Thoracic radiation remains an effective treatment for many types of neoplasms. The clinical benefit of radiation therapy on cancer mortality is counterbalanced by an increased risk of cardiovascular events in survivors. The long-term cardiovascular sequelae of thoracic radiation include premature coronary artery disease, valvular disease, pericardial disease, myocardial disease with systolic and especially diastolic dysfunction, and conduction system abnormalities. Radiation heart disease progresses over time and may manifest decades after the initial exposure. Since the risk of cardiac complications is significantly increased following chest irradiation, appropriate screening and long-term cardiac follow-up of these patients is essential. This article will summarize the pathophysiological features, clinical presentations, and current recommendations for screening and prevention of the wide spectrum of radiation induced cardiovascular disease.