Patients with acute coronary syndromes (ACS) have a poor short- and long-term prognosis. We sought to examine the presence of established coronary risk factors in contemporary patients presenting with an ACS for the first time and no known coronary artery disease (CAD) in the past. The study was conducted in 3171 consecutive patients admitted with the diagnosis of ACS. Of these, 941 patients (30%) had the admission as the first occurrence of ACS and no prior history of CAD. We studied the degree to which these first presenters with ACS had 1 or more established risk factors. We found that 98% of patients presenting with an ACS for the first time and no previous CAD had at least 1 established risk factor. Current population-based screening efforts must be improved to allow more effective prevention strategies and more individualized risk prediction.