The magnitude of age-related public health problems, such as atrial fibrillation (AF) and heart failure (HF) is enormous and escalating, despite conventional strategies of clinical risk factor assessment and management. New paradigms for risk stratification need to be considered. Of all technologies, echocardiography is the only imaging modality that has a wide margin of patient safety and is mature enough for preventive applications. Along with its unique characteristics of portability, ready availability at the population level, and relatively low cost, echocardiography is well-positioned for integration into preventive strategies. The ability to detect subclinical abnormalities early in the natural history of a disease may potentially allow treatment within the window of opportunity, interrupting the cascade of events that lead to adverse outcomes. The 2008 Feigenbaum Lecture describes the body of literature confirming the important contribution of echocardiography in prognostication and its role in risk stratification, and documents the evolution of echocardiography from being solely a tool for confirming diagnosis to one that will also guide prevention of public health problems.