Beyond Traditional Risk Scores: Artificial Intelligence in Coronary Plaque Characterization and Personalized Atherosclerosis Management

Atherosclerosis remains a leading global cause of cardiovascular morbidity and mortality, yet its insidious progression and multifaceted etiology, spanning genetic, metabolic, and environmental determinants, often delay clinical recognition until adverse events occur. Traditional risk stratification tools, while foundational in preventive cardiology, are constrained by their reliance on limited variables and static linear assumptions, frequently misclassifying individuals at the extremes of risk. This review critically examines the transformative role of artificial intelligence (AI), particularly machine learning (ML) and deep learning (DL), in redefining atherosclerosis management across three interconnected domains. First, we explore how AI-driven predictive models integrate high-dimensional data, from genomics and imaging to real-time wearable metrics, to achieve superior cardiovascular risk stratification compared with conventional scores. Second, we detail AI’s capacity to automate and enhance plaque characterization through advanced imaging analysis, enabling reproducible quantification of burden, composition, and vulnerability markers that are imperceptible to human readers. Third, we investigate AI-powered clinical decision support systems, digital twins, and reinforcement learning approaches that facilitate dynamic, personalized treatment planning tailored to each patient’s evolving profile. We also critically address the ethical imperatives, algorithmic fairness, data privacy, transparency, and accountability, alongside practical challenges of clinical integration, regulatory validation, and health equity.