Optical Coherence Tomography Elastography (OCTE) has the potential to be an important diagnostic tool for pathologies including coronary artery disease, osteoarthritis, malignancies, and even dental caries. Many groups, including our own, have performed OCTE using a wide range of approaches. However, current OCTE approaches are not scalable to video rate modulus assessments. While considerable effort has gone into techniques for applying stress and measuring tissue changes, there are substantial challenges that are overlooked largely because they play little role at slow acquisition rates. The most significant of these are the tissue responses (and to a lesser degree static tissue properties), such as tissue strain response times, preload variability, and conditioning variability. This paper examines these limitations and explores overcoming them through a top down approach. First, an example clinical scenario is discussed where OCTE could play an important role in patient morbidity and mortality. This is in the prevention of myocardial infarction or heart attacks. Second, the principles behind OCTE will be examined. Third, the limitations tissue properties (dynamic and static) place on current OCTE, for in vivo video rate assessments, will be discussed. These are a minor issue at slow acquisition rates but prevent current approaches from being scaled up to real time. Finally, we introduce one approach to overcoming these limitations. For this approach, one component is that stress is applied with constant frequency, amplitude-modulated ultrasound. The amplitude is changed between two values on every first and third frame so that tissue strain plateaus during measurement on every second and fourth frame. While this general approach overcomes the obstacles, the approach is not limited to a specific embodiment as will be seen.