Background: Empirically derived dietary patterns show strong cross-sectional associations with cardiovascular disease (CVD) risk factors in the Multi-Ethnic Study of Atherosclerosis (MESA). Objective: We investigated associations between dietary patterns and risk of incident CVD in 5316 men and women. Design: White, black, Hispanic, and Chinese adults aged 45-84 y and free of CVD and diabetes completed food-frequency questionnaires at baseline. Dietary patterns were derived by using principal components analysis. Incident CVD events (n = 207) identified over a median of 4.6 y were verified by death certificates and medical records. Results: The Fats and Processed Meat dietary pattern was associated with a greater risk (hazard ratio quintile 5 compared with quintile 1: 1.82; 95% CI: 0.99, 3.35), and the Whole Grains and Fruit dietary pattern was associated with a lower risk (0.54; 0.33, 0.91) of CVD after adjustment for demographic and lifestyle confounders. Associations between CVD and the Whole Grains and Fruit dietary pattern remained strong after adjustment for waist circumference, blood pressure, lipids, or inflammatory markers. Conclusions: Data from this multiethnic cohort reinforce findings from predominantly white cohorts, ie, that "healthy" and "unhealthy" dietary patterns empirically exist and that these patterns are important lifestyle predictors of CVD incidence.