Smoldering multiple myeloma (SMM) patients are a heterogeneous group with variable prognosis. A subset of SMM patients have a higher risk of progressing to multiple myeloma (MM) within 2 years. The definition of high-risk patients is not consistent among different risk models, and the combination of various biomarkers and new technologies improves the predictive performance of risk models. In clinical research, different risk models are often combined and applied. New drugs for treating MM are gradually being applied in the treatment of high-risk SMM. Single or dual drug therapy prolongs the progression free survival of patients, but most studies have not yet shown an overall survival benefit for patients. Multi drug combination and intensive treatment can achieve deep relief in high-risk SMM, but most of the studies are single arm studies, which are not yet sufficient to prove that multi drug treatment is more effective than lower intensity treatment. Further exploration of treatment plans for high-risk SMM patients is still needed. This article reviews the progress in risk stratification and treatment of high-risk SMM.