Introduction Conventional imaging modalities, including magnetic resonance (MR), are primarily based on anatomical, functional or metabolic properties to study (patho)physiology. Molecular imaging is a rapidly evolving field of research, aiming to image and quantify molecular and cellular targets in vivo. Molecular imaging can be applied to a wide range of scientific and clinical fields of interest. One of the most promising applications of molecular imaging is in the field of cardiovascular imaging. Imaging of cardiac anatomy, dimensions and function has some limitations concerning, for example, prediction of therapy outcome. Addition of specific information on, for instance, plaque composition and total plaque burden can be very helpful in guiding therapy. 1 MR imaging has some inherent properties that make it very suitable for cardiovascular molecular imaging. The interaction between inherent tissue properties and specific contrast agents may lead to more specific clinical conclusions and prediction of therapy outcome. Thereby, cardiovascular molecular MR imaging may help in diagnosing cardiovascular disease, and in deciding whether expected beneficial effects of (invasive) therapy counterbalance the risk of complications of therapy. A conventional approach to molecular MR imaging concerns MR spectroscopy. Furthermore, there are two main innovative contrast agents that may be used clinically soon: (1) iron oxide MR contrast agents and (2) fibrin-targeted MR contrast agents. MR spectroscopy 31 1 2 31 3 4 Fig. 1 Left panel  Right panel 31 left right 2  23 5 23 23 23 23 23 23 6 23 1 7 1 1 8 1 1 1 1 2 Fig. 2 a b c d e  1  Gadolinium-based contrast agents 9 9 10 11 3 Fig. 3 Left panel  Right panel  Based on as yet unpublished scientific developments, it is expected that gadolinium-based delayed enhancement of the vessel wall may become reality. This MR imaging technique may allow fast total body screening for total plaque burden, an important predictor for morbidity and mortality. In general, gadolinium-based contrast agents are not perfectly suited for molecular imaging because of the inherent high threshold of detectability. Therefore, new contrast agents are under development to potentiate the effect of distortion of the magnetic field. Iron oxide MR contrast agents 12 12 4 12 Fig. 4 SE GRE Delayed upper panel arrows MI lower panel arrows  LV  RV 12  Another promising application of SPIO MR imaging is visualisation of vessel wall inflammation. SPIOs are ‘digested’ by macrophages, involved in inflammatory processes. Imaging of the SPIO-induced magnetic inhomogeneities allows for imaging of inflammation. Such an approach is currently only available in a research setting; it is, however, expected that these contrast agents will become available for clinical application soon. Fibrin-targeted MR contrast agents 13 14 5 Fig. 5  Left panel arrowheads  Right panel arrow 14  6 7 Fig. 6  left panel upper lower  right panel LA arrow  LV 14  Fig. 7  upper row arrow  lower panel arrows 14  The above-described applications of molecular MR imaging may be especially suitable for fast screening for cardiovascular disease in an emergency setting. Patients presenting with chest pain in the emergency room can be studied by MR imaging to confirm or rule out ischaemic heart disease or pulmonary embolus. Molecular MR imaging using fibrin-targeted contrast agents allows selective visualisation of acute coronary, cardiac and pulmonary thrombi. Additional functional cardiac imaging can help determine the functional effects of detected thrombi. Conclusion Molecular MR imaging is an exciting and rapidly evolving new area of cardiovascular imaging. MR imaging seems very suitable for molecular imaging, although many technical difficulties have to be overcome. The main current limitation is the low sensitivity of MR imaging to detect small changes in magnet homogeneity. We expect that in the next decade, currently promising MR molecular imaging agents will be introduced into the clinical arena to guide diagnosis and therapy of cardiovascular disease.