Coronary heart disease (CHD) is the leading cause of death in the UK. Approximately 50% of myocardial infarctions occur in patients with no prior history of CHD or cardiovascular risk factors while sudden death is often the first manifestation of CHD in as many as 35% of patients. The realisation that standard risk factors incompletely predict incident CHD events has led to the development of several non-invasive imaging techniques to accurately assess the risk of CHD over the last decade. Several epidemiological studies have established that the total coronary atherosclerotic plaque burden is a powerful predictor of future hard coronary events (myocardial infarction and death). This article reviews the role of electron beam computed tomography (EBCT) in the early detection of subclinical coronary artery disease, the identification of ‘high-risk’ asymptomatic patients for intensive medical intervention, and its role in evaluating the progression of coronary artery disease and in monitoring the efficacy of medical therapies.