Cardiovascular imaging modalities such as coronary computed tomography, carotid ultrasonography, and cardiovascular magnetic resonance imaging are increasingly being used to measure cardiovascular disease progression. Imaging measures, most notably carotid intima-media thickness (CIMT), are being applied as surrogate markers for clinical end points such as myocardial infarction and death in clinical trials. Clinicians and their patients are faced with the challenge of evaluating these imaging measures for their efficacy and practicality in clinical practice, as well as in clinical trials. The investigators determined from a review of clinical trials and guidelines that CIMT measurement may be useful in evaluating cardiovascular disease risk in select patient populations but may not always be an appropriate surrogate for clinical end points. In conclusion, although CIMT has clear advantages over alternative cardiovascular imaging modalities, ultimately, prospective trials comparing the effectiveness of CIMT as a predictive tool of cardiovascular risk with that of other novel markers would best direct clinical recommendations for this imaging measure.