Despite advances in its understanding and treatment, coronary heart disease remains the leading cause of death worldwide. Acute coronary syndromes most commonly result as a consequence of the rupture of non-flow-limiting, high-risk coronary artery plaques. Advances in multimodality imaging have allowed the detailed assessment of the high-risk plaque including the assessment of plaque burden, high-risk plaque features, plaque activity and thrombosis. This in turn may help identify those patients at greatest risk, and thus benefit from intensification of pharmacotherapies or from local preventative strategies including coronary revascularisation. However, the optimal management of high-risk plaques and the prevention of consequent adverse coronary events have yet to be established. Further development and observational studies are required to determine how best to apply high-risk plaque metrics into clinical practice. Nevertheless, a new era of precision medicine is upon us, with advanced plaque imaging allowing enhanced risk stratification and targeting of the growing armamentarium of atherosclerotic therapies to the highest risk patients.
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