Coronary Plaque Vulnerability and Pericoronary Adipose Tissue Inflammation: Emerging Insights from Advanced CT Imaging

Cardiovascular emergencies most frequently arise from the sudden destabilization of atherosclerotic plaques. Conventional diagnostic strategies predominantly focus on luminal stenosis, despite the fact that most acute coronary events originate from non-obstructive lesions with high inflammatory activity. Recent advances in cardiac computed tomography (CCT) enable visualization of plaque morphology and surrounding perivascular fat, offering a unique window into coronary inflammation. The fat attenuation index (FAI), derived from pericoronary adipose tissue (PCAT) radiodensity, has emerged as a dynamic imaging biomarker capable of detecting vascular inflammation before clinical events occur. This review summarizes current evidence on the role of PCAT inflammation in plaque vulnerability, its implications for acute cardiovascular presentations, and recent technological innovations—including AI-enhanced analysis and photon-counting CT—that advance risk prediction. Inflammation-based imaging derived from CCT, including PCAT-FAI, has emerged as a promising research tool that may enhance risk stratification in patients presenting with chest pain. These developments signify a shift from purely anatomical assessment toward biological characterization of CAD, potentially transforming prevention and acute care.