Contrast-enhanced x-ray imaging remains essential to the diagnosis and treatment of many types of cardiac and vascular disease. Despite the rapid advancements in less invasive imaging techniques, only traditional angiography provides a high-resolution, real-time, dynamic view of vascular structures. Cardiologists have become concerned about contrast selection since the introduction of new agents over the last 2 decades. This concern has sparked three sequential debates within our community: the cost effectiveness of low osmolal contrast; whether nonionic agents are prothrombogenic; and whether the potential for nephrotoxicity differs between contrasts. Following is a summary of clinically relevant aspects of the cost effectiveness of low osmolal contrast and the prothrombogenicity of nonionic agents. These issues are important not only to those who perform angiography, but also to those who refer patients to, or follow them after, the procedure.