The potential risk of fatal malignancy related to cardiac imaging with ionizing radiation is frequently discussed in the medical literature and in the lay press. Clinicians must weigh this risk against the potential benefits of cardiac imaging, which are typically not considered in these reports about radiation risk. This review summarizes the evidence regarding both the radiation risks and clinical benefits of cardiac imaging to provide guidance to the clinician in specific clinical scenarios. Choosing the right test for the right patient, and performing it with the lowest possible radiation dose, remains a challenge.