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1. Individuals with elevated fat attenuation index scores without obstructive coronary artery disease had significantly increased rates of major adverse cardiac events.

2. Fat attenuation index score and AI-Risk classification showed an additive risk for cardiac mortality based on the number of involved coronary vessels.

Evidence Rating Level: 2 (Good)

Study Rundown: Coronary computed tomography angiography (CCTA) is commonly used to assess chest pain, resulting in many patients without obstructive coronary artery disease (CAD) whose prognosis remains unclear. Measuring coronary inflammation with the fat attenuation index (FAI) score from CCTA could help predict cardiovascular risk for patients without obstructive CAD. This randomized controlled trial assessed risk profiles and event rates in UK CCTA patients, testing if coronary inflammation drives major adverse cardiac events (MACE) and validating an artificial intelligence (AI)-Risk algorithm. The primary outcome of this study was rate of MACEs while a key secondary outcome was the accuracy of the AI-Risk prediction algorithm. According to study results, patients without obstructive CAD still had a significant risk for cardiac events. Although this study was well done, it was limited by data from only eight hospitals, which may affect the generalizability of findings.

Click to read the study in The Lancet

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In-depth [prospective cohort]: 48 466 patients were assessed for eligibility across 8 UK hospitals. Included were patients undergoing CCTA with or without CAD. Altogether, 43 484 patients (40 091 in cohort A – understanding the risk profile of people undergoing CCTA – and 3 393 in cohort B – validating FAI score, AI-Risk, and the AI-Risk classification) were included in the final analysis. In cohort A, patients without obstructive CAD (32 533 of 40 091, 81.1%) accounted for most of the total MACE (2857 of 4307, 66.3%) and cardiac deaths (1118 of 1754, 63.7%). Increased FAI score was associated with increased cardiac mortality (hazard ratio [HR] 29.8, p<0.001) or MACE (HR 12.6, p<0.001), as was AI-Risk classification score (HR 6.75, p<0.001 for cardiac mortality and HR 4.68, p<0.001 for MACE). Findings from this study suggest that the FAI Score and AI-Risk algorithm provide valuable prognostic information beyond traditional risk factors and CCTA interpretation, particularly for patients without obstructive CAD.

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