Intravascular imaging (intravascular ultrasound and optical coherence tomography) and physiological assessment of coronary blood flow become popular in Russian clinical practice. However, incidence and features of these assessment modalities in patients with acute coronary syndrome are not sufficiently systematized in the Russian Federation. The Russian Register of Intravascular Imaging and Physiological Methods has been functioning since 2021. This register allows objective assessment of state and trends in development of intravascular diagnostic methods in Russian hospitals. In 2021—2022, this registry included data on 7967 intravascular diagnostic procedures in 23 hospitals and 14 cities. Of these, 1630 (20.5%) procedures were performed in patients with acute coronary syndrome. Assessment of functional blood flow reserve was performed in 594 cases (non-hyperemic index in 75% of cases). As a rule, physiological examinations were performed at the diagnostic stage and excluded intervention on the target segment in 65% of these cases. Intravascular imaging methods were used in 1034 cases (intravascular ultrasound — 910, optical coherence tomography — 124). In most cases, intraoperative intravascular imaging was used for accurate selection of instruments (65%) or assessment of the need for additional intervention in case of suboptimal result (20%). The use of intravascular imaging varies between hospitals, but only two departments perform the majority of procedures. Despite several different approaches and unsolved issues regarding intravascular imaging and physiological assessment in acute coronary syndrome, these methods are important for coronary angiography and percutaneous coronary intervention in patients with ACS. Available experience and registry data indicate these methods as safe and perspective ones.