Coronary atherosclerosis is the most important primary etiologic factor predisposing to the development of heart failure. The mechanisms by which coronary atherosclerosis lead to heart failure likely involve the initial development of regional myocardial dysfunction, later progressing to global ventricular failure and symptomatic congestive disease. A variety of imaging strategies have been investigated for their value in identifying and characterizing markers of atherosclerosis in the effort to detect early cardiac disease. Non-invasive imaging techniques for assessing anatomic or functional manifestations of atherosclerosis include carotid ultrasonography, coronary computed tomography, cardiovascular magnetic resonance imaging, brachial artery reactivity testing, and the ankle-brachial index. Many of these imaging methods are shown to have accuracy, reliability, and the potential to add value to an office-based cardiovascular risk assessment. Further development of such imaging methods could facilitate early intervention in the development of myocardial dysfunction while enhancing our understanding of the natural course of atherosclerotic disease.