Background: Vulnerable atherosclerotic plaques are lesions prone to rupture or erosion, leading to acute coronary syndrome. Conventional angiography evaluates luminal stenosis but does not reliably identify plaque composition or biological instability.

Objective: To evaluate imaging biomarkers associated with plaque vulnerability using coronary CT angiography, intravascular ultrasound, optical coherence tomography, near-infrared spectroscopy, and emerging hybrid imaging methods.

Methods: This narrative research article reviews contemporary imaging biomarkers of vulnerable plaque and presents a dummy observational dataset of 320 patients undergoing multimodality coronary plaque assessment.

Results: Major vulnerability biomarkers included thin fibrous cap, large lipid-rich necrotic core, positive remodeling, low attenuation plaque, spotty calcification, macrophage infiltration, microchannels, plaque burden, and high lipid-core burden index.

Conclusion: Imaging biomarkers provide essential insight beyond stenosis severity and may improve risk stratification, preventive therapy selection, and interventional planning.