Research paper| Volume 16, ISSUE 6, P483-490, November 2022

Download started.


Perivascular fat attenuation for predicting adverse cardiac events in stable patients undergoing invasive coronary angiography



      Inflammation surrounding the coronary arteries can be non-invasively assessed using pericoronary adipose tissue attenuation (PCAT). While PCAT holds promise for further risk stratification of patients with low coronary artery disease (CAD) prevalence, its value in higher risk populations remains unknown.


      CORE320 enrolled patients referred for invasive coronary angiography with known or suspected CAD. Coronary computed tomography angiography (CCTA) images were collected for 381 patients for whom clinical outcomes were assessed 5 years after enrollment. Using semi-automated image analysis software, PCAT was obtained and normalized for the right coronary (RCA), left anterior descending (LAD), and left circumflex arteries (LCx). The association between PCAT and major adverse cardiovascular events (MACE) during follow up was assessed using Cox regression models.


      Thirty-seven patients were excluded due to technical failure. For the remaining 344 patients, median age was 62 (interquartile range, 55–68) with 59% having ≥1 coronary artery stenosis of ≥50% by quantitative coronary angiography. Mean attenuation values for PCAT in RCA, LAD, and LCx were −74.9, −74.2, and −71.2, respectively. Hazard ratios and 95% confidence intervals (CI) for normalized PCAT in the RCA, LAD, and LCx for MACE were 0.96 (CI: 0.75–1.22, p ​= ​0.71), 1.31 (95% CI: 0.96–1.78, p ​= ​0.09), and 0.98 (95% CI: 0.78–1.22, p ​= ​0.84), respectively. For death, stroke, or myocardial infarction only, hazard ratios were 0.68 (0.44–1.07), 0.85 (0.56–1.29), and 0.57 (0.41–0.80), respectively.


      In patients referred for invasive coronary angiography with suspected CAD, PCAT did not predict MACE during long term follow up. Further studies are needed to understand the relationship of PCAT with CAD risk.



      AUC (area under receiver operator characteristics curve), CABG (coronary artery bypass grafting), CAD (coronary artery disease), CCTA (coronary computed tomography angiogram), CI (confidence interval), HR (hazard ratio), HU (Hounsfield units), ICA (invasive coronary angiography), LAD (left anterior descending artery), LCx (left circumflex artery), MACE (major adverse cardiovascular events), MI (myocardial infarction), PCI (percutaneous coronary intervention), PCAT (pericoronary adipose tissue attenuation), RCA (right coronary artery)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      Full access to the journal is a member benefit for SCCT Members, Login via the SCCT website to access all journal content.


      Subscribe to Journal of Cardiovascular Computed Tomography
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Arbab-Zadeh A.
        • Nakano M.
        • Virmani R.
        • Fuster V.
        Acute coronary events.
        Circulation [Internet]. 2012 Mar 6; 125 (Available from:): 1147-1156
        • Antonopoulos A.S.
        • Sanna F.
        • Sabharwal N.
        • et al.
        Detecting human coronary inflammation by imaging perivascular fat.
        Sci Transl Med. 2017; 9
        • Antonopoulos A.S.
        • Antoniades C.
        Perivascular fat attenuation index by computed tomography as a metric of coronary inflammation.
        J Am Coll Cardiol. 2018 Jun 12; 71: 2708-2709
        • Oikonomou E.K.
        • Marwan M.
        • Desai M.Y.
        • et al.
        Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data.
        Lancet [Internet]. 2018; 392 (Available from: 929-939
        • Antoniades C.
        • Kotanidis C.P.
        • Berman D.S.
        State-of-the-art review article. Atherosclerosis affecting fat: what can we learn by imaging perivascular adipose tissue?.
        J Cardiovasc Comput Tomogr. 2019 Sep 1; 13: 288-296
        • van Diemen P.A.
        • Bom M.J.
        • Driessen R.S.
        • et al.
        Prognostic value of RCA pericoronary adipose tissue CT-attenuation beyond high-risk plaques, plaque volume, and ischemia.
        JACC Cardiovasc Imaging. 2021 Aug; 14: 1598-1610
        • Goeller M.
        • Marwan M.
        Is PCAT CT attenuation the ‘game changer’ in the prediction of death and myocardial infarction?.
        JACC Cardiovasc Imaging [Internet]. 2021; 14: 1611-1613
        • Antonopoulos A.S.
        • Angelopoulos A.
        • Tsioufis K.
        • Antoniades C.
        • Tousoulis D.
        Cardiovascular risk stratification by coronary computed tomography angiography imaging: current state-of-the-art.
        Eur J Prev Cardiol [Internet]. 2021 Apr 30; 29 (Available from:): 608-624
        • Rochitte C.E.
        • George R.T.
        • Chen M.Y.
        • et al.
        Computed tomography angiography and perfusion to assess coronary artery stenosis causing perfusion defects by single photon emission computed tomography: the CORE320 study.
        Eur Heart J [Internet]. 2014 May 1; 35 (Available from:): 1120-1130
        • Andreini D.
        • Magnoni M.
        • Conte E.
        • et al.
        Coronary plaque features on CTA can identify patients at increased risk of cardiovascular events.
        JACC Cardiovasc Imaging [Internet]. 2020 Aug 1; 13 (Available from:): 1704-1717
        Date accessed: October 22, 2021
        • Lin A.
        • Dey D.
        • Wong D.T.L.
        • Nerlekar N.
        Perivascular adipose tissue and coronary atherosclerosis: from biology to imaging phenotyping [Internet].
        Current Atherosclerosis Reports. Current Medicine Group LLC. 2019; 21 (Available from:/pmc/articles/PMC7172444/): 47
        Date accessed: June 26, 2021
        • Hansson G.K.
        • Libby P.
        • Tabas I.
        Inflammation and plaque vulnerability.
        J Intern Med [Internet]. 2015 Nov 1; 278 (Available from:/pmc/articles/PMC5082111/): 483
        Date accessed: October 22, 2021
        • Oikonomou E.K.
        • Williams M.C.
        • Kotanidis C.P.
        • et al.
        A novel machine learning-derived radiotranscriptomic signature of perivascular fat improves cardiac risk prediction using coronary CTangiography.
        Eur Heart J [Internet]. 2019 Nov 14; 40 (Available from:): 3529-3543
        • Hedgire S.
        • Baliyan V.
        • Zucker E.J.
        • et al.
        Perivascular epicardial fat stranding at coronary CT angiography: a marker of acute plaque rupture and spontaneous Coronary Artery Dissection.
        Radiology [Internet]. 2018 Feb 5; 287 (Available from:): 171568