Prognostic Value of Pericoronary Adipose Tissue on ECG-Gated Non-Contrast CT in Patients With Stable Chest Pain: Insights from the PROMISE Trial

AIMS: To investigate whether computed tomography (CT)-derived pericoronary adipose tissue (PCAT) metrics are associated with coronary artery disease (CAD) characteristics and adverse cardiovascular outcomes in patients with stable chest pain. METHODS AND RESULTS: PCAT attenuation and body surface area-indexed PCAT volume were quantified on non-contrast, electrocardiogram (ECG)-gated CT in the PROMISE CT arm. Associations with CAD characteristics were assessed using mixed-effects logistic regression adjusted for technical parameters, atherosclerotic cardiovascular disease (ASCVD) risk score, and body mass index. Cox proportional hazards models evaluated major adverse cardiovascular events (MACE; all-cause death or nonfatal myocardial infarction), with additional adjustment for obstructive CAD. PCAT attenuation and volume were included simultaneously in all models.Among 3,799 individuals (51% female; mean age 61±8 years), PCAT attenuation and volume were -81.4±6.4 Hounsfield units (HU) and 12.9±3.1 cm3/m2, respectively. Higher (less negative) PCAT attenuation and higher PCAT volume were independently associated with stenosis ≥50% and high-risk plaque (adjusted odds ratios; attenuation: 1.02-1.03 (per 1 HU) and volume: 1.42-1.47 (per 1 cm3/m2); all p≤0.04). Both were independently associated with MACE (adjusted hazard ratios [aHR]: 1.09-1.15; all p≤0.02). PCAT improved MACE discrimination beyond ASCVD risk score, body mass index, and obstructive CAD (area under the curve: 0.70-0.72; p=0.03). In an exploratory analysis among participants without coronary plaque, higher PCAT attenuation remained associated with MACE (aHR 1.21, 95% CI 1.05-1.39; p=0.007). CONCLUSION: PCAT metrics, measured on ECG-gated non-contrast CT, are independently associated with adverse CAD features and MACE and provide incremental prognostic value beyond clinical risk factors and obstructive CAD.