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Observational Study
. 2025 Jun;7(3):e240200.
doi: 10.1148/ryct.240200.

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

Alan C Kwan  1 , Evangelos Tzolos  1 , Eyal Klein  1 , Donghee Han  1 , Andrew Lin  1 , Keiichiro Kuronuma  1 , Billy Chen  1 , Guadalupe Flores Tomasino  1 , Heidi Gransar  1 , Piotr J Slomka  1 , Susan Cheng  1 , Catherine Gebhard  2 , Philipp Kaufmann  2 , Jeroen J Bax  3 , Filippo Cademartiri  4 , Kavitha Chinnaiyan  5 , Benjamin J W Chow  6 , Edoardo Conte  7 , Ricardo C Cury  8 , Gudrun Feuchtner  9 , Martin Hadamitzky  10 , Yong-Jin Kim  11 , Jonathon A Leipsic  12 , Erica Maffei  13 , Hugo Marques  14 , Fabian Plank  9 , Gianluca Pontone  7 , Todd C Villines  15 , Mouaz H Al-Mallah  16 , Pedro de Araújo Gonçalves  17 , Ibrahim Danad  18 , Yao Lu  19 , Ji-Hyun Lee  20 , Sang-Eun Lee  21 , Lohendran Baskaran  22 , Subhi J Al'Aref  23 , Matthew J Budoff  24 , Habib Samady  25 , Peter H Stone  26 , Renu Virmani  27 , Stephan Achenbach  28 , Jagat Narula  29 , Hyuk-Jae Chang  30 , Leslee J Shaw  29 , Daniel S Berman  1 , Fay Lin #  19 , Damini Dey #  1
Affiliations
Observational Study

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

Alan C Kwan et al. Radiol Cardiothorac Imaging. 2025 Jun.

Abstract

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.

Keywords: Acute Coronary Syndrome; CT-Angiography; Cardiovascular Risk; Coronary Arteries; ICONIC Study; Inflammation; Noncalcified Plaque; Pericoronary Adipose Tissue Attenuation.

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Conflict of interest statement

Disclosures of conflicts of interest: A.C.K. Grants from Doris Duke Charitable Foundation, American Heart Association Career Development Award, Smidt Heart Institute, and National Institutes of Health. E.T. No relevant relationships. E.K. No relevant relationships. D.H. No relevant relationships. A.L. No relevant relationships. K.K. No relevant relationships. B.C. No relevant relationships. G.F.T. No relevant relationships. H.G. No relevant relationships. P.J.S. Grants from National Institutes of Health and Siemens Medical Systems; software royalties from Cedars-Sinai; consulting fees from Synektik; patent with Cedars-Sinai (US8885905B2/WO2011069120A1, Method and System for Plaque Characterization); past president of SNMMI CVC and AI task force member for ASNC; shareholder at APQ Health. S.C. No relevant relationships. C.G. No relevant relationships. P.K. No relevant relationships. J.J.B. No relevant relationships. F.C. No relevant relationships. K.C. Member of the executive committee and board of directors for the Society of Cardiovascular CT. B.J.W.C. Grant from TD Bank and research support from Artyra; consulting fees from Artrya; stock options from Artrya. E.C. No relevant relationships. R.C.C. Consulting fees from GE HealthCare, Cover Health, and Cleerly; stock options from Cleerly. G.F. No relevant relationships. M.H. Research grant from Cleerly. Y.J.K. No relevant relationships. J.A.L. Consulting fees from Heartflow, Arineta, and Circle CVI; support for attending meetings and/or travel from Arineta and Heartflow; stock options from Heartflow; deputy editor or Radiology: Cardiothoracic Imaging. E.M. No relevant relationships. H.M. No relevant relationships. F.P. Consulting fees from Chiesi, Daichi-Sankyo, and Bayer; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Chiesi, Daichi-Sankyo, and Bayer; support for attending meetings and/or travel from Chiesi, Daichi-Sankyo. G.P. Grants from GE HealthCare, Heartflow, Novartis, Alexion; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from GE HealthCare, Heartflow, Novartis, Alexion, and Bracco. T.C.V. No relevant relationships. M.H.A.M. Grants from Siemens and GE HealthCare; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from GE HealthCare, Medtrace, Pfizer, and Jubilant. P.d.A.G. No relevant relationships. I.D. No relevant relationships. Y.L. No relevant relationships. J.H.L. No relevant relationships. S.E.L. No relevant relationships. L.B. No relevant relationships. S.J.A. Grants from National Institutes of Health; royalties or licenses from Elsevier; consulting fees from Shockwave Medical; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Weill Cornell Medicine-Qatar. M.J.B. No relevant relationships. H.S. No relevant relationships. P.H.S. No relevant relationships. R.V. Personal grant from CVPath Institute; institutional research support from RECOVER Initiative, National Institutes of Health RECOVER480, Biomedical, 4C Medical, 4Tech, Abbott Vascular, Ablative Solutions, Absorption Systems, Advanced NanoTherapies, Aerwave Medical, Alivas, Amgen, Asahi Medical, Aurios Medical, Avantec Vascular, BD, Biosensors, Biotronik, Biotyx Medical, Bolt Medical, Boston Scientific, Canon, Cardiac Implants, Cardiawave, CardioMech, Cardionomic, Celonova, Cerus EndoVascular, Chansu Vascular Technologies, Children’s National Institutional grant Hospital, Concept Medical, Cook Medical, Cooper Health, Cormaze, CRL, Croivalve, CSI, Dexcom, Edwards Lifesciences, Elucid Bioimaging, eLum Technologies, Emboline, Endotronix, Envision, Filterlex, Imperative Care, Innovalve, Innovative Cardiovascular Solutions, Intact Vascular, Interface Biologics, Intershunt Technologies, Invatin, Lahav, Limflow, L&J Bio, Lutonix, Lyra Therapeutics, Mayo Clinic, Maywell, MD Start, MedAlliance, Medanex, Medtronic, Mercator, Microport, Microvention, Neovasc, Nephronyx, Nova Vascular, Nyra Medical, Occultech, Olympus, Ohio Health, OrbusNeich, Ossiso, Phenox, Pi-Cardia, Polares Medical, Polyvascular, Profusa, ProKidney, Protembis, Pulse Biosciences, Qool Therapeutics, Recombinetics, Recor Medical, Regencor, Renata Medical, Restore Medical, Ripple Therapeutics, Rush University, Sanofi, Shockwave Medical, SMT, SoundPipe, Spartan Micro, Spectrawave, Surmodics, Terumo Corporation, The Jacobs Institute, Transmural Systems, Transverse Medical, TruLeaf, University of California San Francisco, University of Pittsburgh Medical Center, Vascudyne, Vesper, Vetex Medical, Whiteswell, WL Gore, and Xeltis; consulting fees from Celonova; Cook Medical; CSI; Edwards Lifesciences; Bard BD; Medtronic; OrbusNeich Medical; ReCor Medical; SinoMedical Sciences Technology; Surmodics; Terumo Corporation; WL Gore; Xeltis; honoraria from Abbott Vascular; Biosensors; Boston Scientific; Celonova; Cook Medical; Cordis; CSI; Lutonix Bard; Medtronic; OrbusNeich Medical; CeloNova; SINO Medical Technology; ReCor Medical; Terumo Corporation; W. L. Gore; Spectranetics; participation on a Data Safety Monitoring Board or Advisory Board at Medtronic. S.A. No relevant relationships. J.N. No relevant relationships. H.J.C. No relevant relationships. L.J.S. Honorarium for speaking from Heartflow. D.S.B. Consulting fees from GE HealthCare; software royalties from Cedars-Sinai Medical Center. F.L. No relevant relationships. D.D. Software royalties from Cedars-Sinai Medical Center; member of the Radiology: Cardiothoracic Imaging editorial board.

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