The odyssey of inflammation: pericoronary adipose tissue attenuation as a dynamic marker of coronary-specific inflammation

PURPOSE OF REVIEW: Inflammation drives atherosclerotic cardiovascular disease, yet targeted therapies remain scarce, and identifying which patients benefit has been a central challenge. High-sensitivity C-reactive protein (hsCRP), a systemic marker, has been used to select patients for anti-inflammatory trials but has proven neither sufficient nor necessary: the Ziltivekimab Cardiovascular Outcomes Trial (ZEUS), a recent phase 3 trial of an anti-interleukin-6 agent, lowered hsCRP yet did not reduce events, whereas colchicine reduced cardiovascular events in COLCOT and LoDoCo2 without hsCRP-based selection. Pericoronary adipose tissue (PCAT) attenuation offers a novel, coronary-specific measure of inflammation; whether it translates into better patient selection for anti-inflammatory therapy remains to be shown. RECENT FINDINGS: Measured from routine coronary CT angiography (CCTA), PCAT attenuation reflects inflammation within the coronary wall and, in large observational cohorts, predicts cardiac events independent of plaque burden, traditional risk factors, and hsCRP. Early interventional studies suggest it may also serve as a dynamic endpoint, though this evidence remains preliminary. SUMMARY: PCAT attenuation could enable precision anti-inflammatory prevention - selecting patients by coronary inflammatory risk rather than nonspecific systemic markers, and serving as a pharmacodynamic endpoint in mechanistic trials. Key gaps remain: randomized evidence that PCAT-guided care improves outcomes, treatment thresholds, longitudinal stability, reproducibility, and contrast-free validation.