Patients with systemic lupus erythematosus (SLE) have increased risk of developing atherosclerotic cardiovascular disease (ASCVD). This excessive risk starts to accumulate during the earliest stages of SLE. ASCVD in SLE is associated with an adverse outcome. SLE-enhanced atherogenesis is most likely the consequence of a complex interplay between traditional risk factors and chronic auto-immune inflammation. This underscores the importance of conscientious management of traditional risk factors as well as maintaining low SLE disease activity. Shared immune pathways in SLE and ASCVD can affect the vascular biology of the atherosclerotic process in patients with SLE. In this review, we will discuss how the ASCVD risk evolves during the SLE disease course, and we consider whether patients with SLE are prone to developing superficial erosion of atherosclerotic plaques. This is highly relevant as pilot studies in the general population suggest antithrombotic therapy without stenting could be the better therapeutic approach in patients with plaque erosion.