Coronary artery disease (CAD) is the leading cause of morbidity and mortality in patients with diabetes mellitus. Patients with diabetes have a higher prevalence of CAD and a larger magnitude of ischemia, and they are more likely to have silent myocardial ischemia and myocardial infarction. However, recent large cohort studies demonstrate that diabetic patients are not a homogenous group with similar high risk for cardiac events. In fact, more than 30% of asymptomatic diabetic patients do not have evidence of coronary atherosclerosis and have a very low annual cardiac event rate. Accordingly, there has been a recent paradigm shift as to whether the detection of subclinical coronary atherosclerosis through imaging can best guide therapeutic decision making. This review discusses the role of various cardiac imaging techniques for stratifying cardiovascular risk and optimizing therapy in asymptomatic diabetic patients.