Background: Cardiovascular disease (CVD) remains a leading cause of global mortality, with many risk factors being potentially modifiable, highlighting the importance of early risk assessment. Machine learning (ML) can support accurate CVD risk prediction and provide explanations for individual predictions. However, the practical use of explainable AI (XAI) remains limited by unstable feature rankings across training samples, limited distinction between modifiable and non-modifiable factors, and insufficient verification of whether recommended changes reduce model-estimated risk. Objective: To bridge these gaps, this study introduces pCARE-CV, a unified XAI framework that integrates predictive modeling, bootstrap-based SHapley Additive exPlanations (SHAP) stability analysis, a SHAP-guided recommendation module (SGRM), and multi-method counterfactual (CF) analysis within a single, deployable, and clinically interpretable cardiovascular risk assessment system. Thus, our work extends the methodological foundation of interpretable ML for applications in biomedical. Methods: Seven ML classifiers were evaluated on two synthetic cohorts, EarlyMed (n = 70,000) and HDD-25 (n = 3,069), and one real-world cohort, UCI-HDD (n = 920), using multiple predictive performance metrics with bootstrap confidence intervals. SHAP ranking stability was assessed through 200 bootstrap refits using Spearman correlation, Kendall’s tau, and top-k overlap. Multi-Objective Counterfactuals (MOC), Nearest Instance Counterfactual Explanations (NICE), and What-If CF methods were compared on EarlyMed and UCI-HDD using validity, sparsity, proximity, plausibility, and predicted probability reduction. The proposed framework is demonstrated through a Streamlit-based web application that enables real-time translation and provides an applicability and feasibility recommendation. Results: CatBoost achieved accuracies of 99.36%, 63.03%, and 85.87% on EarlyMed, HDD-25, and UCI-HDD, respectively. Mean bootstrap Spearman correlations of SHAP rankings were 0.886, 0.732, and 0.837, indicating differences in attribution stability across datasets. On EarlyMed, MOC achieved the highest validity (1.000) and mean probability reduction (0.7075), while What-If achieved the highest plausibility (1.3255). NICE generally required fewer feature modifications but showed slightly lower validity. On UCI-HDD, the relative performance of the CF methods varied across evaluation criteria, underscoring the potential applicability of CFs in clinical settings. Conclusion: pCARE-CV integrates prediction, explanation stability, actionable recommendations, and CF analysis within a single deployable framework. The results highlight the importance of evaluating predictive performance and explanation stability across datasets, as well as CF explanations in medical domains using multiple complementary criteria. Together, these evaluations can support more nuanced and effective cardiovascular patient care strategies.