EAT is an emerging imaging biomarker that reflects local inflammation and cardiometabolic risk. According to the 2025 European Society of Cardiology (ESC) guidelines, tissue-based imaging measures can enhance cardiovascular risk stratification in individuals without overt coronary artery disease.

This prospective study included 1,024 participants (mean age 58.3 years; 76% male) from a Southern European cohort free of clinical coronary artery disease. Participants were followed for an average of 7.3 years. Non-contrast CT quantified both CACS and EAT volume, defining high EAT as >7.37 cm³. Participants with higher EAT showed significantly greater CACS categories (p<0.0001).

After multivariable adjustment for age, diabetes, blood pressure, renal function, inflammatory markers, and other risk factors, high EAT independently predicted MACE (hazard ratio 1.95; 95% CI 1.02–3.75; p=0.044). Kaplan–Meier analysis demonstrated early divergence of survival curves, with poorer outcomes in participants with elevated EAT volume.

These findings indicate that EAT volume not only parallels coronary calcification but also serves as an independent prognostic marker for cardiovascular events. Incorporating EAT assessment into routine imaging may enhance early risk detection and guide preventive strategies in asymptomatic individuals at elevated cardiovascular risk.