Liver fat on spectral CT links to coronary plaque danger signs in chest pain patients

People who undergo a single CT scan that captures both the heart and the upper abdomen may be giving their doctors two sets of warnings at once. A retrospective study published in BMC Medical Imaging reports that the severity of fatty liver disease, measured on spectral CT, was associated with the presence of high-risk coronary plaque features on coronary CT angiography, and that a spectral CT measure of hepatic fat was linked to the volume of fat surrounding the coronary arteries.

The study, published in BMC Medical Imaging on 27 October 2026 with Xinyi Shi and Qi Li listed as first authors among a larger team, focused on metabolic dysfunction-associated steatotic liver disease, or MASLD.

The study included consecutive patients who underwent coronary CT angiography for chest pain or suspected coronary artery disease in 2025, with a concurrent contrast-enhanced upper-abdominal spectral CT scan. Of 733 consecutive patients screened, 568 were finally included. Based on the liver-to-spleen CT attenuation ratio obtained from unenhanced CT images, the participants were stratified into three groups: 271 without MASLD, 194 with mild MASLD, and 103 with moderate or severe MASLD.

The technical core of the paper lies in the spectral CT multi-material decomposition algorithm, which the team used to measure the hepatic fat volume fraction, abbreviated FVF, along with liver volume. The authors report that MASLD severity was positively associated with FVF, liver volume, and multiple metabolic and inflammatory markers, and inversely associated with high-density lipoprotein cholesterol and the alanine aminotransferase to aspartate aminotransferase ratio, with all of these associations reaching p < 0.001.

The coronary side of the analysis centred on the pericoronary adipose tissue, or PCAT, the fat that surrounds the coronary arteries. The researchers measured the PCAT fat attenuation index, a marker of fat inflammation, and PCAT volume across three major coronary arteries: the left anterior descending artery, the left circumflex artery, and the right coronary artery. The fat attenuation index for all three arteries differed significantly among the three MASLD severity groups, with all p values below 0.05.

When the full cohort of 568 patients was analysed in the study’s Model 2, FVF was associated with total PCAT volume, with a coefficient of 0.033 cubic centimetres and p = 0.004, but it was not associated with mean PCAT-FAI, which showed a coefficient of −0.007 Hounsfield units and p = 0.926. In other words, greater hepatic fat tracked with more fat around the coronaries, but not with the attenuation-based inflammatory signature of that fat in this cohort.

The link to high-risk plaque was more direct. The prevalence of high-risk coronary plaque, assessed on coronary CT angiography, was 20.7 percent in the non-MASLD group, 33.5 percent in the mild MASLD group, and 37.9 percent in the moderate or severe MASLD group, a difference with p < 0.001. Compared with patients without MASLD, the odds ratios for high-risk plaque were 1.935 for mild and 2.340 for moderate or severe MASLD in Model 1, 1.834 and 2.827 in Model 2, and 1.986 and 2.750 in Model 3, with multivariable logistic regression used to assess the relationship and prespecified subgroup analyses performed.

Those subgroup analyses showed that the association between MASLD severity and high-risk plaque was not uniform across the cohort. Interaction p values were 0.004 for age, 0.027 for hypertension, and 0.050 for diabetes, suggesting that factors such as a patient’s age may modify how strongly liver steatosis and coronary plaque features travel together. The authors note that these are associations observed in a single retrospective cohort of patients imaged for suspected coronary disease, so the findings describe relationships rather than proving that fatty liver causes dangerous plaques.

The study’s conclusion frames the practical implication: spectral CT-derived FVF was associated with MASLD severity, FVF was associated with total PCAT volume but not with mean PCAT-FAI, and MASLD severity was associated with high-risk plaque. The authors write that an integrated one-stop heart-liver CT assessment is feasible and may facilitate the concurrent imaging assessment of hepatic fat and coronary features, meaning that patients already undergoing coronary CT angiography with spectral imaging could, in principle, have their liver fat graded from the same examination.

Subject of Research: Spectral CT assessment of hepatic fat and its association with pericoronary adipose tissue and high-risk coronary plaque

Article Title: Association of spectral CT-derived hepatic fat fraction with pericoronary adipose tissue attenuation and high-risk coronary plaque features

Article References: Shi, X., Li, Q., Wang, Z., Cui, T., Ding, H., Liu, L., Li, X., Li, J., Li, J., & Liu, J. (2026). Association of spectral CT-derived hepatic fat fraction with pericoronary adipose tissue attenuation and high-risk coronary plaque features. BMC Medical Imaging. https://doi.org/10.1186/s12880-026-02989-7

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02989-7

Keywords: spectral CT, MASLD, hepatic fat volume fraction, pericoronary adipose tissue, coronary CT angiography, high-risk plaque, liver-to-spleen ratio, fat attenuation index, cardiometabolic imaging, retrospective study, Association, spectral