Pericoronary Adipose Tissue in Coronary Artery Disease: Integrating Molecular Mechanisms, Imaging Biomarkers, and Therapeutic Insights.

Pericoronary adipose tissue (PCAT), the epicardial adipose tissue directly surrounding the coronary arteries, has emerged as a critical marker of the inflammatory process underlying coronary artery disease (CAD). Under physiological conditions, this tissue supports vascular homeostasis through anti-inflammatory and vasoregulatory signaling. Under cardiometabolic stress, it undergoes phenotypic remodeling toward a pro-inflammatory state, promoting endothelial dysfunction, atherosclerotic progression, and plaque vulnerability through bidirectional signaling with the vessel wall. Advances in coronary computed tomography angiography allow non-invasive quantification of PCAT attenuation, which reflects subclinical coronary inflammation and is associated with high-risk plaque features and adverse cardiovascular outcomes. PCAT attenuation and the fat attenuation index appear responsive to lipid-lowering and anti-inflammatory therapies. Altogether, these insights underscore PCAT as a promising link between coronary inflammation and atherosclerotic risk, potentially reshaping future approaches to CAD detection, risk stratification, and intervention.