What if low CAC doesn’t always mean low coronary risk?

ESC 2026 · 10 Scientific Presentations · Oral & Poster · 9/10

Low CAC. Higher EAT. More non-calcified plaque.

A low coronary artery calcium (CAC) score can be reassuring - but it may not tell the whole story.

Some individuals with low or even zero CAC may still carry non-calcified coronary plaque. Could another biomarker already visible on the same scan help identify them?

In a new HeartLung.AI scientific poster at ESC Congress 2026, researchers investigated whether automated epicardial adipose tissue (EAT) analysis could identify increased non-calcified plaque burden, particularly in non-obese individuals with low CAC scores.

The study analyzed 1,259 participants from the Miami Heart Study with paired CAC and coronary CT angiography (CCTA).

Among 663 participants with low CAC (0 - 99):

• Those in the highest EAT quartile had a 3-fold higher median non-calcified plaque burden

• Median NCP volume was 34.5 vs. 11.9 mm³

• The difference was significant at P < 0.001

• The association was particularly notable among non-obese individuals

Looking beyond the calcium score

These findings suggest that automated EAT analysis from a routine CAC scan may provide another layer of cardiometabolic information - potentially helping identify individuals with a more adverse coronary phenotype despite low CAC and normal-to-overweight BMI.

The opportunity?

Further studies are needed to determine whether incorporating EAT volume into CAC and CCTA reporting can improve patient outcomes

📍 To be presented at ESC Congress 2026 · Munich

‌By Hamed Zarei, M.D.