Imaging techniques, such as carotid intima media thickness (cIMT) and coronary artery calcium (CAC) score, have attracted considerable interest as adjuncts for CV risk stratiﬁcation. In the IMPROVE trial, a 12.1% reclassiﬁcation improvement of patients at increased CV risk was found when information derived from a single cIMT was combined with classical risk factors However, the MESA investigators showed that the addition of CAC, rather than cIMT to the Framingham risk score resulted in a net reclassiﬁcation index of 0.659. This is not surprising as CAC represents a cumulative burden of disease rather than a ‘snapshot’ of current CV risk factors. Currently, the European and American guidelines include cIMT and CAC measurement as a class IIa recommendation for asymptomatic adults at moderate CV risk. New imaging modalities, such as MRI, are likely to improve further ability to characterize functional and structural arterial wall changes. It is important to note, however, that there is currently no evidence to support the use of these imaging methods to monitor the evolution of disease in relation to the overall risk.