Coronary artery disease is the No. 1 cause of death in the developed world. Effective means of treatment such as drug therapy to lower cholesterol levels are available, but clinical application to patients at highest risk remains imprecise. Electron beam computed tomography (EBCT) has been suggested as a means to diagnose subclinical coronary disease and facilitate risk stratification, but no current interpretive consensus exists in clinical practice. We critically reviewed current, pertinent literature regarding EBCT coronary calcium scanning from a clinical perspective and, in particular, studies that evaluated it as a measure of atherosclerotic coronary disease. Additionally, we reviewed studies that quantified the EBCT "calcium score" in relationship to coronary heart disease events. The available data suggest that the EBCT calcium score can help identify persons at higher than anticipated risk of future coronary events: the greater the EBCT coronary calcium score, the greater the extent of atherosclerotic plaque disease. Based on the literature review, we offer EBCT interpretation guidelines as they relate to drug therapy and risk reduction in asymptomatic persons with borderline cholesterol levels. Considerable evidence shows that coronary calcium is specific for atherosclerotic plaque and that it can be sensitively detected and accurately quantified by using EBCT. The coronary calcium score can help guide initiation of clinical prevention programs as part of a risk stratification and management scheme aimed at improving outcomes in patients determined to be at highest risk of coronary disease for their respective age and gender.