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Understanding the etiology and evolution of the vulnerable coronary plaque is important for the early detection, treatment, and prevention of coronary artery disease. Intravascular optical coherence tomography (OCT) enables imaging of the coronary arteries in vivo with sufficient resolution to accurately differentiate arterial pathology, however, the clinical utility of this technology has been limited due to slow image acquisition rates. The development of high-speed Fourier-domain OCT techniques, including optical frequency-domain imaging, enables comprehensive microstructural imaging of long coronary artery segments. Other OCT advancements, including polarization sensitive OCT provide complementary birefringence information that is related to tissue composition. Together with new image processing, acquisition, and display techniques, these advances have enhanced the usability and utility of intracoronary OCT, bringing it closer to becoming a mainstream imaging modality in interventional cardiology.