AbstractBackground and AimsNon‐alcoholic fatty liver disease (NAFLD) is associated with a high risk of cardiovascular disease. Whether risk scores developed in the general population accurately assess cardiovascular risk in the NAFLD population is unknown. This study aimed to evaluate the performance of the Pooled Cohort Equations (PCE) in NAFLD.MethodsIndividuals in the Multi‐Ethnic Study of Atherosclerosis with baseline non‐contrast cardiac computed tomography scans with sufficient data to determine the presence of hepatic steatosis were identified and assessed for the development of incident 10‐year atherosclerotic cardiovascular disease. The discrimination and calibration of the PCE were evaluated, and the observed and expected events by risk category (<5%, 5–<7.5%, 7.5–<20%, ≥20%) were determined. Risk reclassification with the addition of NAFLD to the PCE was assessed.ResultsOf 4014 participants included, 698 (17.4%) with NAFLD were identified, including 247 (35.3%) with moderate‐to‐severe steatosis. Discrimination of the PCE was suboptimal in NAFLD (c‐statistic 0.69), particularly moderate‐to‐severe steatosis (0.65), and calibration was overall poor. While risk was overestimated in non‐NAFLD, it was underestimated in NAFLD in lower/intermediate risk categories, predominantly in women (5–<7.5% observed/expected ratio = 1.67). The addition of NAFLD to the PCE improved risk classification in women.ConclusionsThe PCE overall performed suboptimally in cardiovascular risk assessment in NAFLD, particularly in women and individuals with moderate‐to‐severe steatosis in clinically relevant risk categories. Primary prevention may need to be considered at a lower risk threshold in these groups, and further work is needed to improve risk stratification in this growing high‐risk population.