Among 167 heart transplant candidates analyzed via computed tomography angiography, 24% had no traditional cardiovascular risk factors (diabetes, hypertension, high cholesterol, or smoking history) yet still harbored substantial atherosclerotic plaque throughout their thoracic and abdominal arteries. Patients with ischemic cardiomyopathy showed higher overall plaque burden than those with non-ischemic disease, but surprisingly, plaque burden was identical between those with and without standard risk factors across both groups. Current cardiovascular screening protocols rely heavily on identifying these traditional risk factors to guide atherosclerosis assessment and treatment decisions. This finding suggests a fundamental blind spot in how clinicians evaluate cardiovascular disease risk, particularly in advanced heart failure patients. The results challenge the assumption that absence of diabetes, hypertension, hyperlipidemia, and smoking reliably indicates lower atherosclerotic burden. For clinical practice, this implies that imaging-based atherosclerosis screening may be warranted regardless of traditional risk factor profiles in certain high-risk populations. However, as this medRxiv preprint awaits peer review, the findings require validation before changing screening protocols. The study's retrospective design and focus on transplant candidates may limit broader applicability to general cardiovascular populations.