Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification?

Epicardial fat thickness in rheumatoid arthritis: Insights from echocardiographic analysis and autoimmune correlations

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease that primarily affects the joints. RA is associated with high cardiovascular mortality and morbidity. One of the new markers of cardiometabolic risk is epicardial fat thickness, the study of EFT in patients with RA and its association with echocardiographic parameters may provide valuable insight into the potential cardiac involvement and overall cardiovascular risk in these patients.

METHOD

The present study is a cross-sectional study with a comparison group conducted in 2024. The study population included 66 RA patients and 66 healthy participants. Echocardiographic parameters, laboratory data including lipid profile and inflammatory markers, were obtained from the medical record.

RESULTS

Comparison of echocardiographic parameters between RA and healthy participants showed that E parameter and EFT were statistically significant in RA patients. (EFT was 5.22 ± 2.6 in RA patients which in comparison with healthy participant (5.22 ± 2.06) was statistically significant (p-value: <.001)). Also, EFT was correlated with RF, Anti-CCP, ESR, and systolic blood pressure.

CONCLUSION

To the best of our knowledge, ours is the first EFT study on RA patients in Iran, which shows a higher EFT in RA patients. High EFT is correlated with more cardiovascular events and is an early sign and independent predictor of atherosclerosis in RA patients, which greatly underlines the importance of cardiovascular assessment in RA patients.

Epicardial fat and insulin resistance in healthy older adults: a cross-sectional analysis

Insulin resistance (IR) and cardiovascular diseases (CVD) are relevant concerns in the elderly population; as the world's population ages, IR and CVD are two universal public health problems. While a link between IR a CVD has been established, the mediating mechanisms are uncertain and rigorous investigations are needed to fully elucidate them. The study aimed at assessing the relationship between epicardial fat (EF), an indicator of cardiovascular risk, and IR in Italian free-living elderly (n = 89). Baseline data from a previous cohort was used. Anthropometric measurements, EF, and IR-related variables, including the HOMA-IR index and other biochemical parameters were obtained. The correlation between EF and IR was explored. Further analysis was conducted to identify significant differences regarding IR variables among EF quartiles. EF correlated positively with glucose levels in females, males and the total population. The pairwise comparison among EF quartiles showed significant differences in glucose levels, HOMA-IR index, triglycerides, and total cholesterol levels. To our knowledge, this is the only study assessing the relationship between EF and IR in healthy elderly, while most of the studies have investigated EF and IR in diseased populations. Further research with a longitudinal approach should be conducted to design concrete conclusions about this relationship.

The Role of Epicardial Adipose Tissue in Acute Coronary Syndromes, Post-Infarct Remodeling and Cardiac Regeneration

Epicardial adipose tissue (EAT) is a fat deposit surrounding the heart and located under the visceral layer of the pericardium. Due to its unique features, the contribution of EAT to the pathogenesis of cardiovascular and metabolic disorders is extensively studied. Especially, EAT can be associated with the onset and development of coronary artery disease, myocardial infarction and post-infarct heart failure which all are significant problems for public health. In this article, we focus on the mechanisms of how EAT impacts acute coronary syndromes. Particular emphasis was placed on the role of inflammation and adipokines secreted by EAT. Moreover, we present how EAT affects the remodeling of the heart following myocardial infarction. We further review the role of EAT as a source of stem cells for cardiac regeneration. In addition, we describe the imaging assessment of EAT, its prognostic value, and its correlation with the clinical characteristics of patients.

Epicardial Adipose Tissue: A Precise Biomarker for Cardiovascular Risk, Metabolic Diseases, and Target for Therapeutic Interventions

Epicardial adipose tissue (EAT) is located between the heart muscle and visceral pericardium, where it has direct contact with coronary blood vessels. Elevated thickness of this tissue can induce local inflammation affecting the myocardium and the underlying coronary arteries, contributing to various cardiovascular diseases such as coronary artery disease, atrial fibrillation, or heart failure with preserved ejection fraction. Recent studies have identified EAT thickness as a simple and reliable biomarker for certain cardiovascular outcomes. Examples include the presence of atherosclerosis, incident cardiovascular disease (CVD) in individuals with type 2 diabetes mellitus (T2DM), and the prevalence of atrial fibrillation. Furthermore, EAT measurements can help to identify patients with a higher risk of developing metabolic syndrome. Since the EAT thickness can be easily measured using echocardiography, such examinations could serve as a useful and cost-effective preventive tool for assessing cardiovascular health. This review also summarizes therapeutical interventions aimed at reducing EAT. Reducing EAT thickness has been shown to be possible through pharmacological, surgical, or lifestyle-change interventions. Pharmaceutical therapies, including thiazolidinediones, glucagon-like peptide 1-receptor agonists, sodium-glucose cotransporter 2 inhibitors, dipeptidyl peptidase-4 inhibitors, and statins, have been shown to influence EAT thickness. Additionally, EAT thickness can also be managed more invasively through bariatric surgery, or noninvasively through lifestyle changes to diet and exercise routines.

Heart ventricles of the dromedary camel (Camelus dromedarius): new insights from sectional anatomy, 3D computed tomography, and morphometry

BACKGROUND

Dromedary camel heart morphology is a crucial research topic with clinical applications. The study aims to understand the dromedary camel anatomy, morphology, and architecture of the ventricular mass.

RESULTS

Sagittal and transverse gross sections were compared to sagittal, transverse, and 3D render volume reconstruction computed tomography (CT) scans. The subepicardial fat, which covered the heart base, the coronary groove (sulcus coronarius), the left longitudinal interventricular groove (sulcus interventricularis paraconalis), and the right longitudinal interventricular groove (sulcus interventricularis subsinuosus), had a relatively low density with a homogeneous appearance in the 3D render volume CT. The pericardium in the color cardiac window was identified better than the black and white window (ghost). Transverse and sagittal CT scans demonstrated the internal structures of the heart, including the right atrioventricular orifice (ostium atrioventriculare dextrum), right atrioventricular orifice (ostium atrioventriculare sinistrum), and aortic orifice (ostium aortae), chordae tendineae, the cusps of the valves (cuspis valvae), and the papillary muscles (musculi papillares). The papillary muscle (musculi papillares) was presented with a more moderate density than the rest of the heart, and the cusps of the valves (cuspis valvae) had a lower density. The ventricular wall (margo ventricularis) exhibited different densities: the outer part was hyperdense, while the inner part was hypodense. The thicknesses of the ventricular mural wall and the interventricular septum (septum atrioventriculare) were highest at the midpoint of the ventricular mass, and the lowest value was present toward the apical part. The coronary groove (sulcus coronarius) circumference measured 51.14 ± 0.72 cm, and the fat in the coronary groove (sulcus coronarius) (56 ± 6.55 cm2) represented 28.7% of the total cross-sectional area.

CONCLUSION

The current study provided more information about ventricular mass measurements by gross and CT analysis on the heart, which provides a valuable guide for future cardiac CT investigations in camels in vivo.

Echocardiographic Association of Epicardial Adipose Tissue with Ascending Aorta Elasticity in Patients with Type 2 Diabetes Mellitus

Epicardial adipose tissue (EAT) is an emerging cardiovascular risk factor located between the myocardium and visceral pericardium. In order to investigate the association between EAT and ascending aorta elasticity in patients with type 2 diabetes mellitus (T2DM), we prospectively enrolled a total of 135 T2DM patients and 63 age- and gender-matched non-T2DM controls in this study. They all underwent transthoracic echocardiography to measure EAT thickness and ascending aorta inner diameters which were used to calculate ascending aorta elastic parameters: compliance (C), distensibility (D), strain (S), stiffness index (SI), and Peterson's elastic modulus (EM). We found that the values of C, D, and S were significantly lower, while SI, EM, and EAT thickness were significantly higher in T2DM patients compared with non-T2DM controls. Compared with T2DM patients with EAT < 5 mm group, C, D, and S were significantly reduced, SI and EM were significantly increased in T2DM patients with EAT ≥ 5 mm group (all P < .05). Bivariate correlation and multivariate linear regression analysis revealed that EAT was independently associated with ascending aorta elasticity. Our findings suggest that thickened EAT in patients with T2DM is associated with ascending aorta elasticity, independent of blood glucose.

Cellular cross talk between epicardial fat and cardiovascular risk

A variety of fat compartments have several local and systemic effect and play a crucial role in the maintenance of health and development of disease. For the past few years, special attention has been paid to epicardial fat. It is the visceral fat compartment of the heart and has several local and systemic effects. It can perform a role in the development of cardiometabolic risk. The epicardial adipose tissue (EAT) is a unique and multifunctional fat compartment of the heart. It is located between the myocardium and the visceral pericardium. During normal physiological conditions, the EAT has metabolic, thermogenic, and mechanical (cardioprotective) characteristics. The EAT can produce several adipocytokines and chemokines depending on microenvironments. It can influence through paracrine and vasocrine mechanism and participate in the development and progression of cardiovascular (CVS) diseases. In addition, metabolic disease leads to changes in both thickness and volume of the EAT, and it can modify the structure and the function of heart. It has been associated with various CVS diseases such as, cardiomyopathy, atrial fibrillation, and coronary artery disease. Therefore, EAT is a potential therapeutic target for CVS risk.

Epicardial adipose tissue and right ventricular function in type 2 diabetes mellitus using two-dimensional speckle tracking echocardiography

BACKGROUND

Epicardial adipose tissue is an emerging cardiovascular risk factor. The aim of this study was to evaluate right ventricular function and investigate its association with EAT in T2DM patients.

METHODS

154 T2DM patients were divided into two groups according to EAT thickness: T2DM with EAT <5 mm and T2DM with EAT ≥5 mm. Seventy non-T2DM patients were enrolled as control group. RV function was evaluated using both conventional echocardiography as well as two-dimensional speckle tracking echocardiography. EAT thickness was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of pericardium at end-systole.

RESULTS

Compared to control group, EAT thickness was significantly higher and RV systolic function and early diastolic function are all impaired in all T2DM patients. In T2DM with EAT ≥5 mm group, RV systolic function and early diastolic function suffered more severe impairment when compared with T2DM with EAT <5 mm group. Multivariate linear regression analysis revealed that EAT was associated with RV systolic and early diastolic dysfunction independent of traditional cardiovascular risk factors.

CONCLUSIONS

Our research suggest that in T2DM patients RV systolic function and early diastolic function are all impaired which are associated with the thickened EAT.

Increased epicardial adipose tissue thickness correlates with endothelial dysfunction in spondyloarthritis

INTRODUCTION

We aimed to investigate the relationship between epicardial adipose tissue (EAT) thickness, flow-mediated dilation (FMD), and carotid intima-media thickness (cIMT) in spondyloarthritis (SpA) patients compared to healthy controls.

METHODS

We performed a cross-sectional study including SpA patients aged ≤ 50 years without traditional cardiovascular risk factors and healthy controls matched for age and gender. Baseline characteristics, laboratory data, and SpA-related parameters were recorded. All participants underwent ultrasound examination with measurement of EAT thickness, FMD, and cIMT by both an experienced cardiologist and radiologist blinded to clinical data. The relationships between the ultrasound measurements were analyzed using Spearman's correlation coefficient and Person correlation.

RESULTS

The study included 94 subjects (47 SpA and 47 healthy controls). The sex-ratio was 2.35; the median age of patients was 36 years (IQR: 28-46), and the median disease duration was 11 years (IQR: 5-16). Compared to the control group, SpA patients had significantly higher values of EAT thickness (p = 0.001) and cIMT (p < 0.0001). FMD values were significantly lower in SpA patients compared to controls (p = 0.008). The univariate analysis detected a significant negative association between EAT thickness and FMD (p = 0.026; r =  - 0.325), and between left cIMT and FMD (p = 0.027; r =  - 0.322). No association was found between EAT thickness and cIMT.

CONCLUSION

EAT thickness, FMD, and cIMT were significantly impaired in SpA patients compared with healthy controls supporting evidence of accelerated atherosclerosis in SpA. EAT thickness was correlated to endothelial dysfunction suggesting the role of EAT in predicting the early reversible stages of atherosclerosis. Key Points • Spondyloarthritis is associated with impaired subclinical atherosclerosis markers accurately increased epicardial fat and carotid intima-media thickness and endothelial dysfunction. • Increased epicardial fat thickness is correlated with impaired endothelial function in spondyloarthritis patients.

Epicardial Adipose Tissue and Cardiac Arrhythmias: Focus on Atrial Fibrillation

Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia and its prevalence increases with age. AF is strongly associated with an increased risk of stroke, heart failure and cardiovascular mortality. Among the risk factors associated with AF onset and severity, obesity and inflammation play a prominent role. Numerous recent evidence suggested a role of epicardial adipose tissue (EAT), the visceral fat depot of the heart, in the development of AF. Several potential arrhythmogenic mechanisms have been attributed to EAT, including myocardial inflammation, fibrosis, oxidative stress, and fat infiltration. EAT is a local source of inflammatory mediators which potentially contribute to atrial collagen deposition and fibrosis, the anatomical substrate for AF. Moreover, the close proximity between EAT and myocardium allows the EAT to penetrate and generate atrial myocardium fat infiltrates that can alter atrial electrophysiological properties. These observations support the hypothesis of a strong implication of EAT in structural and electrical atrial remodeling, which underlies AF onset and burden. The measure of EAT, through different imaging methods, such as echocardiography, computed tomography and cardiac magnetic resonance, has been proposed as a useful prognostic tool to predict the presence, severity and recurrence of AF. Furthermore, EAT is increasingly emerging as a promising potential therapeutic target. This review aims to summarize the recent evidence exploring the potential role of EAT in the pathogenesis of AF, the main mechanisms by which EAT can promote structural and electrical atrial remodeling and the potential therapeutic strategies targeting the cardiac visceral fat.

Association between epicardial adipose tissue and left ventricular function in type 2 diabetes mellitus: Assessment using two-dimensional speckle tracking echocardiography

BACKGROUND AND AIMS

Epicardial adipose tissue (EAT) is the visceral fat between the myocardium and the visceral pericardium. Dysfunctional EAT can cause cardiovascular diseases. The aim of this study was to investigate the association between EAT and left ventricular function in type 2 diabetes mellitus (T2DM) patients by two-dimensional speckle tracking echocardiography (2D-STE).

METHODS

We prospectively enrolled 116 T2DM patients who were divided into two groups according to their left ventricular global longitudinal strain (GLS): 53 with GLS <18% and 63 with GLS ≥18%. The thickness of EAT was measured as the echo-free space between the free wall of the right ventricle and the visceral layer of pericardium at end-systole. LV systolic function was evaluated by GLS measured by 2D-STE. LV diastolic function was defined as the ratio of the early diastolic transmitral flow velocity (E) to average mitral annular velocity (e¯).

RESULTS

Compared with patients with GLS ≥18% group, the age, body mass index (BMI), waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure (DBP), low-density lipoprotein cholesterol (LDL-C), glycosylated hemoglobinA1c (HbA1c), E/e¯, and thickness of EAT were higher in patients with GLS <18% group (all P < 0.05). Multivariate linear regression analysis revealed that the thickness of EAT was independently associated with left ventricular GLS and E/e¯.

CONCLUSIONS

Thickened EAT is associated with impaired left ventricular function in T2DM patients. To investigate the association between EAT and left ventricular function can help us gain a deeper understanding of the pathogenesis of impaired cardiac function in T2DM patients.

Inflammation and Cardiovascular Diseases in the Elderly: The Role of Epicardial Adipose Tissue

Human aging is a complex phenomenon characterized by a wide spectrum of biological changes which impact on behavioral and social aspects. Age-related changes are accompanied by a decline in biological function and increased vulnerability leading to frailty, thereby advanced age is identified among the major risk factors of the main chronic human diseases. Aging is characterized by a state of chronic low-grade inflammation, also referred as inflammaging. It recognizes a multifactorial pathogenesis with a prominent role of the innate immune system activation, resulting in tissue degeneration and contributing to adverse outcomes. It is widely recognized that inflammation plays a central role in the development and progression of numerous chronic and cardiovascular diseases. In particular, low-grade inflammation, through an increased risk of atherosclerosis and insulin resistance, promote cardiovascular diseases in the elderly. Low-grade inflammation is also promoted by visceral adiposity, whose accumulation is paralleled by an increased inflammatory status. Aging is associated to increase in epicardial adipose tissue (EAT), the visceral fat depot of the heart. Structural and functional changes in EAT have been shown to be associated with several heart diseases, including coronary artery disease, aortic stenosis, atrial fibrillation, and heart failure. EAT increase is associated with a greater production and secretion of pro-inflammatory mediators and neuro-hormones, so that thickened EAT can pathologically influence, in a paracrine and vasocrine manner, the structure and function of the heart and is associated to a worse cardiovascular outcome. In this review, we will discuss the evidence underlying the interplay between inflammaging, EAT accumulation and cardiovascular diseases. We will examine and discuss the importance of EAT quantification, its characteristics and changes with age and its clinical implication.

Epicardial Fat Thickness: A Cardiometabolic Risk Marker in Rheumatoid Arthritis

Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder of unknown etiology which mainly involves synovial joints. However, the corresponding systemic inflammation may result in disorders of multiple other organ systems. Several organs and organ systems are potentially involved in RA, particularly in severe diseases. The organs most involved are the lung, heart, eyes, and nervous system. Extra-articular manifestations of RA may develop even before the onset of arthritis. Emerging epidemiological evidence shows that cardiovascular disease (CVD) accounts for near about 50% of RA-associated death. Epicardial fat thickness (EFT) has recently emerged as a new marker of cardiometabolic risk. Although Epicardial fat (EF) is needed for heart muscle function, given its intrinsic inflammatory status, EFT displays the potential to serve as a therapeutic target in patients with RA.

Objectives: To evaluate EFT using echocardiography in RA patients compared to age and sex-matched control and to find the factors associated with EFT in RA patients.

Materials and methods: This current study was conducted in the Department of Medicine, Postgraduate Institute of Medical Education & Research. The study was conducted from November 2016 to March 2018. Patients with BMI ≥ 30 kg/m², diabetes mellitus, primary hyperlipidemia, and uncontrolled hypertension were particularly excluded. Thirty patients of age and sex-matched controls were also taken for the study. All the patients and controls selected for the study were subjected to detailed history taking and clinical examination. They were subjected to lab investigations and echocardiography. The 30 RA patients included in the study were diagnosed according to the 2010 ACR-EULAR criteria. Disease activity was measured by the disease activity score (DAS28) index.

Results: Group 1 included 30 patients with RA and group 2 included 30 age and sex-matched controls. Pearson correlation analysis was done between EFT and other variables. Only HDL, erythrocyte sedimentation rate (ESR), high-sensitivity C-reactive protein (hS-CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), DAS28, and disease duration were found to have a significant correlation with EFT.

Conclusion: In patients with RA, EFT, left ventricular mass, and diastolic dysfunction are increased in RA patients compared to healthy controls. Out of the conventional CVD risk factors, only HDL was associated with increased EFT in RA patients. In RA patients, DAS28, disease duration, RF, anti-CCP, and markers of inflammation (ESR, hs-CRP) were also associated with increased EFT.

Can EAT be an INOCA goalkeeper

Ischemia with non-obstructive coronary artery (INOCA) is a blind spot of coronary artery disease (CAD). Such patients are often reassured but offered no specific care, that lead to a heightened risk of adverse cerebrovascular disease (CVD) outcomes. Epicardial adipose tissue (EAT) is proven to correlate independently with CAD and its severity, but it is unknown whether EAT is a specific and sensitive indicator of INOCA. This review focuses on the INOCA epidemiology and related factors, as well as the association between EAT.

Multi-Parametric Diagnostic Approach and Potential Markers of Early Onset Subclinical Cardiovascular Disease in a Cohort of Children, Adolescents and Young Adults Vertically Infected with HIV on cART

Background: HIV infection and lifelong cART are responsible of an increase in cardiovascular risk. The aim of this study was to describe the subclinical cardiovascular disease and to identify early markers of cardiovascular damage in adolescents and young adults vertically infected with HIV on cART, through an innovative multi-parametric approach. Methods: We enrolled 52 patients vertically infected with HIV. Demographic records, traditional cardiovascular risk factors, laboratory findings and echocardiographic measurements were collected in a one-year routine follow up. The echocardiographic examination included measurements of the 2D and 3D ejection fraction (EF), E/A ratio, E/E′ ratio, carotid intima media thickness (cIMT), flow-mediated dilation (FMD) and global longitudinal strain (GLS). Results: At the time of enrolment, all the patients were on cART therapy. The viral load was suppressed in 95% of them. EF was normal in 94.2% of patients (66 ± 7.2%), and GLS (mean value: −20.0 ± 2.5%) was reduced in 29% of patients. The cIMT mean value was higher than the 95th centile for sex and age in 73%, and FMD was impaired in 45% of patients. Clinically evident disease was found in three patients: dilative cardiomyopathy in one, thoracic-abdominal aneurysm Crawford type II with a bilateral carotid dilation in one and carotid plaque with 30% of stenosis in a third patient. Conclusions: This study confirms the presence of clinical and subclinical cardiovascular disease in a very young population vertically infected with HIV, underlining the importance of an early, multi-parametric cardiovascular follow up.

Right Heart Morphology and Its Association With Excessive and Deficient Cardiac Visceral Adipose Tissue

Visceral adipose tissue is an independent risk factor for the development of atherosclerotic coronary disease, arterial hypertension, diabetes and metabolic syndrome. Right heart morphology often involves the presence of adipose tissue, which can be quantified by non-invasive imaging methods. The last decade brought a wealth of new insights into the function and morphology of adipose tissue, with great emphasis on its role in the pathogenesis of heart disease. Cardiac adipose tissue is involved in thermogenesis, mechanical protection of the heart and energy storage. However, it can also be an endocrine organ that synthesises numerous pro-inflammatory and anti-inflammatory cytokines, the effect of which is accomplished by paracrine and vasocrine mechanisms. Visceral adipose tissue has several compartments that differ in their embryological origin and vascularisation. Deficiency of cardiac adipose tissue, often due to chronic pathological conditions such as oncological diseases or chronic infectious diseases, predicts increased mortality and morbidity. To date, knowledge about the influence of visceral adipose tissue on cardiac morphology is limited, especially the effect on the morphology of the right heart in a state of excess or deficient visceral adipose tissue.

Optimization of change in epicardial fat thickness for obese patients who lost weight via the bariatric surgery method using central composite and Box-Behnken experimental designs

Background

The aim of this study was to detect the optimal values for Age, Body Mass Index (BMI) and HOMA-IR of obese patients prior to surgery that results in a maximal decrease of visceral fat mass 6 months after bariatric surgery.

Method

In this study, 3³ experimental set-ups were designed. This study was approved by Baskent University Medical and Health Sciences Research Board (Approval number: KA16/281). The study data consisted of 40 obese patients who lost weight through the bariatric surgery between February 2015 and December 2016. The values of BMI, Age and HOMA for the obese patients who lost weight through the bariatric surgery were evaluated in three categories and at three levels; the response variable was determined as the Change in Epicardial Fat Thickness (ΔEFT).

Results

As a result of CCD analysis, the optimum ΔEFT = 2.571 was determined when Age = 30.52, BMI = 45.30, and HOMA = 34.62. As a result of the BBD analysis, the optimum ΔEFT = 3.756 was determined, when Age = 38.36, BMI = 63.18, and HOMA = 14.95. The optimum ΔEFT was modeled with Contour and Response Surface plots.

Conclusion

Based on the two surface response models used in our study, the maximal decrease of visceral fat mass as assessed by measuring echography images of epicardial fat thickness can be obtained by bariatric surgery of persons who are between 31 and 38 year old, have a BMI between 45 and 63 kg/m2 and have a HOMA-IR 34 between 15 and 35. Central Composite Design and a Box-Behnken Design of suitable patient data predicted 35 optimal settings of independent variables for the maximal clinical response of an intervention.

Cardiac Adiposity and Arrhythmias: The Role of Imaging

Increased cardiac fat depots are metabolically active tissues that have a pronounced pro-inflammatory nature. Increasing evidence supports a potential role of cardiac adiposity as a determinant of the substrate of atrial fibrillation and ventricular arrhythmias. The underlying mechanism appears to be multifactorial with local inflammation, fibrosis, adipocyte infiltration, electrical remodeling, autonomic nervous system modulation, oxidative stress and gene expression playing interrelating roles. Current imaging modalities, such as echocardiography, computed tomography and cardiac magnetic resonance, have provided valuable insight into the relationship between cardiac adiposity and arrhythmogenesis, in order to better understand the pathophysiology and improve risk prediction of the patients, over the presence of obesity and traditional risk factors. However, at present, given the insufficient data for the additive value of imaging biomarkers on commonly used risk algorithms, the use of different screening modalities currently is indicated for personalized risk stratification and prognostication in this setting.

Epicardial fat and coronary artery disease: Role of cardiac imaging

Epicardial adipose tissue (EAT) represents the fat depot located between the myocardium and the visceral pericardial layer. Far from being an inert tissue, EAT has been recognized as secreting a large amount of bioactive molecules called adipokines, which have numerous exocrine and paracrine effects. Recent evidence demonstrates that pericoronary adipose tissue (PCAT) - the EAT directly surrounding the coronary arteries - has a complex bidirectional interaction with the underlying vascular wall. While in normal conditions this mutual cross-talk helps maintain the homeostasis of the vascular wall, dysfunctional PCAT produces deleterious pro-inflammatory adipokines involved in atherogenesis. Importantly, PCAT inflammation has been associated with coronary artery disease (CAD) and major cardiovascular events. This review aims to provide an overview of the imaging techniques used to assess EAT, with a specific focus on cardiac computed tomography (CCT), which has become the key modality in this field. In contrast to echocardiography and cardiac magnetic resonance (CMR), CCT is not only able to visualize and precisely quantify EAT, but also to assess the coronary arteries and the PCAT simultaneously. In recent years, several papers have shown the utility of using CCT-derived PCAT attenuation as a surrogate measure of coronary inflammation. This noninvasive imaging biomarker may potentially be used to monitor patient responses to new antinflammatory drugs for the treatment of CAD.

Heart fat and carotid artery atherosclerosis progression in recently menopausal women: impact of menopausal hormone therapy: The KEEPS trial

OBJECTIVE

Heart fat deposition has been linked to atherosclerosis, and both accelerate after menopause. Hormone therapy (HT) may differentially slow heart fat deposition and progression of atherosclerosis, depending on the specific HT agent or its route of administration. Our objective was to evaluate the effects of different HT agents, oral and transdermal, on associations between heart fat accumulation and atherosclerosis progression, measured by carotid intima-media thickness (CIMT), in recently menopausal women from the Kronos Early Estrogen Prevention Study (KEEPS) trial.

METHODS

KEEPS was a randomized, placebo-controlled trial of the effects of 0.45 mg/d oral conjugated equine estrogens (o-CEE) or 50 mcg/d transdermal 17β-estradiol (t-E2), compared with placebo, on 48 months progression of CIMT. Epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT) volumes were quantified by computed tomography.

RESULTS

In all, 467 women (mean age [SD] 52.7 [2.5]; 78.2% White; 30% on o-CEE, 30.8% t-E2, 39.2% placebo) with heart fat volumes and CIMT at baseline and 48 months were included. EAT and PAT changes were not associated with CIMT progression; however, the assigned treatment significantly modified the association between PAT (but not EAT) change and CIMT progression. In the o-CEE group, adjusted CIMT progression was 12.66 μm (95% confidence interval [CI] 1.80, 23.52) lower than in t-E2 group (P = 0.02), and 10.09 μm (95% CI 0.79, 19.39) lower than in placebo group (P = 0.03), as per 1-SD increase in PAT.

CONCLUSION

Compared with t-E2, o-CEE appears to slow down the adverse effect of increasing PAT on progression of atherosclerosis. Whether this beneficial association is specific to CEE or to the oral route of CEE administration is unclear and should be assessed further.

Visceral fat in different locations assessed by ultrasound: Correlation with computed tomography and cut-off values in patients with metabolic syndrome

The aim of this study was to evaluate the correlation between ultrasound measurements of visceral adipose tissue (VAT) in different locations and visceral fat area parameters estimated by computed tomography (CT), as well as to determine the cut-off values of ultrasound measurements in patients with metabolic syndrome and in normal controls. Altogether, 304 patients aged 18 to 65 years were enrolled in the study. Ultrasound measurements of visceral fat volume were performed using a number of already described techniques. The correlations of ultrasound indices of VAT and СТ (104 patients) ranged from 0.420 to 0.726. For the most effective diagnostic VAT ultrasound indices, the cut-off values in metabolic syndrome were (200 patients): 21.12 cm² for the inferior part of perirenal fat (AUC = 0.983); and 47.00, 61.3 and 72.7 mm for the distance between the internal surface of the rectus abdominis muscle and the anterior wall of the aorta, the posterior wall of the aorta and the lumbar vertebra (AUC = 0.960, 0.966, 0.968, respectively). Ultrasound VAT measurements highly correlated with CT results. Cut-off VAT values, determined by ultrasound for the patients with metabolic syndrome, yielded good diagnostic operational characteristics.

The Effect of Laparoscopic Sleeve Gastrectomy on Subclinical Atherosclerosis in Patients with Severe Obesity

PURPOSE

Cardiovascular diseases (CVD) are one of the leading causes of mortality in obese patients. In this study, we investigated the effects of laparoscopic sleeve gastrectomy (LSG) operation on carotid intima-media thickness (CIMT), epicardial fat thickness (EFT), and serum endocan levels, which are independent predictors of subclinical atherosclerosis.

MATERIALS AND METHODS

A total of 47 patients (35 females and 12 males) with a mean age of 38 ± 10.48 with standard indications for LSG were prospectively included in the study. Mean CIMT values with B-mode duplex ultrasound, EFT measurements with standard transthoracic 2D echocardiography, and serum endocan levels were measured before the operation and 6 months after the operation. Delta (Δ) values were obtained by subtracting sixth month values from baseline values.

RESULTS

Body mass index (BMI) decreased significantly from an average of 47.31 ± 6.10 to 37.25 ± 5.61 kg/m² in the sixth month after LSG (p < 0.001). EFT, CIMT, and serum endocan values decreased significantly in the sixth month after surgery (0.67 ± 0.15 vs. 0.60 ± 0.14 mm, p < 0.001; 1.07 ± 0.05 vs. 1.00 ± 0.14 mm, p < 0.001; and 89.18 ± 66.22 vs. 37.74 ± 15.37, p < 0.001, respectively). There were mild-moderate positive relationships between Δ-BMI and the values of EFT and CIMT (r = 0.386, p = 0.007 and r = 0.314, p = 0.024, respectively). We also found weak linear relationships between Δ-BMI and Δ-endocan (r = 0.267, p = 0.036), and between Δ-EFT and Δ-CIMT (r: 0.221; p: 0.046).

CONCLUSION

LSG can lead to reduction in the risk of cardiovascular disease by providing improvements in CIMT, EFT, and serum endocan values, which reflect early structural atherosclerotic changes in patients with severe obesity.

Thickness of epicardial and pericoronary adipose tissue measured using 128-slice MSCT as predictors for risk of significant coronary artery diseases

Aim

Determination the relationship between the epicardial adipose tissue thickness (EATT) and pericoronary adipose tissue thickness (PATT) and the risk of significant coronary artery diseases (CAD) using the coronary artery calcium score (CACS).

Materials and methods

The study group consisted of 80 patients. The risk of significant CAD was estimated based on CACS. Adipose tissue thickness was measured based on multiplanar reformation (MPR), left ventricle short axis and mid-chamber level. EATT in the middle of the length of the right ventricular free wall, PATT around the left anterior descending (LAD), around the left circumflex (LCX) and around the right coronary artery in the posterior interventricular sulcus (RCA).

Results

The median (IQR) values of CACS and EATT were 12.00 (97.90) and 8.65 (3.90) mm. It was found that in the subgroup CACS = 0 statistically significantly lower than in the subgroup CACS > 0 were mean values EATT and PATT RCA. Based on the regression analysis, it was demonstrated that higher CACS is associated with higher EATT, independent of older age and higher BMI. On the basis the ROC curve analysis, the highest prediction sensitivity of 98.4% was demonstrated for EATT ≥ 16.7 mm as a predictor of high risk of significant CAD and the highest specificity of 61.5% for the criterion EATT ≤ 8.7 mm as a predictor of practically no risk of significant CAD.

Conclusion

There is a positive relationship between the risk of a significant CAD estimated based on the coronary artery calcium score and the epicardial adipose tissue thickness.

Metabolic and cardiovascular risk factors in Klinefelter syndrome

Klinefelter syndrome (KS), which normally presents with a 47,XXY karyotype, is the most common sex chromosome disorder in males. It is also the most common genetic cause of male infertility. KS subjects are typically tall, with small and firm testes, gynecomastia, broad hips, and sparse body hair, although a less evident presentation is also possible. KS is also characterized by a high prevalence of hypogonadism, metabolic syndrome (MetS) and cardiovascular disease. The aim of this article is to systematically review metabolic and the cardiovascular risk factors in KS patients. Hypogonadism has an important role in the pathogenesis of the changes in body composition (particularly visceral obesity) and hence of insulin resistance and MetS, but the association between KS and MetS may go beyond hypogonadism alone. From childhood, KS patients may show an increase in visceral fat with a reduction in lean body mass and an increase in glucose and impaired fat metabolism. Their increased incidence of congenital anomalies, epicardial adipose tissue, and thromboembolic disease suggests they have a higher risk of cardiovascular disease. There is conflicting evidence on the effects of testosterone therapy on body composition and metabolism.

Adipose Tissue Distribution, Inflammation and Its Metabolic Consequences, Including Diabetes and Cardiovascular Disease

Adipose tissue plays essential roles in maintaining lipid and glucose homeostasis. To date several types of adipose tissue have been identified, namely white, brown, and beige, that reside in various specific anatomical locations throughout the body. The cellular composition, secretome, and location of these adipose depots define their function in health and metabolic disease. In obesity, adipose tissue becomes dysfunctional, promoting a pro-inflammatory, hyperlipidemic and insulin resistant environment that contributes to type 2 diabetes mellitus (T2DM). Concurrently, similar features that result from adipose tissue dysfunction also promote cardiovascular disease (CVD) by mechanisms that can be augmented by T2DM. The mechanisms by which dysfunctional adipose tissue simultaneously promote T2DM and CVD, focusing on adipose tissue depot-specific adipokines, inflammatory profiles, and metabolism, will be the focus of this review. The impact that various T2DM and CVD treatment strategies have on adipose tissue function and body weight also will be discussed.

Novel imaging biomarkers: epicardial adipose tissue evaluation

Epicardial adipose tissue (EAT) is a metabolically activated beige adipose tissue, non-homogeneously surrounding the myocardium. Physiologically, EAT regulates toxic fatty acids, protects the coronary arteries against mechanical strain, regulates proinflammatory cytokines, stimulates the production of nitric oxide, reduces oxidative stress, and works as a thermogenic source against hypothermia. Conversely, EAT has pathologic paracrine interactions with the surrounded vessels, and might favour the onset of atrial fibrillation. In addition, initial atherosclerotic lesions can promote inflammation and trigger the EAT production of cytokines increasing vascular inflammation, which, in turn, may help the development of collateral vessels but also of self-stimulating, dysregulated inflammatory process, increasing coronary artery disease severity. Variations in EAT were also linked to metabolic syndrome. Echocardiography first estimated EAT measuring its thickness on the free wall of the right ventricle but does not allow accurate volumetric EAT estimates. Cardiac CT (CCT) and cardiac MR (CMR) allow for three-dimensional EAT estimates, the former showing higher spatial resolution and reproducibility but being limited by radiation exposure and long segmentation times, the latter being radiation-free but limited by lower spatial resolution and reproducibility, higher cost, and difficulties for obese patients. EAT radiodensity at CCT could to be related to underlying metabolic processes. The correlation between EAT and response to certain pharmacological therapies has also been investigated, showing promising results. In the future, semi-automatic or fully automatic techniques, machine/deep-learning methods, if validated, will facilitate research for various EAT measures and may find a place in CCT/CMR reporting.

Epicardial fat: the role of testosterone and lipid metabolism in a cohort of patients with Klinefelter syndrome

CONTEXT

Klinefelter syndrome (KS), in which subjects have additional copies of X chromosomes, is the most common male sex chromosome abnormality, with a prevalence of 1 in 660 and an incidence of about 1 in 500-700 newborns. Its sign and symptoms include infertility, generally low testosterone levels, and an increased prevalence of obesity and metabolic syndrome. Epicardial fat thickness (EFT) reflects visceral adiposity rather than general obesity.

OBJECTIVE

The aim of this study was to analyze echocardiographic EFT in a cohort of patients with KS in comparison with non-obese and obese euploid controls, and to evaluate its correlation with biochemical parameters.

DESIGN, SETTING AND PARTICIPANTS

Two hundred and twenty-one KS patients referred to our Rare Endocrine Diseases clinic and 77 age-matched controls underwent Doppler echocardiography and a full investigation of anthropometric and body composition, Serum levels of total testosterone (T), estradiol (E2), sex hormone binding globulin (SHBG), fasting plasma glucose, insulin, cholesterol and triglycerides were obtained. All participants underwent dual energy X-ray absorptiometry (DEXA) scan to assess truncal body fat (TrBF).

MAIN OUTCOME MEASURE

EFT, body composition and metabolic parameters in KS patients and how they are affected by genotype.

RESULTS

EFT was greater in KS patients than in healthy non-obese (NOb) controls, but lower than in obese (OB) controls. When KS patients were divided into groups (hypogonadal; eugonadal; receiving testosterone replacement therapy [TRT]), EFT was greater in hypogonadal patients than in NOb controls and eugonadal patients, but showed no difference from the OB controls or TRT patients. Hypogonadal patients showed increased TrBF in comparison with NOb controls and eugonadal and TRT patients, and similar TrBF to OB controls. As expected, there was a strong correlation between BMI and EFT in both KS patients and controls (P < 0.0001). In contrast, there was a strong inverse correlation between testosterone and EFT in the control group, but not in KS patients. EFT was significantly correlated with TrBF in both populations (P < 0.0001). Multivariate analyses showed that the major determinants of both EFT and TrBF were BMI and the presence of KS itself. Testosterone and triglycerides were not included as variables in the models.

CONCLUSION

EFT in hypogonadal KS subjects was similar to that of the obese eugonadal controls. Even though there was a direct correlation between BMI and EFT in both populations, the influence of TrBF on EFT was stronger. The presence of the supernumerary X chromosome appeared to be one of the strongest determinants of EFT and TrBF, independent of testosterone levels.

The epicardial adipose tissue and the coronary arteries: dangerous liaisons

The adipose tissue (AT) is an endocrine organ that produces adipocytokines (adipokines), able to influence metabolic homeostasis. In the conventional classification, there are two large AT depots, characterized by different paracrine activities: the subcutaneous AT, which would mostly produce cytokines with protective properties against cardiovascular disease; and the visceral AT, responsible for the secretion of cytokines with proinflammatory, prothrombotic, and proatherogenic effects. A third component, the epicardial AT (EAT) is now receiving increasing attention due to its unique anatomical and functional proximity to the myocardium and the coronary arteries. In rodents, the EAT protects the heart from exposure to high levels of free fatty acids, and provides energy to the myocardium under high metabolic demands. The observation that atherosclerotic plaques are more prevalent in regions of coronary arteries surrounded by the EAT, while they tend to be less present in segments penetrating the myocardium (the septal branches and segments under myocardial bridges), has led to the hypothesis of a possible role of the EAT in promoting the development of atherosclerosis through endocrine and paracrine effects, in addition to the role of biomechanical forces affecting transendothelial lipid permeability into the intima. In this article, we review the clinical and molecular evidence linking the EAT and coronary artery disease through a systematic review of the literature. We, here, discuss current diagnostic techniques in evaluating the interaction between EAT and the onset of coronary artery disease and ischaemic heart disease. Finally, we review current knowledge on the underlying mechanisms by which the EAT may affect coronary atherosclerosis, and potential clinical implications of this interaction, making the EAT an attractive target for new therapeutics in cardiovascular disease.

Association between epicardial adipose tissue thickness and parameters of target organ damage in patients undergoing coronary angiography

Epicardial adipose tissue (EAT), metabolically active visceral fat, is easily measurable using transthoracic echocardiography (TTE). This study aimed to clarify the relationship between EAT thickness and parameters for target organ damage (TOD). A total of 338 consecutive patients (64.5 ± 10.9 years, 58.0% men) undergoing invasive coronary angiography in a stable condition were prospectively enrolled. TTE was performed, and the EAT thickness was measured perpendicular to the right ventricular free wall at end-systole. We investigated TOD parameters, including the estimated glomerular filtration rate, proteinuria, left ventricular (LV) mass index (LVMI), septal e' velocity, E/e', brachial-ankle pulse wave velocity, ankle-brachial index, aortic pulse pressure (APP), and presence of coronary artery disease (CAD). APP and CAD were assessed by invasive cardiac catheterization. Most patients (77.5%) had significant CAD (≥50% stenosis). In Pearson's bivariate correlation analyses, the EAT thickness was significantly correlated with the septal e' velocity (r = -0.203, P < 0.001) and E/e' (r = 0.217, P < 0.001), but not with other TOD parameters (P > 0.05). Multiple linear regression analysis showed that the correlations of the EAT thickness with septal e' velocity (β = -0.172, P = 0.047) and E/e' (β = 0.207, P = 0.011) remained significant even after adjusting for potential confounders. EAT thickness is more closely related to LV diastolic function than other TOD parameters, including renal function, LVMI, arterial stiffness, peripheral artery disease, and CAD. These findings provide additional evidence for the potential role of EAT in the pathogenesis of LV diastolic dysfunction.

The Association of Epicardial Adipose Tissue and the Metabolic Syndrome in Community Participants in South Africa

Background:

We sought to determine the association of echocardiographically derived epicardial adipose tissue (EAT) thickness, which is a component of visceral adipose tissue, with the metabolic syndrome (MetS) in a cohort of randomly selected community participants.

Methods:

South African-Asian Indians aged 15–64 years were recruited over a 2-year period after informed consent was obtained. All participants who had complete measurements done for biochemistry and echocardiography (using established criteria), were dichotomized into the MetS or non-MetS groups defined according to the harmonized criteria.

Results:

Of the 953 (232 men and 721 women) participants recruited, 47.1% (448) were classified with the MetS. These participants had larger waist circumference and body mass index (P < 0.001), with larger LA volumes and diameter, thicker ventricular walls, higher left ventricular mass, relative wall thickness, and EAT (P < 0.001). There was a corresponding increase in EAT thickness with increasing number of MetS risk factors at the transition from 0 MetS factors to 1 (95% confidence interval [CI] −0.8; −0.2) and from 2 to 3 MetS factors (95% CI −0.9; −0.4). The AUC of the receiver operator curve was highest for triglycerides (0.845), followed by fasting plasma glucose (0.795) and then EAT (0.789). An EAT value of <3.6 mm predicted the presence of the MetS with a 78% sensitivity and 70% specificity. Using backward stepwise logistic regression, the most significant independent determinants of the MetS after adjusting for age, gender, and type 2 diabetes mellitus, was fasting plasma glucose (odds ratio [OR] = 1.2), triglycerides (OR = 7.1), and EAT (OR = 2.3).

Conclusion:

Although EAT is associated with the MetS, and can identify individuals at increased cardiometabolic risk, it has a limited additional role compared to current risk markers.

Evaluation of Epicardial Fat Thickness in Young Patients With Embolic Stroke of Undetermined Source

OBJECTIVES

Epicardial adipose tissue is metabolically active and is an important predictor of metabolic and cardiovascular diseases. This study investigated the echocardiographic epicardial adipose tissue measurement in young patients with embolic stroke of undetermined source (ESUS).

MATERIALS AND METHODS

We studied 77 volunteers, including 40 patients with ESUS (mean age 43±8 y, 16 female patients) and 37 healthy subjects (mean age 38±7 y, 20 female subjects). All necessary biochemical parameters were analyzed, and epicardial fat thickness (EFT) was measured by echocardiography in all subjects. Additional related diagnostic work-up was conducted in each patient, according to the patients' clinical presentation.

RESULTS

The patients with ESUS had a significantly higher EFT than the control group (5.51±0.82 vs. 3.96±0.51; P<0.01). Furthermore, there was a positive correlation between EFT and serum C-reactive protein levels (r=0.284; P<0.05). As an optimal cut-off point, a high-risk EFT value of 4.6 mm was determined to predict ESUS, with an 87.5% sensitivity and an 81.1% specificity.

CONCLUSION

We found that echocardiographic EFT was significantly higher in young patients with ESUS than in healthy individuals. Increased EFT might be a novel risk factor in these patients.

Effects of antidiabetic drugs on epicardial fat

Epicardial adipose tissue is defined as a deposit of adipocytes with pathophysiological properties similar to those of visceral fat, located in the space between the myocardial muscle and the pericardial sac. When compared with subcutaneous adipose tissue, visceral adipocytes show higher metabolic activity, lipolysis rates, increased insulin resistance along with more steroid hormone receptors. The epicardial adipose tissue interacts with numerous cardiovascular pathways via vasocrine and paracrine signalling comprised of pro- and anti-inflammatory cytokines excretion. Both the physiological differences between the two tissue types, as well as the fact that fat distribution and phenotype, rather than quantity, affect cardiovascular function and metabolic processes, establish epicardial fat as a biomarker for cardiovascular and metabolic syndrome. Numerous studies have underlined an association of altered epicardial fat morphology, type 2 diabetes mellitus (T2DM) and adverse cardiovascular events. In this review, we explore the prospect of using the epicardial adipose tissue as a therapeutic target in T2DM and describe the underlying mechanisms by which the antidiabetic drugs affect the pathophysiological processes induced from adipose tissue accumulation and possibly allow for more favourable cardiovascular outcomes though epicardial fat manipulation.

Association of Epicardial Fat Tissue with Coronary Artery Disease and Left Ventricle Diastolic Function Indicators

Background

Epicardial fat tissue (EAT) acts as brown adipose tissue and protects the heart and coronary arteries against hypothermia. Recent studies demonstrated that EAT is a source of both anti-inflammatory and atherogenic cytokines. In this study, our aim was to investigate the association of vertical, horizontal, and area measurements of EAT thickness and their association with coronary artery disease, diastolic function, and myocardial performance index in patients who underwent coronary angiography.

Material/Methods

The study population consisted of patients who presented to our outpatient clinic with chest pain and whose non-invasive stress tests were positive between June 2015 and July 2017. Echocardiographic examinations were performed prior to the angiography. Coronary angiograms were performed using Judkins method from the femoral artery.

Results

Mean vertical thickness of EAT was 0.6 cm in patients with CAD and 0.46 cm in those without CAD (p=0.0001). Mean horizontal length of EAT was 2.91 cm in patients with CAD and was 2.41 cm in the subjects without CAD (p=0.001). ROC analysis showed 81% sensitivity and 53% specificity for a cut-off value of 0.45, and 67% sensitivity and 71% specificity for a cut-off value of 0.55 for EAT vertical (cm). Multivariate analysis showed that EAT is an independent risk factor for coronary artery disease.

Conclusions

Echocardiography is an inexpensive routine assessment for most patients. EAT thickness determined by echocardiography may be a useful indicator of increased CAD risk, but not diastolic dysfunction, of the left ventricle.

Impact of weight loss on epicardial fat and carotid intima media thickness after laparoscopic sleeve gastrectomy: A prospective study

BACKGROUND AND AIMS

Cardiovascular disease (CVD) is one of the leading causes of mortality in obese patients. We aimed to investigate the influence of significant weight loss following laparoscopic sleeve gastrectomy (LSG) on carotid intima media thickness (CIMT) and epicardial fat thickness (EFT) which are the independent predictors of subclinical atherosclerosis.

METHODS AND RESULTS

Patients were recruited for standard indications. A total of 105 patients (79 women and 26 men) with the mean age of 43.61 ± 12.42 were prospectively enrolled. On B-mode duplex ultrasound; the mean CIMT at the far wall of both left and right common carotid arteries were measured. EFT was measured on the free wall of the right ventricle at end-diastole from the parasternal long-axis view by standard transthorasic 2D echocardiography. Delta (Δ) values were obtained by subtracting sixth month values from the baseline values. Body mass index (BMI) was significantly reduced from 46.95 ± 7.54 to 33.54 ± 6.41 kg/m2 (p < 0.001) in sixth months after LSG. Both EFT and CIMT were significantly decreased after surgery (8.68 ± 1.95 mm vs. 7.41 ± 1.87 mm; p < 0.001 and 0.74 ± 0.13 mm vs. 0.67 ± 0.11 mm; p < 0.001 respectively). A significant correlation between ΔEFT and ΔBMI (r = 0.431, p < 0.001) was shown. ΔCIMT is significantly correlated with ΔEFT, ΔBMI and Δ systolic blood pressure (r = 0.310, r = 0.285 and r = 0.231 respectively, p < 0.05 for all). In multivariate stepwise linear regression analysis; among variables only ΔBMI was the independent predictor of ΔEFT (β = 153, p = 0.001).

CONCLUSION

Early atherosclerotic structural changes may be reversed or improved by sustained weight loss after LSG in asymptomatic obese patients.

Epicardial Fat in the Maintenance of Cardiovascular Health

Epicardial fat is a unique adipose tissue located between the myocardium and the visceral layer of pericardium. This tissue is characterized by highly active fatty acid metabolism and highly expressed thermogenic genes. Epicardial fat and the underlying myocardium share the same microcirculation, suggesting a close and strong interaction between these two structures. Under physiological conditions, epicardial fat protects and supports the heart to exert its normal function. Many clinical studies have shown significant associations between increased amounts of epicardial fat and coronary artery disease (CAD). In patients with CAD, increased epicardial fat becomes inflammatory and may promote plaque development through secretion of proinflammatory cytokines and other mechanisms. Therefore, epicardial fat is a biomarker of cardiovascular risk and a potential therapeutic target for cardiovascular disease. Weight loss and pharmaceuticals can reduce epicardial fat and improve its protective physiological functions.

Relationship of Echocardiographic Epicardial Fat Thickness and Epicardial Fat Volume by Computed Tomography with Coronary Artery Calcification: Data from the CAESAR Study

BACKGROUND AND AIMS

No study has assessed the association between echocardiographic epicardial fat thickness (EFT) and computed tomography (CT)-based epicardial fat volume (EFV) and coronary artery calcification. The aim of this study is to evaluate the association between EFT and EFV and coronary artery calcification.

METHODS

Among the 2,299 individuals enrolled in the CArdiometabolic risk, Epicardial fat, and Subclinical Atherosclerosis Registry (CAESAR) study, 2,276 (1,851 men; mean age 45 ± 8.9 years) who underwent echocardiographic EFT and CT-based EFV measurements and obtained a coronary artery calcium score (CACS) were included in this study.

RESULTS

The overall prevalence of CAC >0 was 19.3%. EFT was significantly correlated with EFV (r = 0.374, p <0.001) but the k statistic showed only slight agreement (k = 0.146, p <0.001). Multivariate regression analyses adjusted for age, sex, body mass index, waist circumference, systolic blood pressure, daily alcohol intake, smoking status, and vigorous exercise and glucose, blood urea nitrogen, uric acid, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-sensitivity C reactive protein, and hemoglobinA1c levels revealed that an increase in the absolute values of EFT and EFV was significantly associated with the presence of coronary artery calcium (ORs [95% CIs], 2.023 [1.282-3.193] and 1.785 [1.173-2.716], respectively) and CACS (standardized β values = 0.082 and 0.061, p = 0.001 and 0.042, respectively).

CONCLUSION

These results show that EFT and EFV are associated with coronary artery calcification in Korean adults despite the relatively weak correlation between EFT and EFV.

Epicardial fat thickness is associated with aortic intima-media thickness in patients without clinical manifestation of atherosclerotic cardiovascular disease

BACKGROUND

Although the relationship between epicardial fat thickness (EFTh) and coronary atherosclerosis is well established, this relation in the early periods of atherosclerosis has not been fully demonstrated. On the other hand, thoracic aortic intima-media thickness (IMT) rather than carotid IMT was reported as an earlier marker of preclinical atherosclerosis.

OBJECTIVE

We aimed to assess the relationship between thoracic aortic IMT and EFTh in patients undergoing transesophageal echocardiography (TEE) examination for different indications.

METHODS

We included 104 patients (mean age 38±11.4 years), who underwent TEE for various indications. The patients were divided into two groups according to the median thoracic aortic IMT values (IMT normal group<10 mm and IMT abnormal group≥10 mm). EFTh was obtained using two-dimensional transthoracic echocardiography on the right ventricular free wall during systole and diastole.

RESULTS

The highest EFTh values (3.3±0.96 mm vs. 4.51±0.66 mm, P<.001) were observed in the abnormal aortic IMT group. Multivariate linear regression analysis showed that aortic IMT was independently correlate with EFTh (β=0.423, P<.001). Moreover, EFTh was found to be associated with history of transient ischemic attack (r=.403, P<.001) and abnormal IMT (r=.643, P<.001) in bivariate analysis.

CONCLUSION

Epicardial fat thickness is independently related to the extent of subclinical thoracic aortic atherosclerosis. Increase in EFTh may be crucial marker for initial atherosclerosis.

Original research. The Assessment of Epicardial Adipose Tissue in Acute Coronary Syndrome Patients. A Systematic Review

Background: This systematic review seeks to evaluate the role of epicardial adipose tissue (EAT), quantified either by thickness, assessed by transthoracic echocardiography, or by volume, assessed by cardiac computed tomography (CT), in the follow-up of patients with acute coronary syndromes (ACS). Method: One-hundred forty-four articles were screened, from which 56 were reviewed in full-text. From those, 47 studies were excluded for the following reasons: they did not meet the inclusion criteria; they were either reviews or meta-analyses; the study cohorts included only stable coronary artery disease patients; they did not state a clear and concise study design, endpoints, or follow-up. The final draft included nine studies for systematic evaluation. Results: Of the 2,306 patients included in the review, 170 underwent cardiac CT while the remaining 2,136 underwent transthoracic echocardiography for the measurement of EAT. The analysis found that the EAT thickness was significantly associated with major adverse cardiovascular events (MACE) rates during hospitalization (OR: -1.3, 95% CI: 1.05-1.62, p = 0.020) and at three years (HR: 1.524, 95% CI: 1.0-2.2, p = 0.038). The included studies found that EAT was correlated with the following clinical and angiographic risk scores for ACS: GRACE (r = 0.438, p <0.001), TIMI risk score (r = 0.363, p = 0.001), SYNTAX score (r = 0.690, p <0.0001; r = 0.610, p <0.01), and Gensini score (r = 0.438, p = 0.001). There was an inverse correlation between ST-segment resolution of <70% after revascularization and EAT (r = −0.414, p = 0.01), and the myocardial blush grade (r = −0.549, p <0.001). The EF aggregation ranged between 2.65 mm and 4.7 mm within the included studies. Conclusions: EAT, evaluated either by echocardiography or cardiac CT, correlates with the severity of coronary lesions, with the clinical and angiographic risk scores for acute coronary syndromes, with indicators for coronary reperfusion, and with short- and long-term MACE rates. Further studies are required to fully elucidate the role of this extensively studied but still novel cardiovascular biomarker as part of a risk prediction tool.

Fat deposition in the left ventricle: descriptive and observacional study in autopsy

BACKGROUND

The human heart contains varying amounts of fat deposits. Cardiac physiological fat occurs predominantly in the right ventricle (RV). The discovery and characterization of adipose tissue along the left ventricle (LV) has been rarely reported. This study aimed to determine the occurrence of fatty deposits in epicardial, pericoronay and myocardial compartments in the LV, and to trace the epidemiological profile and clinical associations with this finding.

METHODS

Epidemiological and morphological data and heart samples were collected from corpses submitted to necropsy. Cardiac samples were fixed, embedded in paraffin and subjected to hematoxylin-eosin for microscopic study.

RESULTS

The research was based on 40 samples of cardiac tissue, 21 male cadavers and 19 female ones with mean age of 68.2 years. 52.2% of the subjects had a history of smoking, 20% of them had alcohol consumption and 43.59% showed cardiac cause as a cause of death (acute myocardial infarction - AMI - was the most frequent immediate cause of death). 82.5% of the subjects showed atherosclerotic disease in the ascending aorta (ADAA). The fat deposition in the left ventricule (FDLV) was observed in 95% of cases. Epicardial fat (EF) and pericoronary adipose tissue (PAT) are the most frequent topographies in fat accumulation in the left heart chamber and the EF deposition is associated with myocardial adiposity (MA) (Fisher test [FT] 0.019; odds ratio [OR] 0.097 [95% CI 0.033 to 0.284]; p < 0.05). FDLV was associated with alcoholism (FT 0.04, OR 0.161 [95% CI 0.072 to 0.36]; p < 0.05); smoking (FT 0.508; OR 0581 [95% CI 0.431 to 0.73]; p < 0.05), presence of Frank's sign (FT 0.502; OR 0.567 [95% CI 0.414 to 0.775]; p < 0.05); ADAA (0.774 OR [95% CI 0.6405 to 0.936]; p < 0.05); AMI (OR 0.730 [95% CI 0.600 to 0.888]; p < 0.05) and macroscopic finding of cardiac hypertrophy (OR 0.700 [95% CI 0.525 to 0.933]; p < 0.05). FDLV is related with the thickness of the abdominal fat cushion.

CONCLUSIONS

FDLV is common and associated with cardiovascular disease risk factors. Cardiac adiposity cannot be considered a random autopsy finding, requiring diagnostic research and more studies to investigate the clinical implications.

Nonalcoholic fatty liver disease - A multisystem disease?

Non-alcoholic fatty liver disease (NAFLD) is one of the most common comorbidities associated with overweight and metabolic syndrome (MetS). Importantly, NAFLD is one of its most dangerous complications because it can lead to severe liver pathologies, including fibrosis, cirrhosis and hepatic cellular carcinoma. Given the increasing worldwide prevalence of obesity, NAFLD has become the most common cause of chronic liver disease and therefore is a major global health problem. Currently, NAFLD is predominantly regarded as a hepatic manifestation of MetS. However, accumulating evidence indicates that the effects of NAFLD extend beyond the liver and are negatively associated with a range of chronic diseases, most notably cardiovascular disease (CVD), diabetes mellitus type 2 (T2DM) and chronic kidney disease (CKD). It is becoming increasingly clear that these diseases are the result of the same underlying pathophysiological processes associated with MetS, such as insulin resistance, chronic systemic inflammation and dyslipidemia. As a result, they have been shown to be independent reciprocal risk factors. In addition, recent data have shown that NAFLD actively contributes to aggravation of the pathophysiology of CVD, T2DM, and CKD, as well as several other pathologies. Thus, NAFLD is a direct cause of many chronic diseases associated with MetS, and better detection and treatment of fatty liver disease is therefore urgently needed. As non-invasive screening methods for liver disease become increasingly available, detection and treatment of NAFLD in patients with MetS should therefore be considered by both (sub-) specialists and primary care physicians.

Atherosclerosis in chronic hepatitis C virus patients with and without liver cirrhosis

Background

Chronic Hepatitis C virus (HCV) infection and liver cirrhosis may be associated with atherosclerosis and coronary artery disease (CAD). There are two phases to atherosclerosis, Subclinical and Clinical. Assessment of atherosclerosis may be started at its Subclinical phase by the evaluation of Epicardial Fat Thickness (EpFT) and Carotid Intima Thickness (CIMT).

Aim of the study

The aim of the study was to evaluate Clinical and Subclinical atherosclerosis in chronic HCV patients with and without liver cirrhosis by evaluating CIMT and EpFT and correlating the results with Child-Pugh functional scoring of cirrhosis as well as with ultrasound and laboratory parameters that define the severity of liver disease.

Patients and methods

This study involved 64 chronic HCV patients that were divided into two groups: 24 patients without liver cirrhosis and 40 patients with liver cirrhosis in addition to 20 apparently healthy volunteers serving as control. All of the 84 subjects were subjected to the following: Clinical evaluation; Routine Laboratory Evaluation (CBC, Liver Function Tests, Renal Function Tests, Serum electrolytes, Cholesterol, Triglycerides, HBs antigen and HCV antibody); ECG; Abdominal ultrasound; Echocardiographic evaluation of segmental wall motion abnormalities and EpFT and B-Mode Carotid ultrasonography for evaluation of CIMT.

Results

In the cirrhotic HCV group, the CIMT and EpFT were both significantly increased [Compared to control group (p = 0.000), compared to the non-cirrhotic HCV group (p = 0.000)]. In the non-cirrhotic HCV group, the CIMT and EpFT were both significantly increased compared to the control group with a p-value of 0.003 for CIMT and 0.048 for EpFT. The CIMT and EpFT were also positively correlated with each other (r = 0.456, p = 0.001). There was a statistically significant increase in the EpFT and CIMT in Child class B patients compared to Child class A (p = 0.007 for CIMT and p = 0.028 for EpFT) and in Child class C patients compared to Child class B patients (p = 0.001 for CIMT and 0.005 for EpFT). CIMT and EpFT were correlated positively with AST (r = 0.385, p = 0.002 for CIMT, and r = 0.379, p = 0.003 for EpFT), Total Bilirubin (r = 0.378, p = 0.003 for CIMT, and r = 0.384, p = 0.002 for EpFT), INR% (r = 0.456, p = 0.001 for CIMT, and r = 0.384, p = 0.001 for EpFT), CRP (r = 0.378, p = 0.003 for CIMT, and r = 0.386, p = 0.002 for EpFT), spleen span (r = 0.417, p = 0.001 for CIMT, and r = 0.437, p = 0.001 for EpFT) and portal Vein Diameter (r = 0.372, p = 0.003 for CIMT, and r = 0.379, p = 0.003 for EpFT). CIMT and EpFT were correlated negatively with Albumin (r = -0.379, p = 0.003 for CIMT, and r = -0.370, p = 0.003 for EpFT), platelets count (r = -0.382, p = 0.002 for CIMT, and r = -0.378, p = 0.003 for EpFT) and Liver Span (r = -0.433, p = 0.001 for CIMT, and r = -0.424, p = 0.001 for EpFT).

Conclusion

EpFT and CIMT significantly increased in chronic hepatitis C virus patients especially in those with cirrhosis and closely correlated with each other. Their thickness also correlated with the Child-Pugh functional scoring of cirrhosis as well as with ultrasound and laboratory parameters that define the severity of liver disease.The echocardiographic assessment of EpFT and the carotid Doppler assessment of CIMT may provide appropriate and simple screening markers for subclinical atherosclerosis and cardiovascular risk in chronic HCV patients with and without cirrhosis.

Assessment of epicardial adipose tissue and carotid/femoral intima media thickness in insulin resistance

BACKGROUND

Metabolic syndrome is a combination of multiple cardiovascular (CV) risk factors including insulin resistance (IR). Carotid, femoral intima media thickness (IMT), and epicardial fat thickness (EFT) are considered as novel cardiometabolic risk factors. We aimed to test the hypothesis that carotid, femoral IMT, and EFT are increased in patients with IR.

METHODS

We enrolled consecutively and prospectively 113 patients with IR. Then we collected data from an age- and sex-matched control group of 112 individuals without IR. Homeostasis model assessment (HOMA) index value >2.5 was accepted as IR. Patients with diabetes mellitus, CV diseases, systolic heart failure, chronic liver or renal diseases were excluded. On B-mode duplex ultrasound the mean IMT at the far wall of both left and right common carotid/femoral arteries were measured manually. EFT was measured on the free wall of the right ventricle at end-diastole from the parasternal long-axis views by standard transthoracic 2D echocardiography.

RESULTS

Both carotid IMT and EFT were significantly higher in patients with IR compared to controls (0.80±0.21mm vs 0.60±0.21mm; p<0.001 and 7.34±1.96mm vs 5.22±1.75mm; p<0.001, respectively). However, there were no significant differences in femoral IMT between the groups (0.74±0.20 vs 0.69±0.17; p=0.062). In multivariate linear regression analysis age (β=0.223, p=0.010), 2-h blood glucose (β=0.198, p=0.021), and IR (β=0.369, p<0.001) were independent predictors of EFT. On the other hand age (β=0.363, p<0.001) and IR (β=0.321, p<0.001) were independent predictors of carotid IMT.

CONCLUSIONS

Patients with IR have increased carotid IMT and EFT, but not femoral IMT. This apparent incoherence may be due to the involvement of carotid arteries prior to femoral arteries in patients with IR.

Assosiation of Epicardial and Pericardial Fat Thickness with Coronary Artery Disease

INTRODUCTION

Visceral adipose tissue is a known important risk factor for coronary artery disease (CAD). While some studies have suggested relationship between epicardial fat thickness (EFT) and CAD, there are no adequate studies for pericardial fat thickness (PFT). The aim of this study was to determine the association of EFT and PFT with CAD.

METHODS

This cross-sectional study was conducted on patients who were candidates for elective coronary artery angiography, referred to Emam Reza Hospital, Mashhad, Iran during Jan 2014-2016. Demographic and laboratory data were collected. Transthoracic echocardiography was performed to determine average EFT and PFT at the standard parasternal long-axis view at end-systole for 3 cardiac cycles. SCA was performed on the same day. The patients were divided into two groups: CAD (n=59) and non-CAD (n=41) based on presence or absence of epicardial coronary artery stenosis of > 50%. Chi-square, independent T-test, and receiver operating characteristic (ROC) curve were used by SPSS Version 16 for data analysis.

RESULTS

One hundred patients (44 women and 56 men) with an average age of 56.4 ± 9.9 years were studied. The two groups were not significantly different in demographic profile and cronary risk factors. While PFT was not significantly different between the two groups, EFT was significantly higher in CAD group (3.0 ± 3.69 vs. 1.2 ± 3.6, p <0.0001). Moreover, with the increase of the affected coronary arteries, EFT increased (p <0.0001). Gensini score had a strong correlation with amount of EFT (r = 0.765, p <0.0001). EFT with a cutoff value of 4.25 mm (sensitivity=79%, specificity=68%) was specified in predicting CAD.

CONCLUSION

EFT measured by echocardiography can be used as an independent marker to predict CAD. More studies are needed to determine the predictive role of PFT for CAD.