The Framingham algorithm is a great tool for assessing patients at high and low risk for CAD. Establishing a treatment protocol for these patients is also relatively straightforward. However, what do we do for those patients who are at intermediate risk for CAD and who are asymptomatic? The standard of care says we should treat the symptoms of disease. Unfortunately, this may be grossly inadequate because many of these patients are already full of soft plaque (i.e. significant atherosclerosis), and have IMT measurements that place them at very high risk for an ischemic event. Though many physicians will be uneasy with the uncertainty of the Framingham risk assessment in this medium risk group of patients, they will follow the standard of care and avoid aggressive pharmacological treatment in favor of maintaining a vigilant eye on these patients instead. Others will send these patients on for additional testing such as MRI, Stress Echo, or EBCT. Because very few of these patients will have more than 60% stenosis, they will pass the Stress Echo and MRI. EBCT is a great tool for assessing calcified plaque, but is inadequate at identifying the soft and more vulnerable plaque. Many of these patients still have significant amounts of soft plaque lining their arteries. Soft plaque (or echoluscent plaque) of any size has been shown to increase the odds ratio of an ischemic event nearly 2.5 times higher than a person who has an old MI. (Honda, et al J AM Coll Cardiol 2004; 43:1177-84)