Associations of dual-energy computed tomography-derived visceral adipose tissue quality and high-risk coronary plaque in patients with metabolic syndrome

Abstract Objectives To investigate the relationship between metabolic syndrome (MetS), visceral adipose tissue (VAT), and high-risk coronary plaques. Materials and methods This study analyzed 392 hospitalized patients who underwent dual-energy computed tomography (DECT) for cardiac and abdominal imaging between May 2021 and February 2024. VAT multimodal attenuation parameters (CT 40keV , CT 70keV , λ HU , and Eff-Z) were obtained at the third lumbar vertebral level. Multivariable logistic regression was performed to assess independent associations between VAT parameters and coronary high-risk plaques. Prediction models were established to predict the presence of high-risk plaques, and their predictive efficacy was evaluated by ROC analysis. Results MetS patients ( n = 182) demonstrated a higher prevalence of high-risk plaques vs non-MetS ( n = 210) (45.6% vs 25.7%, p < 0.001). DECT-derived VAT parameters were significantly lower in the MetS group than in the non-MetS group ( p < 0.001). Moreover, CT 40keV , CT 70keV , λ HU , and Eff-Z were correlated with the number of MetS components and each component, after adjusting for age and sex ( p < 0.05). CT 40keV was the strongest independent predictor for high-risk plaques in patients with MetS (standard partial regression coefficient Beta = −0.761, p < 0.001). In the predictive models for high-risk plaques, all models incorporating CT 40keV demonstrated improved discriminative capability compared to traditional risk assessment approaches (standalone CACS or FRS), with AUC improvements ranging from Δ0.0729 to Δ0.205 ( p < 0.05). Conclusions VAT was independently associated with the presence of high-risk coronary plaques in the MetS group, and DECT-derived CT 40keV may be a potential biomarker for high-risk plaques. The prediction model incorporating CT 40keV provides incremental value for predicting high-risk plaques. Critical relevance statement This study demonstrates that visceral fat CT 40keV attenuation metrics derived from DECT are strongly associated with high-risk coronary plaques in MetS patients, offering a novel imaging biomarker for early cardiovascular risk stratification. Key Points MetS patients exhibited a significantly higher prevalence of high-risk plaques compared to non-MetS controls. Dual-energy CT-derived CT 40keV was the independent predictor for high-risk plaques in patients with MetS. The prediction model incorporating CT 40keV provides incremental value for predicting high-risk plaques. Graphical Abstract