Vulnerable coronary plaques are the primary substrate for acute coronary syndromes, representing a significant challenge in cardiovascular care. This review examines the pivotal role of intracoronary imaging, specifically intravascular ultrasound (IVUS) and optical coherence tomography (OCT), in the detection and management of these high-risk lesions. We detail the technical principles of these modalities and their unique capabilities in characterizing plaque morphology, from identifying thin-cap fibroatheromas (TCFA) to differentiating mechanisms of plaque rupture and erosion. The article further synthesizes evidence on how imaging-guided strategies—ranging from intensive medical therapy to emerging interventional approaches like preventive stenting—can stabilize vulnerable plaques and improve patient outcomes. Finally, we explore future directions, including the integration of artificial intelligence and hybrid imaging technologies, which promise to refine risk stratification and personalize the treatment of coronary artery disease.