Atherosclerotic heart disease is a leading cause of morbidity and mortality worldwide, and elderly patients are particularly prone to develop coronary artery disease with significant obstructive plaques, extensive calcification, and multivessel involvement; the clinical presentation in these patients may be atypical, and the treatment is challenging, all factors reducing prognosis. Hence, the role of imaging in the early diagnosis of coronary artery disease (CAD) is crucial: different imaging techniques can be used in the diagnosis of CAD, mainly the coronary CT, and in the evaluation of the functional impact of CAD, in particular the stress imaging techniques. Moreover, imaging is fundamental in the evaluation of post-ischemic myocardial modifications and the evaluation of re vascularized patients (Fig. 1). This chapter will investigate the pathophysiological basis of atherosclerotic disease in the elderly and the role of imaging techniques in diagnosing CAD and monitoring post-ischemic revascularization and myocardial remodeling.