Atherosclerosis is a systemic, silent, and deadly disease; however, primary risk reduction is very effective. Cost-effective risk modification relies on accurate and individualized risk stratification; however, traditional risk factor–based assessments fail to account for individual progression along the pathophysiologic continuum. Ultrasound and other imaging techniques that measure both anatomy and function provide well-validated surrogate markers for atherosclerosis that have incremental predictive power to that provided by risk factors, and may be useful in designing primary prevention strategies.