Pericoronary Adipose Tissue Attenuation in Patients with Future Acute Coronary Syndromes: The ICONIC Study

Purpose Pericoronary adipose tissue attenuation (PCATa) measured at coronary CT angiography (CCTA) is an imaging biomarker of coronary inflammation associated with long-term adverse cardiac events. The authors hypothesized that PCATa may independently identify patients at risk for acute coronary syndromes (ACS). Materials and Methods The authors performed a retrospective substudy of the Incident Coronary Syndromes Identified by Computed Tomography (ICONIC) study, a propensity-matched case-control study of patients with CCTA followed by ACS. Two hundred analyzable case and control pairs were identified from the original 234 pairs. PCATa was measured using the adjusted attenuation of fat around proximal coronary vessels. The primary analysis applied conditional Cox models with cluster-robust standard errors to predict patient-level incident ACS, with adjustment for quantitative plaque volumes and clinical reporting-oriented findings of maximal stenosis and high-risk plaque features (HRPF). Results A total of 400 patients with 1174 matched measurable vessels were included. PCATa was not significantly different between patients with future ACS versus controls (-72.99 HU ± 9.42 vs -73.96 HU ± 9.47; P = .08). Conversely, PCATa was significantly associated with incident ACS events in Cox models (adjusted for noncalcified plaque hazard ratio [HR]: 1.015; 95% CI: 1.001, 1.028; P = .03; adjusted for total plaque HR: 1.015; 95% CI: 1.002, 1.029; P = .03; adjusted for stenosis and HRPF HR: 1.014; 95% CI: 1.000, 1.028; P = .049). Conclusion Limited quantitative difference in PCATa between patients and controls matched for risk factors and coronary artery disease suggests that PCATa may not be a useful single marker to identify future ACS. Nonetheless, significant differences seen in adjusted survival models identify a small biologic effect for increased risk of future ACS independent of traditional risk factors. Keywords: CT-Angiography, Inflammation, Coronary Arteries, Acute Coronary Syndrome, Pericoronary Adipose Tissue Attenuation, Noncalcified Plaque, ICONIC Study, Cardiovascular Risk Clinical trials registration no. NCT02959099 Supplemental material is available for this article. © RSNA, 2025.