Mechanisms, precision therapies, and technological frontiers in coronary atherosclerosis: a comprehensive review

Coronary atherosclerosis is a leading cause of morbidity and mortality worldwide and is characterized by complex molecular and cellular mechanisms involving lipid dysregulation, endothelial dysfunction, immune-inflammatory processes, and vascular remodeling. Despite advancements in conventional therapies, including statins and antiplatelet agents, significant residual risk persists, particularly in patients with genetic dyslipidemias, persistent inflammation, or limited access to advanced care. Recent breakthroughs in precision medicine, multiomics technologies, and high-resolution imaging are transforming our approach to cardiovascular risk assessment by enabling refined stratification through single-cell transcriptomics, polygenic risk scoring, and artificial intelligence-powered plaque analysis. This review synthesizes the contemporary understanding of disease mechanisms and emerging therapeutic strategies, highlighting novel interventions targeting PCSK, inflammatory pathways, and vascular regeneration through cell-based therapies. We further explored the transformative potential of CRISPR-Cas9 gene editing for durable lipid lowering, nanotechnology-enabled drug delivery, and gut microbiota modulation targeting metabolites such as trimethylamine N-oxide. Although these innovations promise personalized atherosclerosis management, challenges remain in terms of accessibility, health equity, and clinical implementation. The integration of multimodal data analytics with targeted therapeutics heralds a new era of precision cardiology aimed at reducing the global burden of coronary artery disease.