OBJECTIVE In diabetes, it remains unclear whether the coronary artery calcium (CAC) score provides additional information about total mortality risk beyond traditional risk factors. RESEARCH DESIGN AND METHODS A total of 1,051 participants, aged 34–86 years, in the Diabetes Heart Study (DHS) were followed for 7.4 years. Subjects were separated into five groups using baseline computed tomography scans and CAC scores (0–9, 10–99, 100–299, 300–999, and ≥1,000). Logistic regression was performed adjusting for age, sex, race, smoking, and LDL cholesterol to examine the association between CAC and all-cause mortality. Areas under the curve with and without CAC were compared. Natural splines using continuous measures of CAC were fitted to estimate the relationship between observed CAC and mortality risk. RESULTS A total of 17% (178 of 1,051) of participants died during the follow-up. In multivariate analysis, the odds ratios (95% CIs) for all-cause mortality, using CAC 0–9 as the reference group, were CAC 10–99: 1.40 (0.57–3.74); CAC 100–299: 2.87 (1.17–7.77); CAC 300–999: 3.04 (1.32–7.90); and CAC ≥1,000: 6.71 (3.09–16.87). The area under the curve without CAC was 0.68 (95% CI 0.66–0.70), and the area under the curve with CAC was 0.72 (0.70–0.74) (P = 0.0001). Using splines, the estimated risk (95% CI) of mortality for a CAC of 0 was 6.7% (4.6–9.7), and the risk increased nearly linearly, plateauing at CAC ≥1,000 (20.0% [15.7–25.2]). CONCLUSIONS In diabetes, CAC was shown to be an independent predictor of mortality. Participants with CAC (0–9) were at lower risk (0.9% annual mortality). The risk of mortality increased with increasing levels of CAC, plateauing at approximately CAC ≥1,000 (2.7% annual mortality). More research is warranted to determine the potential utility of CAC scans in diabetes. Diabetes is a coronary heart disease risk equivalent. The associated high overall mortality is largely attributable to increased cardiovascular deaths (1–3). Most of the morbidity and mortality in this high-risk condition are driven by accelerated atherosclerosis (4), characterized by increased amounts of connective tissue, glycoproteins, and calcified plaque in the blood vessels (5,6). Imaging by computed tomography (CT) reveals that individuals afflicted with diabetes have extensive calcification of their vascular beds (7–9). Several studies have shown that subclinical atherosclerosis, as measured by coronary artery calcium (CAC), predicts future cardiovascular disease (CVD) events and death, independent of conventional risk factors (10–12), in the general population. Whether higher CAC scores are associated with adverse clinical outcomes, in particular all-cause mortality, in diabetes has not been studied extensively. Because individuals with diabetes represent a group at high risk for cardiovascular events and death, risk stratification may be particularly useful in this population. This study examines the risk of death in participants with diabetes across higher levels of CAC scores.