Impact of Epicardial Adipose Tissue on Coronary Plaque Composition and Major Adverse Cardiac Event Rate. A New Systematic Approach for Risk Stratification in Patients with Suspected Coronary Artery Disease: Results from the PROMISE trial

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Acute coronary syndrome, on behalf of coronary artery disease (CAD), is one of the most common causes of death in industrialized nations. Until now, in patients with suspected CAD, invasive coronary angiography and functional testing including exercise electrocardiogram, stress echocardiography and stress myocardial perfusion imaging are the gold standard methods for exclusion of CAD in symptomatic patients even with low or intermediate pretest probability. These modalities deliver only information about the lumen of coronary arteries and only limited information about the coronary wall and surrounding anatomical structures. In the last decade, computed tomography (CT) has developed into a parallel non-invasive modality, which can be used for exclusion of CAD in symptomatic patients. According to large randomized multicenter trials, CT demonstrates sensitivity and specificity comparable to the aforementioned functional testing methods. In comparison to these modalities, CT has a clear advantage to deliver additional evidence about surrounding structures such as epicardial adipose tissue (EAT). It is assumed that EAT might have exocrine and endocrine effects and may initiate inflammation-processes in the directly neighboring coronary artery wall resulting in development of CAD. It is still unclear if the volume and density of EAT influence the atherogenesis, lead to genesis of vulnerable coronary plaques and increase rate of major adverse cardiac events (MACE). Even the coronary plaque composition might depend on the volume and density of the EAT. Due to improved spatial and temporal resolution, now CT data can be used for accurate composition analysis of coronary plaques. Besides the routine visual identification of high risk coronary plaque features, CT allows a quantitative analysis of the plaque compounds such as fibrotic, fatty and calcified tissue. We assume that patients with increased volume and density of EAT might present high-risk plaque features more frequently.The primary aim of this study is to investigate the effect of EAT volume and attenuation on the coronary plaque composition and the rate of MACE in median 25 months follow-up in a large cohort. The investigation is a part of the randomized PROspective Multicenter Imaging Study for Evaluation of chest pain trial (PROMISE Trial), which enrolled more than 10,000 patients with suspected CAD. The CT data of all 4589 patients, who were randomized into the anatomical testing arm and received cardiac CT examination, will be included in our study. Besides the improvement of the CT based risk stratification in patients with suspected CAD, the EAT analysis and the coronary plaque composition analysis should build a base for future multicenter, big data studies in Germany and Europe.