From Cardiovascular Risk Prediction to Precision Prevention: Methodological, Contextual, and Implementation Challenges

Despite advances in risk prediction, cardiovascular prevention remains suboptimal, reflecting limitations in model architecture, incomplete integration of contextual determinants, and inadequate translation of risk estimates into clinical practice. This review synthesizes epidemiological, methodological, and health systems evidence published between 2000 and 2025 regarding the performance, evolution, and implementation of cardiovascular risk prediction models. Contemporary risk assessment frameworks remain largely driven by traditional risk factors, and the addition of novel biomarkers or variables has generally produced only modest improvements in discrimination (ΔC-statistic ≈ 0.004-0.007). Alternative approaches, including lifetime risk estimation, competing-risk models, and artificial intelligence-based methods, have expanded analytical capabilities but have not consistently translated into meaningful gains in clinical utility. Moreover, contextual determinants of cardiovascular risk, particularly socioeconomic and environmental exposures, remain inconsistently incorporated, contributing to miscalibration and reduced transportability across populations. Importantly, improvements in risk estimation have not been accompanied by proportional reductions in cardiovascular burden, highlighting persistent gaps between prediction and implementation. These shortcomings reflect not only methodological challenges but also limited integration of risk assessment into clinical workflows and health systems. Future progress in cardiovascular prevention will require risk models that are dynamic, context aware, and closely linked to implementation strategies, ensuring that advances in prediction are translated into effective clinical decision-making and population health benefit.