received consulting honoraria from Amgen, Regeneron and Philips and research grants from Amgen and Philips. The remaining authors have nothing to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)