Artificial intelligence for risk prediction in atherosclerotic cardiovascular disease: A narrative review of advances, validation challenges, and clinical translation (2020-2026).
Since 2020, artificial intelligence (AI) has been increasingly applied to atherosclerotic cardiovascular disease (ASCVD) risk prediction. This structured narrative review with systematic evidence mapping summarizes literature (2020-2026) examining study design, data sources, model architectures, multimodal fusion, model development and validation, performance evaluation, subgroup applications, and implementation barriers. Overall, 126 studies informed the review; 93 provided sufficient information for structured extraction, including prevention setting, exact input variables, comparator scores, validation strategies, discrimination, calibration, dominant model architecture, endpoint category, foundation-model or pretrained-model status, regulatory status, and implementation features. AI-based models may offer modest but clinically meaningful gains over conventional risk equations, especially with multimodal or longitudinal data. Among the 93 studies, traditional machine learning accounted for 83 (89%), deep learning for 7 (8%), and multimodal fusion for 3 (3%). Endpoint definitions were heterogeneous (23% ASCVD-specific; 63% expanded MACE composites). Among these studies, no large language model or federated learning was used for risk prediction. Appropriate comparators should now include contemporary equations such as PREVENT, rather than only legacy tools. Major barriers remain, including limited external validation, performance attenuation, data and algorithmic bias, limited interpretability, inconsistent reporting of calibration, fairness, and clinical utility, unclear regulatory status, and limited prospective evidence. Future work should prioritize calibration, robustness, transportability, fairness, interpretability, regulatory clarity, workflow integration, and prospective evidence of decision impact or post-deployment benefit. The central question is not only whether AI can detect complex patterns, but whether such models can be trusted, implemented, and shown to advance preventive cardiology in real-world settings.