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The term "vulnerable plaque" denotes the plaque characteristics that are susceptible to coronary thrombosis. Previous post-mortem studies proposed 3 major mechanisms of coronary thrombosis: plaque rupture, plaque erosion, and calcified nodules. Of those, characteristics of rupture-prone plaque have been extensively studied. Pathology studies have identified the features of rupture-prone plaque including thin fibrous cap, large necrotic core, expansive vessel remodeling, inflammation, and neovascularization. Intravascular imaging modalities have emerged as adjunctive tools of angiography to identify vulnerable plaques. Multiple devices have been introduced to catheterization laboratories to date, including intravascular ultrasound (IVUS), virtual-histology IVUS, optical coherence tomography (OCT), coronary angioscopy, and near-infrared spectroscopy. With the use of these modalities, our understanding of vulnerable plaque has rapidly grown over the past several decades. One of the goals of intravascular imaging is to better predict and prevent future coronary events, for which prospective observational data is still lacking. OCT delineates microstructures of plaques, whereas IVUS visualizes macroscopic vascular structures. Specifically, plaque erosion, which has been underestimated in clinical practice, is gaining an interest due to the potential of OCT to make an in vivo diagnosis. Another potential future avenue for intravascular imaging is its use to guide treatment. Feasibility of tailored therapy for acute coronary syndromes (ACS) guided by OCT is under investigation. If it is proven to be effective, it may potentially lead to major shift in the management of millions of patients with ACS every year.

Advances in Intravascular Imaging: New Insights into the Vulnerable Plaque from Imaging Studies