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Introduction: Coronary inflammation induces phenotypic changes in the perivascular adipose tissue (PVAT), which can be detected non-invasively through the recently described Fat Attenuation Index (FAIPVAT) using computed tomography (CT). Hypothesis: FAIPVATcan detect unstable coronary plaques as well as stable vessels at risk of plaque progression. Methods: In Arm 1, 26 prospectively enrolled patients underwent coronary CT angiography (CCTA) within 96 hours of primary percutaneous coronary intervention (pPCI) for acute coronary syndrome (ACS). The control group consisted of 25 individuals with stable coronary artery disease (CAD). Six of the ACS patients underwent a further follow-up CCTA at six months. In Arm 2, five patients were scanned before and within seven days of PCI. In Arm 3, 86 individuals (61±9 years, 59% males) underwent paired CCTA scans within 4.1±0.5 years. The prognostic value of baseline FAIPVAT for vessel-specific calcium progression (Delta[calcified plaque burden]>0) was assessed in adjusted logistic regression models, clustered at the patient level. In all cases, FAIPVAT was derived from analysis of the PVAT attenuation histograms as recently described. Results: In Arm 1, FAIPVATwas significantly increased around the acute culprit lesion compared to non-culprit lesions from ACS patients or patients with stable CAD (A). Follow-up of ACS patients at 6 months showed a significant decrease (reversal) of peri-lesion FAIPVAT, suggesting that FAIPVAT allows tracking of lesion-specific fluctuations in coronary inflammation (B). In Arm 2, acute stent implantation did not affect peri-lesion FAIPVAT,suggesting that the observations in Arm 1 relate to plaque rupture rather than stenting (C). In Arm 3, baseline FAIPVATaround stable segments was positively associated with the risk of vascular calcification progression, independent of age, sex, risk factors, past PCI, lumen attenuation, and CT tube voltage (D). Conclusions: FAIPVATis a CCTA-derived, dynamic coronary biomarker linked to coronary disease progression and plaque stability. These observations highlight the value of FAIPVATphenotyping in the comprehensive assessment of the coronary vasculature in modern CCTA. [ABSTRACT FROM AUTHOR]