Patients with systemic lupus erythematosus (SLE) have a significantly increased risk of atherosclerotic coronary events. Traditional risk factors, such as hypertension and hypercholesterolemia, only partly account for the increased risk of coronary disease in SLE. Other important risk factors include disease and treatment-related factors. Novel markers of coronary risk in SLE are being investigated. Several methods have been used to detect subclinical atherosclerosis in patients with SLE. Among these, scintigraphic myocardial perfusion defects have been shown to be predictive of subsequent coronary events, independent of traditional Framingham risk factors. Although the aggressive treatment of reversible risk factors, such as lipids and blood pressure, is advocated by many, no published studies have yet demonstrated a clear reduction in risk of coronary events with this approach. Elucidation of risk factors and preventive strategies for accelerated atherosclerosis in SLE is the subject of ongoing research.