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Ageing is related to complex molecular, inflammatory and biochemical changes that affect coronary pathology and often lead to coronary artery disease and cardiovascular events. Intravascular imaging is considered as the ideal technique to study coronary plaque morphology and assess its burden. Over the recent years several studies have been performed that investigated the association between pathophysiological mechanisms that promote vascular ageing and plaque morphology. In addition, several reports have compared plaque pathology in different age groups and a few studies included serial intravascular imaging to assess changes in the atheroma burden and compositional characteristics of the plaque. This review article summarizes the evidence derived from intravascular imaging studies about the implications of vascular ageing on coronary artery morphology and discusses the potential of coronary imaging in assessing atherosclerotic evolution.Vascular ageing is associated with an increase in plaque burden and calcific tissue component and the formation of vulnerable lesionsAtherosclerosis in elderly is due to metabolic disorders, impaired endothelial function and increased oxidative stress and vascular inflammation.Serial invasive imaging has shown that vascular ageing is a slow, dynamic process.Plaque characteristics the local hemodynamic forces and medications appear to regulate plaque evolution.