Imaging Inflammation: Epicardial Fat Density as an Imaging Marker of Cardiovascular Risk

Epicardial adipose tissue (EAT), located between the myocardium and visceral pericardium, plays an active role in coronary artery disease (CAD) through local inflammatory and metabolic signalling. This review explores the prognostic significance of EAT volume and attenuation (density) as measured by cardiac computed tomography. While increased EAT volume has been linked to higher plaque burden, coronary artery calcium (CAC) and incident CAD - even in low-CAC populations - attenuation offers additional value by reflecting tissue inflammation and remodelling. Lower EAT density has been independently associated with major adverse cardiac events and vulnerable plaque features, outperforming both volume and CAC score in several cohorts. We also highlight the clinical relevance of these metrics in early disease detection and risk stratification, and their potential for therapeutic modulation. As evidence builds, EAT volume and density may soon serve as practical, imaging-based biomarkers to guide personalized prevention in CAD.