Epicardial adipose tissue in contemporary cardiology

The role of echocardiography in the diagnosis of heart failure with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF in older adults. While manifest as distinct clinical phenotypes, almost all patients with HFpEF will present with exercise intolerance or exertional dyspnea. Distinguishing HFpEF from other clinical conditions remains challenging, as the accurate diagnosis of HFpEF involves integrating a diverse array of cardiovascular (CV) structural and physiologic inputs. Owing to its intrinsic ability to characterize the structure and function of the myocardium, cardiac valves, pericardium, and vasculature, echocardiography (TTE) has emerged as an essential modality for diagnosing HFpEF. In contrast to HF with reduced EF, however, no single TTE variable defines HFpEF. Abnormal diastolic function is typically associated with HFpEF, but "diastolic dysfunction" per se is not synonymous with "HFpEF": the pathophysiology of HFpEF is more complex than diastolic dysfunction alone. HFpEF may involve abnormalities at multiple loci within the CV system, including (1) dysfunction of the left ventricle, left atrium, or right ventricle; (2) pulmonary hypertension or pulmonary vascular disease; (3) pericardial restraint; (4) abnormal systemic vascular impedance; (5) coronary or peripheral microcirculatory dysfunction; and (6) defects of tissue oxygen uptake within the periphery. Thus, the accurate diagnosis of HFpEF - and its specific clinical phenotypes - requires diagnostic algorithms that comprise multiple clinical variables, many of which may be derived from TTE data. Refining such algorithms to better discriminate among specific HFpEF phenotypes is the subject of continued investigation.

Epicardial Adipose Tissue and Heterogeneity Parameters Combined with Inflammatory Cells to Predict the Value of Heart Failure with Preserved Ejection Fraction Patients Post Myocardial Infarction

BACKGROUND AND PURPOSE

Epicardial adipose tissue (EAT) comprises three distinct lipid components, each exerting differential effects on cardiovascular diseases. During disease progression, dynamic alterations in lipid composition and spatial distribution contribute to the inherent heterogeneity of EAT. The excessive activation of inflammatory cells may contribute to chronic inflammation, promoting atherosclerosis and cardiac diseases. However, the role of EAT in patients with myocardial infarction (MI) who develop heart failure with preserved ejection fraction (HFpEF) remains unclear. This study aims to quantify the overall and perivascular volumes of EAT using cardiac magnetic resonance (CMR) imaging and assess its heterogeneity, exploring the predictive value of EAT heterogeneity and different EAT volumes combined with inflammatory cells for the occurrence of HFpEF in MI patients with normal left ventricular ejection fraction (LVEF).

METHODS

This retrospective cohort study enrolled patients diagnosed with MI with preserved LVEF via clinical assessment and CMR at the Second Affiliated Hospital of Kunming Medical University between January 2015 and July 2023. Patients who did not undergo percutaneous coronary intervention (PCI) were followed, with the incidence of HFpEF serving as the primary endpoint. The cohort was stratified into two groups: those without HFpEF and those who developed HFpEF.Cardiac structure, function, EAT volume, and infarct volume parameters were obtained using the CMR post-processing software CVI-42, while EAT heterogeneity parameters entropy were derived using Python software. Independent sample t-tests, non-parametric tests, and chi-square tests were employed to analyze the differences in clinical baseline data and CMR metrics between the two groups. Spearman's rank correlation was utilized to analyze the associations between EAT parameters and inflammatory cells, inflammatory markers, and diastolic dysfunction indicators. Furthermore, we conducted univariate and multivariate Cox regression analyses to determine the predictive value of each parameter for the development of HFpEF in MI patients. Time-dependent ROC curves were generated to evaluate the efficacy of each parameter in predicting HFpEF, the AIC values of each parameter and the final model were calculated to evaluate the predictive performance. The optimal cut-off values were identified using time-dependent ROC curves in R software, and Kaplan-Meier event-survival curves were plotted to illustrate the event-free rates based on these optimal thresholds.The median follow-up time was calculated using the reverse Kaplan-Meier method.

RESULTS

A total of 203 MI patients with normal LVEF were included, with 74 in the HFpEF group and 129 in the non-HFpEF group. No significant differences were observed between the two groups regarding age, sex, and infarct volume; however, significant statistical differences were noted in BMI, diabetes, renal failure, leukocytes, neutrophils, monocytes, total EAT, EAT entropy, left ventricular EAT (LV EAT), left atrial end-systolic volume (LAESV), triglycerides, NHR, MHR and LACI(Left atrioventricular coupling index) (P < 0.05). Both overall and local EAT volumes showed a positive correlation with leukocytes and monocytes,as well as with the inflammatory markers MHR and SIRI. Furthermore, EAT volume exhibited a positive correlation with the LACI, a marker of diastolic dysfunction. Univariate and multivariate Cox regression analyses indicated that BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF. And the AIC value of the multivariate regression model was the smallest.Further time-dependent ROC analysis revealed that the maximum AUC for BMI was 0.67, while the AUC for LV EAT was 0.63, and EAT entropy was 0.60, the maximum AUC for monocyte was 0.70, and the combined prediction of LV EAT and EAT entropy had a maximum AUC of 0.70. After a median follow-up of 34 months, Kaplan-Meier survival curves demonstrated that LV EAT greater than 21.23 mL was associated with the occurrence of HFpEF, whereas EAT entropy was not.

CONCLUSIONS

In patients with chronic MI, normal LVEF, and no prior PCI, the occurrence of HFpEF is not correlated with infarct volume; however, BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF with significant predictive value, with the highest predictive efficacy observed monocyte and when combining EAT entropy and LV EAT. Additionally, both overall and local EAT volumes exhibit a moderate positive correlation with leukocytes,monocytes and inflammatory markers, and were also positively correlated with diastolic dysfunction. This suggests that, in clinical practice, beyond traditional indicators, there should be an increased focus on EAT heterogeneity and perivascular EAT in MI patients with normal LVEF who have not undergone PCI to to reduce the incidence of HFpEF.

CVOT summit report 2024: new cardiovascular, kidney, and metabolic outcomes

The 10th Cardiovascular Outcome Trial (CVOT) Summit: Congress on Cardiovascular, Kidney, and Metabolic Outcomes was held virtually on December 5-6, 2024. This year, discussions about cardiovascular (CV) and kidney outcome trials centered on the recent findings from studies involving empagliflozin (EMPACT-MI), semaglutide (STEP-HFpEF-DM and FLOW), tirzepatide (SURMOUNT-OSA and SUMMIT), and finerenone (FINEARTS-HF). These studies represent significant advances in reducing the risk of major adverse cardiovascular events (MACE) and improving metabolic outcomes in heart failure with preserved ejection fraction (HFpEF), chronic kidney disease (CKD), and obstructive sleep apnea (OSA). The congress also comprised sessions on novel and established therapies for managing HFpEF, CKD, and obesity; guidelines for managing CKD and metabolic dysfunction-associated steatotic liver disease (MASLD); organ crosstalk and the development of cardio-kidney-metabolic (CKM) syndrome; precision medicine and person-centered management of diabetes, obesity, cardiovascular disease (CVD) and CKD; early detection of type 1 diabetes (T1D) and strategies to delay its onset; continuous glucose monitoring (CGM) and automated insulin delivery (AID); cardiovascular autonomic neuropathy (CAN) and the diabetic heart; and the role of primary care in the early detection, prevention and management of CKM diseases. The contribution of environmental plastic pollution to CVD risk, the increasing understanding of the efficacy and safety of incretin therapies in the treatment of CKM diseases, and the latest updates on nutrition strategies for CKM management under incretin-based therapies were also topics of interest for a vast audience of endocrinologists, diabetologists, cardiologists, nephrologists and primary care physicians, who actively engaged in online discussions. The 11th CVOT Summit will be held virtually on November 20-21, 2025 ( http://www.cvot.org ).

Epicardial adipose tissue: a new link between type 2 diabetes and heart failure-a comprehensive review

Diabetic cardiomyopathy is a unique cardiomyopathy that is common in diabetic patients, and it is also a diabetic complication for which no effective treatment is currently available. Moreover, relevant studies have revealed that a link exists between type 2 diabetes and heart failure and that abnormal thickening of EAT is inextricably linked to the development of diabetic heart failure. Numerous clinical studies have demonstrated that EAT is implicated in the pathophysiologic process of diabetic myocardial disease. In this overview, we will introduce the physiology, pathophysiology of the disease and potential therapeutic strategies, knowledge gaps, and future directions of the role of epicardial adipose tissue in type 2 diabetes mellitus and heart failure to promote the development of novel therapeutic approaches to improve the prognosis of patients with diabetic cardiomyopathy.

Chest-CT-based radiomics feature of epicardial adipose tissue for screening coronary atherosclerosis

BACKGROUND AND AIMS

This study aims to investigate the diagnostic value of chest-CT epicardial adipose tissue (EAT) radiomics feature in coronary atherosclerotic stenosis.

METHODS

Clinical data from 215 individuals who underwent coronary angiography and chest-CT scan from January to July 2022 at our institution were retrospectively analyzed. Based on the coronary angiography results, the total population, men, and women were divided into the CAD group and non-CAD group. radiomics feature of EAT at the level of the bifurcation of the left-main coronary artery on the transverse level of chest CT were measured. The features contain both first-order feature and shape-order feature.The differences between groups were analyzed using the t test or Chi-square test. The diagnostic efficacy of each parameter in diagnosing atherosclerotic stenosis of coronary arteries was assessed by plotting the receiver operating characteristic (ROC) curve.

RESULTS

First-order features: Mean, IntDen, Median, and RawIntDen; shape-order features: Area, Perim, Round, and BSA index; and clinical index: HbA1c showed statistical significance between the CAD group and the non-CAD group. The ROC curve analysis demonstrated high diagnostic efficacy, with the best for diagnostic efficacy being Median for the first-order feature parameter (AUC, 0.753; 95% confidence interval [CI], 0.689-0.817; t = 4.785, p < 0.001), Round for the shape-order feature (AUC, 0.775; 95% CI, 0.714-0.836; t = 7.842, p < 0.001), and HbA1c for the clinical index (AUC, 0.797; 95% CI, 0.783-0.856; t = 6.406, p < 0.001). After dividing the participants into male and female subgroups, the best diagnostic efficacy was observed with the BSA index for men (AUC, 0.743; 95% CI, 0.656-0.829; t = 5.128, p < 0.001) and Round for women (AUC, 0.871; 95% CI, 0.793-0.949; t = 7.247, p < 0.001).

CONCLUSIONS

Median, Round in radiomics feature of EAT on chest CT may play a role in the assessment of coronary atherosclerotic stenosis.

Epicardial Adipose Tissue as an Independent Risk Factor for Mortality in Pulmonary Arterial Hypertension

BACKGROUND

Increased epicardial adipose tissue (EAT) has adverse effects in cardiovascular diseases, independent of BMI. Estrogen levels may affect EAT accumulation. Little is known about the predictors and potential impact of EAT in pulmonary arterial hypertension (PAH).

RESEARCH QUESTION

Is EAT associated with estrogen levels, disease severity, and mortality in PAH?

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study of patients with PAH enrolled in the Penn Pulmonary Hypertension registry and used chest CT scans to quantify EAT. Serum estrone and estradiol levels were also measured.

RESULTS

A total of 221 patients were included in the analysis, with median follow-up of 88 months. Mean age was 55.1 years, 74.7% were female, mean BMI was 27.20 kg/m2, and the most common PAH etiology was connective tissue disease-associated PAH (43.0%) followed by idiopathic or heritable PAH (35.3%). Median EAT volume was 52.1 mL/m2. Of the 102 patients with a follow-up chest CT scan, EAT increased over time in 74 (71.8%). High EAT volume (hazard ratio, 2.62; 95% CI, 1.62-4.24; P < .001) and greater accumulation of EAT over time (hazard ratio, 1.09; 95% CI, 1.01-1.17; P = .03) were both independently associated with worse survival. Patients with high EAT volume had lower serum estrone (13.70 vs 30.60 pg/mL; P = .009) and estradiol (6.05 vs 19.40 pg/mL; P = .002) levels compared with those with low EAT volume.

INTERPRETATION

In patients with PAH, high EAT and a greater rate of accumulation of EAT volume were independently associated with worse survival. Higher EAT volume was also associated with lower estrogen levels. The association of EAT volume with survival was independent of BMI and disease severity, suggesting that EAT may be a marker for a unique PAH phenotype. Future research should investigate the role of EAT-modifying therapies in PAH and consider incorporating EAT into PAH risk models.

Epicardial adipose tissue features as a biomarker and therapeutic target in coronary artery disease

This study aimed to examine the interplay between epicardial adipose tissue (EAT) features, macrophage polarization, and the cytokines Resistin and Apelin in the context of coronary artery disease (CAD). Using a case-control design with 21 CAD and 20 non-CAD individuals, the study collected demographic data, cardiovascular risk factors, and medical histories. Metabolic risk factors were assessed through laboratory tests, and CAD presence was confirmed by imaging studies. Detailed measurements of epicardial adipose characteristics were obtained through CT scans. Blood samples were analyzed for Resistin and Apelin levels, and tissue samples from EAT for macrophage polarization. The results revealed no significant differences in EAT volume and density between CAD and non-CAD groups, but the CAD group exhibited a significantly higher Calcium score. Apelin and Resistin mRNA expression levels in the right ventricular epicardial and atrioventricular fat tissue showed significantly lower Apelin and higher Resistin levels in CAD patients. CD206 expression levels in EAT were substantially lower in the CAD group, while CD11c expression levels were significantly higher. The CAD group exhibited a significantly higher CD11c/CD206 ratio in adipose tissue macrophages. This investigation highlights the significance of molecular characteristics of EAT in CAD development. While no significant differences were found in EAT volume and density, lower Apelin and higher Resistin mRNA expression in CAD patients' right ventricular fat tissue were observed. Changes in macrophage polarization markers, lower CD206 and higher CD11c, along with a higher CD11c/CD206 ratio in the macrophages of CAD patients have been shown in two investigated regions of EAT.

Targeted intervention in obesity-associated atrial fibrosis using nanoparticle-loaded fusion protein

The association between obesity and atrial fibrillation (AF) has garnered increasing attention. Obesity is a significant risk factor for cardiovascular diseases and promotes the occurrence of AF through multiple mechanisms. This study aims to explore the molecular mechanisms of obesity-induced AF using GLP-1R/GIPR dual-target agonist fusion protein (Fc) loaded into adipose-derived mesenchymal stem cell (ADSC) exosome-liposome hybrid nanoparticles (LE@Fc NPs). We successfully constructed and purified the Fc, verifying its purity and functional activity through SDS-PAGE and UV absorption spectroscopy. The fusion protein was then loaded into nanovesicles, and their morphology, size, and stability were assessed using transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA), and dynamic light scattering (DLS). In vitro experiments demonstrated that LE@Fc NPs exhibit high fusion efficiency and targeted delivery capability. In vivo experimental results show that LE@Fc NPs significantly inhibit ferroptosis in the epicardial adipose tissue (EAT) of obese mice (iron content: 3.69 ± 0.36 vs. 0.88 ± 0.09), by restoring GSH levels (0.45 ± 0.08 vs. 0.87 ± 0.08) and Gpx4 expression (0.32 ± 0.06 vs. 1.01 ± 0.16), and reducing ROS (12.01 ± 0.95 vs. 2.68 ± 0.17), MDA (3.17 ± 0.29 vs. 0.95 ± 0.09), and 4-HNE (3.74 ± 0.51 vs. 0.91 ± 0.09) levels. Furthermore, LE@Fc NPs treatment significantly improved the inflammatory response (IL-1β: 44.08 ± 3.74 vs. 12.07 ± 0.65, IL-6: 515.59 ± 47.70 vs. 288.43 ± 16.81, MCP-1: 1401.04 ± 194.88 vs. 600.28 ± 45.54, TNF-α: 39.96 ± 2.48 vs. 18.01 ± 0.85). LE@Fc NPs also reduced atrial fibrosis, thereby effectively lowering the incidence of AF. Echocardiography and electrocardiogram monitoring revealed that LE@Fc NPs treatment significantly improved atrial remodeling and reduced the occurrence of AF in obese mice. In addition, LE@Fc NPs significantly improved obesity-induced systemic inflammation and metabolic disorders. In conclusion, LE@Fc NPs show great potential for the treatment of obesity-related AF.

Relationship between left atrium, epicardial fat and severity of atrial fibrillation

To investigate the relationship between left atrium (LA) and epicardial adipose tissue (EAT) parameters and different disease severities (paroxysmal and persistent) in patients with atrial fibrillation (AF). A total of 115 patients with AF (58 paroxysmal and 57 persistent) who underwent cardiac computed tomography angiography (CTA) at our institution between October 2021 and May 2022 were included. The left atrium volume index (LAVI) and left atrium fractal dimension (LAFD) were measured for each patient. EAT volumes and attenuation values for total heart and LA in early and delayed enhancement phases were calculated using semi-automated software. LA and EAT parameters were compared with patients with paroxysmal and persistent AF. Compared with paroxysmal AF, persistent AF had significantly greater LAVI (33.60 ml/m2 vs. 26.65 ml/m2, P < 0.001) and LAFD (1.31 vs. 1.22, P = 0.001). At both early and late enhancement, the total EAT volume (136.29 cm3 vs. 88.68 cm3, 152.30 cm3 vs. 88.96 cm3; all P < 0.001) and attenuation values (-84.00 HU vs. -87.50 HU, -83.00 HU vs. -86.00 HU; all P < 0.05) were significantly higher in persistent AF than in paroxysmal AF. Additionally, LA EAT volumes (15.53 cm3 vs. 8.19 cm3, 18.57 cm3 vs. 9.26 cm3; all P < 0.001) and attenuation values (-74.00 HU vs. -77.00 HU, -75.00 HU vs. -77.00 HU; all P < 0.05) were significantly larger in persistent AF compared with paroxysmal AF, in both early and late enhancement phases. Correlation analysis showed that both LA (r = 0.381, 0.310; P < 0.05) and EAT parameters (r = 0.524, 0.334, 0.665, 0.208, 0.537, 0.223, 0.606, 0.276; P < 0.05) were positively associated with AF severity. Both EAT (volume and attenuation values) and parameters for assessing LA size and morphology, including LAVI and LAFD, were related to the severity of AF.

Epicardial Adipose Tissue and Extracellular Volume Fraction in Patients with Hypertrophic Cardiomyopathy: A Multi‑center Prognosis Study

RATIONALE AND OBJECTIVES

Epicardial adipose tissue (EAT) is thought to have a deleterious effect on the progression of myocardial disease; the extracellular volume (ECV) fraction has been validated by histology to correlate with adverse myocardial remodeling. The aim of this study was to investigate the prognostic value of EAT volume index (EATVI) and ECV in patients with hypertrophic cardiomyopathy (HCM).

MATERIALS AND METHODS

ECV and EAT were measured using cardiac magnetic resonance (CMR) imaging in 201 subjects with HCM. All patients were followed up prospectively. Major adverse cardiovascular events (MACEs) were categorized into primary and secondary endpoint events. The primary endpoint was a composite of cardiac death, heart transplant, and cardiopulmonary resuscitation following syncope. The secondary endpoint was defined as rehospitalization for heart failure (HF).

RESULTS

After 26±16 months of follow-up, 43 patients experienced MACEs (14 patients experienced a primary endpoint, and 29 patients experienced a secondary endpoint). Patients suffering from MACEs had significantly higher ECV and EATVI (p<0.001). After adjustment for body mass index (BMI), EATVI showed a significant correlation with ECV (r=0.424, p<0.001) among HCM patients. In the Kaplan-Meier analysis, the incidence of MACE was significantly higher in patients with increased ECV (p<0.001) and higher EATVI (p<0.001). In multivariate Cox regression analysis, ECV (HR=1.12, p<0.001) and EATVI (HR=1.31, p<0.001) were significantly associated with MACEs.

CONCLUSION

In patients with HCM, ECV and EATVI measured by CMR are strong predictors of MACEs and improve risk stratification.

CLINICAL IMPLICATION

Extracellular volume fraction and epicardial adipose tissue are associated with major adverse cardiovascular events in patients with hypertrophic cardiomyopathy and can improve their risk stratification.

Insulin resistance aggravates myocardial fibrosis in non-diabetic hypertensive patients by altering the function of epicardial adipose tissue: a cardiac magnetic resonance study

BACKGROUND

The effect of insulin resistance (IR) on epicardial adipose tissue (EAT) remains uncertain. This study aimed to investigate how early-stage IR influences EAT, contributing to myocardial fibrosis and left ventricular dysfunction in non-diabetic patients with hypertension.

METHODS

A total of 166 hypertensive patients who underwent cardiovascular magnetic resonance (CMR) treatment at two medical centers in China from June 2015 to August 2024 were included. Triglyceride-glucose index (TyG) was calculated, cardiac MRI parameters and EAT were measured. Patients were divided into two groups based on the median TyG. Binary logistic regression model, subgroup analysis and causal mediation analysis were used to evaluate the correlation between EAT, TyG and CMR parameters. Thirty healthy volunteers served as the control group.

RESULTS

The high TyG group exhibited greater EAT volume, higher Native T1, and increased ECV (All P < 0.001) compared to the low TyG group. Additionally, significant differences were observed in GRS (P = 0.025), GLS (P = 0.015), and GCS (P = 0.048). Binary logistic regression analysis indicated that TyG and indexed EAT volume were independently associated with high ECV value (TyG: OR 2.808, p = 0.002;indexed EAT volume: OR 1.038, p = 0.002), with results remaining stable after adjusting for confounding factors. Mediation analysis showed that even after adjusting for confounding factors, EAT continued to play a role in TyG-mediated ECV (indirect effect: 0.8844, [95% CI 0.4539-1.3666]).

CONCLUSIONS

IR in non-diabetic individuals at an early stage may change the physiological function of EAT and lead to the onset of myocardial fibrosis. Addressing IR early on could potentially improve the physiological function of EAT.

Obesity and its management in primary care setting

Obesity is a worldwide epidemic affecting adults and children, regardless of their socioeconomic status. Significant progress has been made in understanding the genetic causes contributing to obesity, shedding light on a portion of cases worldwide. In young children with severe obesity however, recessive mutations, i.e., leptin or leptin receptor deficiency should be sought. Much more has been learned about the far-reaching impact of obesity on complications, including cardiovascular disease, liver and kidney dysfunction, diabetes, inflammation, hypertension, sleep, cancer, and the eye. Preventive strategies, particularly in children, are crucial for reducing obesity rates and mitigating its long-term complications. While dietary modifications and lifestyle changes remain the cornerstone of obesity prevention or treatment, recent advancements have introduced highly effective pharmacological options complementing weight-reduction surgery. Newer medications, like incretin-based therapies including glucagon-like peptide-1 agonists (GLP-1RA), have demonstrated remarkable efficacy in promoting weight loss, offering new insights into margining obesity-related conditions. Primary care providers, whether treating adults or children, play a pivotal role in preventing obesity, initiating treatment, and making onward referrals to specialists to assist in managing obesity and obesity-related complications.

Predictive Value of Peri-Coronary Fat Attenuation Index in Elderly Non-ST-Elevation Myocardial Infarction and Its Correlation with Platelet to Lymphocyte Ratio

BACKGROUND

Inflammatory mediators and immune activation can intensify the inflammatory response within atherosclerotic plaques, increasing the risk of plaque rupture and thrombosis. This study aims to compare peri-coronary adipose tissue fat attenuation index (PCAT-FAI) and platelet-to-lymphocyte ratio (PLR) between NSTEMI and SA patients, and explore their combined predictive ability for NSTEMI.

PATIENTS AND METHODS

The study included 52 NSTEMI patients aged 65 and older who underwent both CCTA and CAG from January 2020 to December 2022, alongside 52 gender- and age-matched SA patients, and 52 control patients. PCAT-volume and PCAT-FAI were measured using Siemens VB20.0, and PLR was calculated from peripheral blood tests.

RESULTS

Among 156 patients, NSTEMI patients had significantly higher PCAT volume (12.13 ± 5.32 mm³) compared to SA (8.39 ± 4.10 mm³, p < 0.001) and controls (6.28 ± 3.40 mm³, p < 0.001). They also had higher PCAT-FAI (-76.28 ± 5.33 HU) than SA (-82.87 ± 6.19 HU, p < 0.001) and controls (-84.19 ± 5.74 HU, p < 0.001). PLR was higher in NSTEMI patients (178.27 ± 107.18) compared to SA (115.54 ± 45.28, p = 0.002) and controls (116.09 ± 38.09, p = 0.006), with no significant difference between SA and controls (p = 1.000). PCAT-FAI correlated with PLR (CC: 0.298; P < 0.01). Combining PLR and PCAT-FAI predicted NSTEMI with an AUC of 0.799 (95% CI, 0.715-0.883).

CONCLUSION

Higher PCAT-FAI and PLR in NSTEMI patients highlight the role of adipose tissue inflammation and thrombosis in coronary artery disease progression. Combined assessment of PCAT-FAI and PLR has potential value in predicting the adverse progression of atherosclerotic plaques.

The role of epicardial adipose tissue remodelling in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a growing global health problem characterized by high morbidity and mortality, with limited effective therapies available. Obesity significantly influences haemodynamic and structural changes in the myocardium and vasculature, primarily through the accumulation and action of visceral adipose tissue. Particularly, epicardial adipose tissue (EAT) contributes to HFpEF through inflammation and lipotoxic infiltration of the myocardium. However, the precise signalling pathways leading to diastolic stiffness in HFpEF require further elucidation. This review explores the dynamic role of EAT in health and disease. Drawing upon insights from studies in other conditions, we discuss potential EAT-mediated inflammatory pathways in HFpEF and how they may contribute to functional and structural myocardial and endothelial derangements, including intramyocardial lipid infiltration, fibrosis, endothelial dysfunction, cardiomyocyte stiffening, and left ventricular hypertrophy. Lastly, we propose potential targets for novel therapeutic avenues.

Role of metabolic dysfunction-associated fatty liver disease in atrial fibrillation and heart failure: molecular and clinical aspects

Metabolic dysfunction-associated fatty liver disease (MASLD) is a rising global health concern. In addition to direct hepatic complications, extra-hepatic complications, including cardiovascular diseases (CVD), type 2 diabetes (T2D), gastroesophageal reflux disease, chronic kidney disease and some malignancies, are increasingly recognized. CVD, including atrial fibrillation (AF) and heart failure (HF), is the leading cause of death in patients with MASLD. External factors, including excess energy intake, sedentary lifestyle and xenobiotic use, induce inflammation-related complications. MASLD, AF, and HF are associated with immune system activation, including the reprogramming of immune cells and the establishment of immune memory. Emerging evidence suggests that the heart and the liver cross-talk with each other through the diverse spectrum of autocrine, paracrine and endocrine mechanisms. Pro-inflammatory cytokines produced from the liver and the heart circulate systemically to orchestrate metabolic derangements that promote the systematic immune dysregulation in the heart-liver axis and the development of end-organ complications. Cardio-hepatic syndrome describes the clinical and biochemical evidence of hepatic dysfunction and cardiac pathology due to the interaction between the heart and the liver. Activation of inflammatory cascades, oxidative stress and immune system dysregulation underlie key mechanisms in bringing about such pathological changes. This review focuses on the current clinical and molecular evidence about the heart-liver cross-talk. It summarizes the epidemiological and pathophysiological associations of MASLD, AF and HF. In addition, we will discuss how repurposing currently available and emerging pharmacotherapies may help tackle the cardiovascular risks resulting from MASLD.

Epicardial fat thickness is increased in menopausal patients in comparison with premenopausal patients with similar excess weight: a cross-sectional study

BACKGROUND

The prevalence of excess weight and ageing is notably high in contemporary Western societies. The effectiveness of body mass index (BMI) and waist circumference as tools for identifying excess weight and ectopic fat deposition, both associated with an increased cardiovascular risk, is questionable.

METHODS

Our objective is to compare women affected by overweight and obesity during fertile years and menopausal time and identify easily accessible clinical parameters associated with ectopic fat deposition, providing valuable insights into cardiovascular risk. Over 1300 female patients with excess weight referred to the CASCO Centre (High Specialization Centre for the Care of Obesity) at Umberto I Polyclinic in Rome, Italy, were included. Each participant underwent a DXA scan and a cardiac ultrasound, and blood tests to verify menopausal status and evaluate metabolic profile and hepatic steatosis through indirect measurements.

RESULTS

775 patients were in the pre-menopausal phase and 617 in the post-menopausal phase. The two cohorts did not differ in BMI, total body fat and lean mass, or waist circumference. However, the post-menopausal group showed an increased visceral fat deposition, evaluated by waist-to-hip ratio and epicardial fat thickness (EFT), and a worse metabolic profile.

CONCLUSION

Menopause is associated with a worsening of the metabolic features observed in obesity, with an increase in visceral fat deposition. Of note, these alterations are more pronounced despite similar BMI and waist circumference.

Metabolic rewiring and inter-organ crosstalk in diabetic HFpEF

Heart failure with preserved ejection fraction (HFpEF) represents a significant and growing clinical challenge. Initially, for an extended period, HFpEF was simply considered as a subset of heart failure, manifesting as haemodynamic disorders such as hypertension, myocardial hypertrophy, and diastolic dysfunction. However, the rising prevalence of obesity and diabetes has reshaped the HFpEF phenotype, with nearly 45% of cases coexisting with diabetes. Currently, it is recognized as a multi-system disorder that involves the heart, liver, kidneys, skeletal muscle, adipose tissue, along with immune and inflammatory signaling pathways. In this review, we summarize the landscape of metabolic rewiring and the crosstalk between the heart and other organs/systems (e.g., adipose, gut, liver and hematopoiesis system) in diabetic HFpEF for the first instance. A diverse array of metabolites and cytokines play pivotal roles in this intricate crosstalk process, with metabolic rewiring, chronic inflammatory responses, immune dysregulation, endothelial dysfunction, and myocardial fibrosis identified as the central mechanisms at the heart of this complex interplay. The liver-heart axis links nonalcoholic steatohepatitis and HFpEF through shared lipid accumulation, inflammation, and fibrosis pathways, while the gut-heart axis involves dysbiosis-driven metabolites (e.g., trimethylamine N-oxide, indole-3-propionic acid and short-chain fatty acids) impacting cardiac function and inflammation. Adipose-heart crosstalk highlights epicardial adipose tissue as a source of local inflammation and mechanical stress, whereas the hematopoietic system contributes via immune cell activation and cytokine release. We contend that, based on the viewpoints expounded in this review, breaking this inter-organ/system vicious cycle is the linchpin of treating diabetic HFpEF.

The interaction of lipomatous hypertrophy of the interatrial septum with pericardial adipose tissue biomarkers by computed tomography

OBJECTIVE

Novel pericardial adipose tissue imaging biomarkers are currently under investigation for cardiovascular risk stratification. However, a specific compartment of the epicardial adipose tissue (EAT), lipomatous hypertrophy of the interatrial septum (LHIS), is included in the pericardial fat volume (PCFV) quantification software. Our aim was to evaluate LHIS by computed tomography angiography (CTA), to elaborate differences to other pericardial adipose tissue components (EAT) and paracardial adipose tissue (PAT), and to compare CT with [18F]FDG-PET.

MATERIALS AND METHODS

Of 6983 patients screened who underwent coronary CTA for clinical indications, 190 patients with LHIS were finally included (age 62.8 years ± 9.6, 31.6% females, BMI 28.5 kg/cm2 ± 4.7) in our retrospective cohort study. CT images were quantified for LHIS, EAT, and PAT density (HU), and total PCFV, with and without LHIS, was calculated. CT was compared with [18F]FDG-PET if available.

RESULTS

CT-density of LHIS was higher (- 22.4 HU ± 22.8) than all other pericardial adipose tissue components: EAT right and left (97.4 HU ± 13 and - 95.1 HU ± 13) PAT right and left (- 107.5 HU ± 13.4 and - 106.3 HU ± 14.5) and PCFV density -83.3 HU ± 5.6 (p < 0.001). There was a mild association between LHIS and PAT right (Beta 0.338, p = 0.006, 95% CI: 0.098-577) and PAT left (Beta 0.249, p = 0.030; 95% CI: 0.024-0.474) but not EAT right (p = 0.325) and left (p = 0.351), and not with total PCFV density (p = 0.164). The segmented LHIS volume comprised 3.01% of the total PCFV, and 4.3% (range, 2.16-11.7%) in those with LHIS > 9 mm. [18F]FDG-PET: LHIS was tracer uptake positive in 83.3% (37.5%: mild and 45.8%: minimal) of 24 patients.

CONCLUSIONS

LHIS is a distinct compartment of PCFV with higher density suggesting brown fat and has no consistent association with EAT, but rather with PAT.

CLINICAL RELEVANCE STATEMENT

LHIS should be recognized as a distinct compartment of the EAT, when using EAT for cardiovascular risk stratification.

KEY POINTS

LHIS is currently included in EAT quantification software. LHIS density is relatively high, it is not associated with EAT, and has a high [18F]FDG-PET positive rate suggesting brown fat. LHIS is a distinct compartment of the EAT, and it may act differently as an imaging biomarker for cardiovascular risk stratification.

Methylene blue reduces monoamine oxidase expression and oxidative stress in human cardiovascular adipose tissue

Cardiovascular diseases represent the major cause of morbidity mainly due to chronic heart failure. Epicardial (EAT) and perivascular adipose tissues (PVAT) are considered major contributors to the pathogenesis of cardiometabolic pathologies. Monoamine oxidases (MAOs) are mitochondrial enzymes recognized as sources of reactive oxygen species (ROS) in cardiometabolic pathologies. Methylene blue (MB) is one of the oldest protective agents, yet no data are available about its effects on adipose tissue. The present pilot study was aimed at assessing the effects of MB: (i) on MAO expression and (ii) oxidative stress in EAT and PVAT harvested from patients with heart failure subjected to cardiac surgery (n = 25). Adipose tissue samples were incubated with MB (0.1 µM/24 h) and used for the assessment of MAO gene and protein expression (qPCS and immune fluorescence) and ROS production (confocal microscopy and spectrophotometry). The human cardiovascular adipose tissues contain both MAO isoforms, predominantly MAO-A. Incubation with MB reduced MAOs expression and oxidative stress; co-incubation with serotonin, the MAO-A substrate, further augmented ROS generation, an effect partially reversed by MB. In conclusion, MAO-A is the major isoform expressed in EAT and PVAT and contribute to local oxidative stress; both effects can be mitigated by methylene blue.

Advances in Pathophysiological Mechanisms of Degenerative Aortic Valve Disease

Degenerative aortic valve disease (DAVD) represents the most prevalent valvular ailment among the elderly population, which significantly impacts their physical well-being and potentially poses a lethal risk. Currently, the underlying mechanisms of DAVD remain incompletely understood. While the progression of this disease has traditionally been attributed to degenerative processes associated with aging, numerous recent studies have revealed that heart valve calcification may represent a response of valve tissue to a specific initiating factor, involving the interaction of various genes and signaling pathways. This calcification process is further influenced by a range of factors, including genetic predispositions, environmental exposures, metabolic factors, and hemodynamic considerations. Based on the identification of its biomarkers, potential innovative therapeutic targets are proposed for the treatment of this complex condition. The present article primarily delves into the underlying pathophysiological mechanisms and advancements in diagnostic and therapeutic modalities pertaining to this malady.

Diagnostic potential of pericoronary adipose tissue mean attenuation for coronary atherosclerotic heart disease: a comparative analysis with the fat attenuation index

Background

The fat attenuation index (FAI), a threshold-based method for assessing pericoronary adipose tissue (PCAT) density, provides strong evidence for patient-specific coronary inflammation assessment. However, the reliance on fat thresholds may result in the omission of some critical information. Thus, this study aimed to explore the diagnostic potential of a novel method, pericoronary adipose tissue mean attenuation (PCATMA), which is not constrained by fat threshold limitations, by investigating the relationships among PCATMA, the FAI, and coronary artery plaque types.

Methods

This single-center observational study enrolled patients undergoing coronary computed tomography angiography (CCTA) between May 2021 and October 2022. In total, 75 patients with plaque and 63 patients without plaque were enrolled in the study. PCAT density was measured at various distances (0.50, 0.75, 1.00, 1.25, 1.50, 1.75, and 2.00 mm) from the vascular wall in the non-plaque group to investigate the effect of varying distances from the coronary artery on PCAT density. A Bland-Altman analysis and intraclass correlation coefficients were used to assess the feasibility and reproducibility of the PCATMA measurements. PCATMA and the FAI were measured in all patients to compare the differences between PCATMA and the FAI in the assessment of coronary atherosclerotic lesions.

Results

As the distance from the lumen increased, the PCAT density gradually decreased, plateauing after a distance of 0.75 mm (P=0.907). There were no differences between PCATMA and the FAI of each vessel in the non-plaque group (P>0.05), but the proximal right coronary artery (RCA) had a higher FAI compared to the mid-RCA (P=0.03). Compared with the non-plaque group, significant differences in PCATMA were observed in coronary artery segments with non-calcified plaque (NCP) (P<0.001) and mixed plaque (MP) (P=0.047); however, no such significant differences were found for the FAI (all P>0.05). Nor were any significant differences found between PCATMA and the FAI in terms of the different types of plaque (all P>0.05).

Conclusions

The novel PCATMA measurement method based on non-fat threshold limitations has good feasibility and repeatability. PCATMA may be more sensitive than the FAI in assessing changes in PCAT density resulting from early coronary artery inflammation, but it is not associated with plaque type.

Novel therapeutic agents for cardiometabolic risk mitigation in heart transplant recipients

Heart transplant (HT) recipients experience high rates of cardiometabolic disease. Novel therapies targeting hyperlipidemia, diabetes, and obesity, including proprotein convertase subtilisin/kexin inhibitors, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 agonists, are increasingly used for cardiometabolic risk mitigation in the general population. However, limited data exist to support the use of these agents in patients who have undergone heart transplantation. Herein, we describe the mechanisms of action and emerging evidence supporting the use of novel pharmacologic agents in the post-HT setting for cardiometabolic risk mitigation and review evidence supporting their ability to modulate immune pathways associated with atherogenesis, epicardial adipose tissue, and coronary allograft vasculopathy.

Sex Difference in the Association Between Regional Adipose Tissue and Left Ventricular Hypertrophy

Background: Left ventricular hypertrophy (LVH) is a key predictor of cardiovascular disease. This study aimed to investigate the correlation between LVH and regional adipose tissue deposits, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and epicardial adipose tissue (EAT), and sex-related differences in these correlations. Methods: A total of 416 individuals (median age 66 years, range 20-95), without structural heart disease or a history of hypertension and coronary artery disease, underwent echocardiography and abdominal computed tomography. Statistical analyses included logistic and linear regression to assess the associations between adipose tissue measures and LVH. Results: LVH was associated with older age, higher systolic blood pressure, and increased EAT thickness. EAT thickness was independently associated with LVH in women (OR 1.21, 95% CI 1.03-1.44, p = 0.024) but not in men. Scatter plot analysis revealed a positive correlation between EAT and left ventricular mass index (LVMI) in women (r = 0.366, p < 0.001) and a negative correlation in men (r = -0.153, p = 0.038). Conclusions: VAT and SAT showed no significant associations with LVMI or LVH in either sex. These findings suggest that EAT, but not VAT or SAT, is linked to cardiac remodeling in a sex-specific manner.

Deep learning-quantified body composition from positron emission tomography/computed tomography and cardiovascular outcomes: a multicentre study

BACKGROUND AND AIMS

Positron emission tomography (PET)/computed tomography (CT) myocardial perfusion imaging (MPI) is a vital diagnostic tool, especially in patients with cardiometabolic syndrome. Low-dose CT scans are routinely performed with PET for attenuation correction and potentially contain valuable data about body tissue composition. Deep learning and image processing were combined to automatically quantify skeletal muscle (SM), bone and adipose tissue from these scans and then evaluate their associations with death or myocardial infarction (MI).

METHODS

In PET MPI from three sites, deep learning quantified SM, bone, epicardial adipose tissue (EAT), subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and intermuscular adipose tissue (IMAT). Sex-specific thresholds for abnormal values were established. Associations with death or MI were evaluated using unadjusted and multivariable models adjusted for clinical and imaging factors.

RESULTS

This study included 10 085 patients, with median age 68 (interquartile range 59-76) and 5767 (57%) male. Body tissue segmentations were completed in 102 ± 4 s. Higher VAT density was associated with an increased risk of death or MI in both unadjusted [hazard ratio (HR) 1.40, 95% confidence interval (CI) 1.37-1.43] and adjusted (HR 1.24, 95% CI 1.19-1.28) analyses, with similar findings for IMAT, SAT, and EAT. Patients with elevated VAT density and reduced myocardial flow reserve had a significantly increased risk of death or MI (adjusted HR 2.49, 95% CI 2.23-2.77).

CONCLUSIONS

Volumetric body tissue composition can be obtained rapidly and automatically from standard cardiac PET/CT. This new information provides a detailed, quantitative assessment of sarcopenia and cardiometabolic health for physicians.

Characterizing cardiac adipose tissue in post-acute myocardial infarction patients via CT imaging: a comparative cross-sectional study

AIMS

To identify differences in CT-derived perivascular adipose tissue (PVAT) and epicardial adipose tissue (EAT) characteristics that may indicate inflammatory status differences between post-treatment acute myocardial infarction (AMI) and stable coronary artery disease (CAD) patients.

METHODS AND RESULTS

A cohort of 205 post-AMI patients (age 59.8 ± 9.2, 92.2% male) was propensity-matched with 205 stable CAD patients (age 60.5 ± 10.0, 90.2% male). Coronary CT angiography and non-contrast CT scans were performed to assess PVAT mean attenuation across major coronary segments and EAT mean attenuation and volumes, respectively. For post-AMI patients, CT scans were conducted 28.6 ± 13.8 days after the AMI incidence. Post-AMI patients showed higher non-culprit PVAT and EAT mean attenuation than stable CAD patients (8.01 HU, 95% CI 5.90-10.11 HU, P < 0.001, 2.48 HU, 95% CI 0.83-4.13 HU, P = 0.003, respectively). The EAT volume percentage at higher attenuation levels was higher in post-AMI patients compared with stable CAD (33.93 cm3, 95% CI 16.86-51.00 cm3, P < 0.001), with the difference maximized at the -70 HU threshold (4.75%, 95% CI 3.64%-5.87%, P < 0.001). PVAT mean attenuation positively correlated with EAT mean attenuations and the percentage of EAT volume > -70 HU (P < 0.001 for both).

CONCLUSION

Post-AMI patients showed higher PVAT and EAT attenuation than stable CAD patients, potentially indicating AMI-associated inflammatory cardiac adipose tissue changes. A total of -70 HU can act as a potential cut-off for inflamed EAT. These findings highlight the potential of using CT-derived adipose tissue characteristics to assess inflammation and guide post-AMI management strategies.

Pulse pressure and aortic valve peak velocity and incident heart failure after myocardial infarction: a cohort study

BACKGROUND

Heart failure with preserved ejection fraction is a recognised outcome in patients with myocardial infarction, although heart failure with reduced ejection fraction is more common. Identifying early indicators specific to heart failure with preserved ejection fraction in patients with myocardial infarction could support targeted preventive strategies. This study aimed to determine if pulse pressure and aortic valve peak velocity could serve as early predictors of heart failure with preserved ejection fraction in patients with myocardial infarction.

METHODS

We retrospectively analysed data from 5188 participants in the Atherosclerosis Risk in Communities Study who were free from heart failure at baseline, including 802 individuals with a history of myocardial infarction. Heart failure events were classified as either heart failure with preserved ejection fraction (left ventricular ejection fraction ≥50%) or heart failure with mildly reduced or reduced ejection fraction (left ventricular ejection fraction <50%). Competing risk regression models were used to examine associations of baseline pulse pressure and aortic valve peak velocity with heart failure subtypes.

RESULTS

Over 6 years of follow-up, 217 cases of heart failure with preserved ejection fraction (including 50 in patients with myocardial infarction) and 127 cases of heart failure with mildly reduced or reduced ejection fraction (33 in patients with myocardial infarction) were identified. Among patients with myocardial infarction, a 1-SD increase in pulse pressure was associated with a 1.60-fold higher risk of heart failure with preserved ejection fraction (95% CI 1.30 to 1.97), and a similar association was observed for aortic valve peak velocity (HR: 1.37, 95% CI 1.19 to 1.58). Patients with pulse pressure ≥68 mm Hg had a 3.83-fold higher risk of heart failure with preserved ejection fraction compared with those with lower pulse pressure, and those with aortic valve peak velocity ≥1.4 m/s had a 2.10-fold higher risk compared with those with lower values. Patients with myocardial infarction with two or more risk factors among elevated pulse pressure, aortic valve peak velocity, diabetes and atrial fibrillation had over 16 times the risk of developing heart failure with preserved ejection fraction compared with those without these risk factors (p<0.001).

CONCLUSIONS

Pulse pressure and aortic valve peak velocity are significant predictors of heart failure with preserved ejection fraction in patients with myocardial infarction, suggesting their potential value in early risk stratification. These findings support the use of these markers to guide timely interventions aimed at preventing the progression to heart failure with preserved ejection fraction.

Epicardial Fat in Heart Failure and Preserved Ejection Fraction: Novel Insights and Future Perspectives

PURPOSE OF REVIEW

Cardiovascular effects of obesity may be driven, in part, by the distribution of fat. More recently, epicardial adipose tissue (EAT) has gained recognition as an adverse visceral fat impacting cardiac dysfunction in heart failure with preserved ejection fraction (HFpEF).

RECENT FINDINGS

EAT can be identified and measured using several non-invasive imaging techniques, including transthoracic echocardiography, computed tomography, and cardiac magnetic resonance. The presence of EAT is associated with increased risk of HFpEF and worse clinical outcomes among patients with established HFpEF, independent of total adiposity. EAT may serve a pivotal role in the pathogenesis of HFpEF by worsening volume distribution, enhancing pericardial restraint and ventricular interaction, worsening right ventricular dysfunction, and diminishing exercise tolerance. No large trials have tested the effects of reducing fat in specific areas of the body on cardiovascular outcomes, but some studies that followed people in communities and trials over time have suggested that drug and non-drug treatments that lower EAT could improve the risk factors for heart problems in patients with HFpEF. Further understanding the role that pathogenic fat depots play in HFpEF incidence and progression may provide future therapeutic targets in treating the obese-HFpEF phenotype.

Detection of arterial remodeling using epicardial adipose tissue assessment from CT calcium scoring scan

Introduction

Non-contrast CT calcium scoring (CTCS) exams have been widely used to assess coronary artery disease. However, their clinical applications in predicting coronary arterial remodeling remain unknown. This study aimed to develop a novel machine learning model to predict positive remodeling (PR) from CTCS scans and evaluate its clinical value in predicting major adverse cardiovascular events (MACE).

Methods

We analyzed data from 1,324 patients who underwent both CTCS and CT angiography. PR was defined as an outer vessel diameter at least 10% greater than the average diameter of the segments immediately proximal and distal to the plaque. We utilized a total of 246 features, including 23 clinical features, 12 Agatston score-derived features, and 211 epicardial fat-omics features to predict PR. Feature selection was performed using Elastic Net logistic regression, and the selected features were used to train a CatBoost machine learning model. Classification performance was evaluated using 1,000 repetitions of five-fold cross-validation and survival analyses, comparing actual and predicted PR in the context of predicting MACE.

Results

PR was identified in 429 patients (32.4%). Using Elastic Net, we identified the top 13 features, including four clinical features, three Agatston score-derived features, and six fat-omics features. Our method demonstrated excellent classification performance for predicting PR, achieving a sensitivity of 80.3 ± 1.7%, a specificity of 89.7 ± 1.7%, and accuracy of 81.9 ± 2.5%. The Agatston-score-derived and fat-omics features provided additional benefits, improving classification performance. Furthermore, our model effectively predicted MACE, with a hazard ratio (HR) of 4.5 [95% confidence interval (CI): 3.2-6.4; C-index: 0.578; p < 0.00001] in the training set and an HR of 3.2 (95% CI: 2.5-4.0; C-index: 0.647; p < 0.00001) in the external validation set.

Conclusion

We developed an innovative machine learning model to predict coronary arterial remodeling from epicardial fat and calcification features from low-cost/no-cost screening CTCS scans. Our results suggest that vast number of CTCS scans can support more informed clinical decision-making and potentially reduce the need for invasive and costly testing for low-risk patients.

The role of estrogen in the sex difference for the risk factors of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a major subtype of heart failure, primarily characterized by a normal or mildly reduced left ventricular ejection fraction along with left ventricular diastolic dysfunction. Recent studies have shown that the prevalence of HFpEF is higher in women than that in men, particularly in postmenopausal women. Concurrently, it has been observed that the incidence of risk factors contributing to HFpEF (such as obesity, hypertension, diabetes, and atrial fibrillation) also notably increases post-menopause, affecting the incidence of HFpEF. This review aimed to examine the relationship between estrogen and risk factors associated with HFpEF, clarifying the underlying mechanisms through which estrogen affects these risk factors from epidemiological and pathophysiological perspectives. This review also provides a comprehensive understanding of the association between estrogen and the risk factors for HFpEF, thus helping explore potential targets for HFpEF treatment.

Targeting Epicardial/Pericardial Adipose Tissue in Cardiovascular Diseases: A Novel Therapeutic Strategy

Cardiovascular diseases (CVDs) remain a global health concern, prompting ongoing research into novel contributors to their pathogenesis. Due to the proximity of the coronary arteries and the myocardium in epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT), these tissues have emerged as key areas of interest for their potential influence on cardiac function and vascular health. This review synthesizes current research on the physiological and biological characteristics of EAT and PAT, exploring their composition and clinical measurement approaches. The roles of EAT and PAT in coronary artery disease (CAD), atrial fibrillation, and heart failure are discussed, and the contributions of EAT and PAT to these cardiovascular conditions are highlighted alongside their potential as therapeutic targets.

Characterization of epicardial adipose tissue thickness and structure by ultrasound radiomics in acute and chronic coronary patients

We hypothesize that epicardial adipose tissue (EAT) structure differs between patients with coronary disease and healthy individuals and that EAT may undergo changes during an acute coronary syndrome (ACS). This study aimed to investigate EAT thickness (EATt) and structure using ultrasound radiomics in patients with ACS, patients with chronic coronary syndrome (CCS), and controls and compare the findings between the three groups. This prospective monocentric comparative cohort study included three patient groups: ACS, CCS, and asymptomatic controls. EATt was assessed using transthoracic echocardiography. Geometrical features (as mean gray value and raw integrated density) and texture features (as angular second moment, contrast and correlation) were computed from grayscale Tagged Image File Format biplane images using ImageJ software. EATt did not significantly differ between the ACS group (8.14 ± 3.17 mm) and the control group (6.92 ± 2.50 mm), whereas CCS patients (9.96 ± 3.19 mm) had significantly thicker EAT compared to both the ACS group (p = 0.025) and the control group (p < 0.001). Radiomics analysis revealed differences in geometrical parameters with discriminatory capabilities between both ACS group and controls and CCS group and controls. A multivariate analysis comparing ACS and CCS patients revealed that differences in EAT characteristics were significant only in patients with a body mass index below 26.25 kg/m². In this subgroup, patients older than 68 exhibited a higher modal gray value (p = 0.016), whereas those younger than 68 had a lower minimum gray value (p = 0.05). Radiomic analysis highlights its potential in developing imaging biomarkers for early diagnosis and coronary artery disease progression monitoring.

Visceral fat as the main tomographic risk factor for COVID-19 mortality

BACKGROUND

Obesity is a risk factor for COVID-19 mortality; a BMI >35 increases the risk of death up to 12-fold; two previous studies have examined the association between visceral fat quantified by tomography and the risk of severe COVID-19, but not its association with mortality.

OBJECTIVE

Examine whether tomographic findings differentiated data from patients who died of COVID-19 pneumonia from those who survived in a cohort of patients at a tertiary hospital.

METHODS

This was a case-control study (1:1) in which we recruited data from patients at a tertiary care hospital in Mexico. Cases (N = 213) were data from patients with COVID-19 pneumonia discharged due to death, and controls (N = 216) were data from patients discharged due to improvement. All had chest computed tomography (CT) scans in the Picture Archiving and Communication System (PACS) platform. Multivariate analysis was used to identify tomographic variables associated with mortality, and odds ratios were calculated. As tomographic variables, we refer to the total severity score, the total percentage of pulmonary involvement, the pattern of involvement, the location of the lesions, and subcutaneous and visceral fat.

RESULTS

A total of 429 sets of data from Mexican patients were analyzed, with an overall age of 57 years (18-93). Sixty-three percent were male, and arterial hypertension was the most common comorbidity in 48.3 %. An odds ratio (OR) of 8.79 (95 % CI 1.44-53.73) was found for visceral fat and mortality; the rest of the tomographic variables did not show a statistically significant association.

CONCLUSION

Visceral fat was the most significant tomographic risk factor for mortality in patients with COVID-19 pneumonia.

Epicardial fat volume assessment and strain analysis by cardiac magnetic resonance: a novel method for evaluating microcirculation dysfunction after myocardial infarction

Background

In the context of acute ST-segment elevation myocardial infarction (STEMI), epicardial fat volume (EFV) has a significant impact on the formation of microvascular obstruction (MVO). This study aimed to quantitatively measure the EFV and myocardial strain parameters by cardiac magnetic resonance (CMR) and to explore their relationship with the presence or absence of mcrocirculation dysfunction after myocardial infarction.

Methods

This was a retrospective study. From June 2022 to December 2023, 56 consecutive patients diagnosed with acute STEMI who underwent percutaneous coronary intervention (PCI) were selected from The First Affiliated Hospital of Bengbu Medical University. Patients were divided into two groups based on the presence of MVO group and the non-MVO (NMVO) group, with 22 cases (39%) and 34 cases (61%) respectively. The characteristics of the infarction were assessed by delayed enhancement with gadolinium. Based on standard cine images, the global circumferential strain (GCS), global radial strain (GRS), and global longitudinal strain (GLS) of the left and right ventricles were evaluated using CMR feature tracking (CMR-FT) imaging. The volume of EFV was quantified along the short-axis slices of the left and right ventricles at the end of diastole by CMR imaging. The differences in baseline characteristics, EFV, and myocardial strain parameters between the groups were compared using Pearson or Spearman correlation analysis. The specificity and sensitivity of myocardial strain parameters in predicting MVO were obtained using receiver operating characteristic (ROC) curves. The predictive factors for MVO were analyzed using univariate and multivariate logistic regression analyses.

Results

A total of 56 patients were selected, with an average age of 59.84±12.37 years, including 42 males (75%) and 14 females (25%). There was a statistically significant difference in EFV between the MVO group and the NMVO group (P<0.001). The prediction model for MVO based on EFV [area under the ROC curve (AUC): 0.856; 95% confidence interval (CI): 0.736-0.935; sensitivity: 77.27%; specificity: 91.18%], GLS (AUC: 0.929; 95% CI: 0.828-0.980; sensitivity: 90.90%; specificity: 94.12%), GCS (AUC: 0.770; 95% CI: 0.638-0.872; sensitivity: 86.36%; specificity: 61.76%), GRS (AUC: 0.789; 95% CI: 0.659-0.886; sensitivity: 90.19%; specificity: 70.59%). The left ventricular ejection fraction in the MVO group was lower than that in the NMVO group (P=0.001). The GLS, GRS, and GCS in the MVO group were significantly lower than those in the NMVO group (P<0.001). Correlation analysis found that EFV (r=0.602, P<0.001), GLS (r=0.726, P<0.001), GCS (r=0.457, P<0.001) was significantly positively correlated with postoperative myocardial infarction with mcrocirculation obstruction, while GRS (r=-0.486, P<0.001) were negatively correlated with postoperative myocardial infarction with mcrocirculation obstruction.

Conclusions

After myocardial infarction, there is more EFV in the presence of mcrocirculation dysfunction, and the local myocardial function is reduced more. Monitoring EFV plays a significant role in the early anti-lipid treatment strategy for patients with MVO.

Tirzepatide Reduces LV Mass and Paracardiac Adipose Tissue in Obesity-Related Heart Failure: SUMMIT CMR Substudy

BACKGROUND

Obesity is a known risk factor for heart failure with preserved ejection fraction (HFpEF) and is considered a distinct phenotype with more concentric remodeling. Epicardial adipose tissue (EAT) is also increased in obesity-related HFpEF and is associated with adverse events.

OBJECTIVES

The cardiac magnetic resonance (CMR) substudy of the SUMMIT trial aimed to examine the effects of tirzepatide on cardiac structure and function with the underlying hypothesis that it would reduce left ventricular (LV) mass and EAT in obesity-related HFpEF.

METHODS

A total of 175 patients with obesity-related HFpEF from the parent study of tirzepatide (2.5 mg subcutaneously weekly, increasing to a maximum of 15 mg weekly) or matching placebo underwent CMR at baseline, which consisted of multiplanar cine imaging. A total of 106 patients completed the CMR and had adequate image quality for analysis of LV and left atrial structure and function and paracardiac (epicardial plus pericardial) adipose tissue at both baseline and 52 weeks. The prespecified primary endpoint of this substudy was between-group changes in LV mass.

RESULTS

LV mass decreased by 11 g (95% CI: -19 to -4 g) in the treated group (n = 50) when corrected for placebo (n = 56) (P = 0.004). Paracardiac adipose tissue decreased in the treated group by 45 mL (95% CI: -69 to -22 mL) when corrected for placebo (P < 0.001). The change in LV mass in the treated group correlated with changes in body weight (P < 0.02) and tended to correlate with changes in waist circumference and blood pressure (P = 0.06 for both). The LV mass change also correlated with changes in LV end-diastolic volume and left atrial end-diastolic and end-systolic volumes (P < 0.03 for all).

CONCLUSIONS

The CMR substudy of the SUMMIT trial demonstrated that tirzepatide therapy in obesity-related HFpEF led to reduced LV mass and paracardiac adipose tissue as compared with placebo, and the change in LV mass paralleled weight loss. These physiologic changes may contribute to the reduction in heart failure events seen in the main SUMMIT trial. (A Study of Tirzepatide [LY3298176] in Participants With Heart Failure With Preserved Ejection Fraction [HFpEF] and Obesity: The SUMMIT Trial; NCT04847557).

Quantitative Detection of Pericardial Adhesions Using Four-Dimensional Computed Tomography: A Novel Motion-Based Analysis Framework

OBJECTIVE

Pericardial adhesions can unexpectedly occur prior to cardiac surgery or catheter ablation, even in patients without known risk factors, potentially increasing procedural risks. This study proposed and validated a novel, quantitative, and noninvasive method for detecting pericardial adhesions using four-dimensional computed tomography (4D CT).

METHODS

We evaluated preoperative 4D CT datasets from 20 patients undergoing cardiac surgery with and without pericardial adhesions. Our novel approach integrates expert-guided pericardial segmentation, symmetric diffeomorphic registration, and motion disparity analysis. The method quantifies tissue motion differences by computing the displacement fields between the pericardium and epicardial adipose tissue (EAT), with a particular focus on the left anterior descending (LAD) region.

RESULTS

Statistical analysis revealed significant differences between adhesion and non-adhesion groups (p < 0.01) using two newly developed metrics: peak ratio (PR) and distribution width index (DWI). Adhesion cases demonstrated characteristic high PR values (>100) with low DWI values (<0.3), while non-adhesion cases showed moderate PR values (<50) with higher DWI values (>0.4).

CONCLUSIONS

This proof-of-concept study validated a novel quantitative framework for assessing pericardial adhesions using 4D CT imaging and provides an objective and computationally efficient tool for preoperative assessment in clinical settings. These findings suggest the potential clinical utility of this framework in surgical planning and risk assessment.

The Association Between Epicardial Adipose Tissue Thickness and the Triglyceride-glucose Index in Prediabetic Obese Patients

Obesity and pre-diabetes are metabolic disorders associated with insulin resistance (IR). Excess epicardial adipose tissue is also associated with increased IR. The triglyceride-glucose index (TyG) has been evaluated as an alternative measure of the IR in a variety of metabolic and cardiovascular disorders. However, its relationship with EAT thickness has not been studied yet. The study included 176 prediabetic and obese patients. EAT thickness was assessed using echocardiography. EAT thickness, TyG index, anthropometric obesity indices (body mass index (BMI), waist circumference (WC), and waist-hip ratio (WHR)), homeostatic model assessment (HOMA-IR), and biochemical parameters were compared. The following correlations between EAT thickness and related parameters were observed: WC (r = .529), BMI (r = .514), ALT (r = .358), TyG index (r = .338), and HOMA-IR (r = .322; P < .001 for all). Multiple regression analysis showed that WC (Beta = .428; P = .004), age (Beta = .223; P < .001), BMI (Beta = .196; P = .029), ALT (Beta = .168; P = .012), and TyG index (Beta = .128; P = .049) were the strongest independent variables correlated with EAT thickness. A model based on WC, BMI, age, TyG index, and ALT provided the best R-square (.387) for estimating EAT thickness (P < .001). The TyG index showed a significant and independent relationship with EAT, suggesting that it may be useful as an indicator of EAT thickness.

Sex-specific Associations of Aldosterone and Renin With Body Composition: A Population-based Cohort Study

CONTEXT

Renin-angiotensin-aldosterone system (RAAS) activation is closely linked to obesity; however, the sex-specific associations between RAAS activity and body composition among individuals without obesity are not well understood.

OBJECTIVE

To investigate the associations of aldosterone and renin with body composition according to sex in the general population.

DESIGN

Population-based cohort study.

SETTING

Québec (Canada).

PARTICIPANTS

Adults aged 40 to 69 years enrolled in CARTaGENE between 2009 and 2010 (N = 3687).

EXPOSURES

Plasma aldosterone and renin concentrations.

MAIN OUTCOME MEASURES

Body composition assessed via anthropometrics (waist circumference and waist-to-hip ratio), bioelectrical impedance (lean body mass, fat mass, and muscle mass), and cardiac magnetic resonance imaging (epicardial and pericardial adipose tissue volumes).

RESULTS

The mean (SD) age and body mass index were 55 (8) years and 27.3 (4.8) kg/m2, respectively. Among males, higher aldosterone and renin were associated with increased waist circumference, increased waist-to-hip ratio, increased fat mass, decreased lean body mass, and decreased muscle mass (P < .05). Aldosterone (P = .02), but not renin (P = .43), was associated with increased ectopic cardiac adiposity in males. In contrast, higher renin (P < .05), but not aldosterone (P ≥ .05), was associated with increased waist circumference, increased waist-to-hip ratio, and increased cardiac adiposity in females. Among females, higher renin and aldosterone were associated with increased fat mass (P < .05) but were not associated with lean body mass or muscle mass (P ≥ .05). All aforementioned associations were independent of body weight.

CONCLUSION

Independent of body weight, increased RAAS activity is associated with unfavorable differences in body composition; however, the strength and pattern of association varies by sex.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Clinical Role of Epicardial Adipose Tissue

Although the epidemic of atherosclerosis has slowed down in industrialized nations, it has increased in speed and severity in developing countries. The worldwide expanding incidence and prevalence of obesity, insulin resistance, and diabetes mellitus may be among the most important drivers of this trend, and the role of visceral adipose tissue as a promoter of atherosclerosis has come under intense scrutiny. Epicardial adipose tissue (EAT) is embryologically similar to the visceral fat in the intraperitoneal space. Both adipose compartments are capable of secreting numerous pro-atherosclerotic cytokines and have been shown to promote inflammation in patients with dysmetabolic syndromes and in patients with established coronary artery disease. The adverse cardiovascular effects of EAT extend to influencing the development of atrial fibrillation and heart failure, mostly with preserved ejection fraction, through a combination of inflammatory, pro-fibrotic, and pro-arrhythmogenic pathways. In this work we provide an overview of the current understanding of the role of EAT in the development of several cardiovascular conditions as well as some of the therapeutic advances in the field.

Uncovering the role of prokineticin pathway on Epicardial Adipose Tissue (EAT) development and EAT-associated cardiomyopathy

Epicardial adipose tissue (EAT), a unique fat depot surrounding the heart, plays a multifaceted role in glucose and lipid metabolism, thermogenesis, and the secretion of bioactive molecules that influence cardiac structure and function. Its proximity to the myocardium allows it to contribute directly to CVDs, including coronary artery disease, arrhythmias, and heart failure. In particular, excessive EAT has emerged as a significant factor in heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure, especially in individuals with obesity and diabetes. Traditional metrics like body mass index (BMI) fail to capture the complexities of visceral fat, as patients with similar BMIs can exhibit varying CVD risks. EAT accumulation induces mechanical stress and fosters a pro-inflammatory and fibrotic environment, driving cardiac remodeling and dysfunction. Pharmacological modulation of EAT has shown promise in delivering cardiometabolic benefits. Recent advancements in diabetes therapies, such as SGLT2 inhibitors and GLP-1 receptor agonists, and antilipidemic drugs have demonstrated their potential in reducing pro-inflammatory cytokine production and improving glucose regulation, which directly influences EAT. These discoveries suggest that EAT could be a significant therapeutic target, though further investigation is necessary to elucidate its role in HFpEF and other CVDs. Recent advances have identified the prokineticin/PKR1 signaling pathway as pivotal in EAT development and remodeling. This pathway regulates epicardial progenitor cells (EPDCs), promoting angiogenesis while reducing EAT accumulation and metabolic stress on the heart, particularly under high-calorie conditions. Prokineticin, acting through its receptor PKR1, limits visceral adipose tissue growth, enhances insulin sensitivity, and offers cardioprotection by reducing oxidative stress and activating cellular survival pathways. In this review, we provide a comprehensive analysis of EAT's role in CVDs, explore novel therapeutic strategies targeting EAT, and highlight the potential of prokineticin signaling as a promising treatment for HFpEF, obesity, and diabetes.

Epicardial Fat Tissue: A Potential Marker for Coronary Microvascular Dysfunction

BACKGROUND

Coronary microvascular dysfunction (CMD), which mimics symptoms of obstructive coronary artery disease, has significant prognostic implications. While epicardial adipose tissue normally has a protective role, increased epicardial adipose tissue is associated with inflammation and may contribute to CMD. However, a direct correlation remains unclear. We aimed to investigate this association.

METHODS AND RESULTS

The CMDR (Coronary Microvascular Disease Registry) is a prospective, 2-center registry that is enrolling patients with angina and nonobstructive coronary artery disease who underwent invasive hemodynamic assessment of the coronary microvasculature. Patients with chest computed tomography within 1 year of CMD evaluation were included. We measured epicardial fat volume (EFV) and calculated the EFV index. Logistic regression analysis was used to investigate the association between EFV and EFV index to CMD. Our study included 130 CMDR patients with associated chest CT; 35 were diagnosed with CMD. The CMD-negative patients were younger than the CMD-positive patients (58.52±11.97 versus 63.37±9.56 years; P=0.033), with numerically fewer women (64.2% versus 74.3%; P=0.279). Univariate regression analysis demonstrated a statistically significant association between EFV index and CMD diagnosis (odds ratio, 1.037 [95% CI, 1.014-1.063]; P=0.003), while no significance was observed for EFV (odds ratio, 1.006 [95% CI, 0.995-1.017]; P=0.292).

CONCLUSIONS

Our results suggest a strong association between EFV index (a significant risk factor) and the presence of CMD. Future studies involving larger cohorts are needed to confirm the association of epicardial adipose tissue with CMD and investigate therapeutic targets to prevent CMD.

REGISTRATION

URL: https://www.clinicaltrials.gov; unique identifier: NCT05960474.

Study on the Regulated Cell Death of Hypertrophic H9c2 Cells Induced by Au:Ag Nanoparticles

Background and Aim

Over the past years, noble metal-based nanoparticles have been extensively investigated for their applications in nanomedicine. However, there are still concerns about the potential adversities that these nanoparticles may present in an organism. In particular, whether they could cause an exacerbated cytotoxic response in susceptible tissues due to damage or disease, such as the heart, liver, spleen, or kidneys. In this regard, this study aims to evaluate the cytotoxicity of mono- and bimetallic nanoparticles of gold and silver (Au:Ag NPs) on healthy and hypertrophic cardiac H9c2 cells, and on healthy and metabolically activated macrophages derived from U937 cells. The main objective of this work is to explore the susceptibility of cells due to exposure to Au:Ag NPs in conditions representing cardiometabolic diseases.

Methods

Au:Ag NPs were synthesized in different molar ratios (Au:Ag, 100:0, 75:25, 50:50, 25:75, 0:100) using starch as a capping and reducing agent. Their physicochemical properties were characterized through UV-vis spectroscopy, X-ray diffraction (XRD), Fourier transform infrared (FTIR) spectroscopy, dynamic light scattering (DLS), ζ-potential measurements, and transmission electron microscopy (TEM). Moreover, the effect of the metal-based nanoparticle exposure on healthy and hypertrophic H9c2 cells was measured by analyzing the cellular vitality, the loss of mitochondrial membrane potential (∆Ψm), and the production of mitochondrial reactive oxygen species (mROS).

Results

The Au:Ag NPs did not affect the cell vitality of healthy or metabolically activated macrophages. On the contrary, healthy H9c2 cells showed decreased mitochondrial metabolism when exposed to NPs with higher Ag concentrations. Furthermore, hypertrophic H9c2 cells were more susceptible to the same NPs compared to their non-hypertrophic counterparts, and presented a pronounced loss of ∆Ψm. In addition, these NPs increased the production of mROS and regulated cell death in both cardiac cells.

Conclusion

In conclusion, low doses of high-Ag load in Au:Ag NPs produced cytotoxicity on H9c2 cardiac cells, with hypertrophic cells being more susceptible. These results suggest that cardiac hypertrophic conditions are more prone to a cytotoxic response in the presence of bimetallic Au:Ag NPs compared to healthy cells. In addition, this work opens the door to explore the nanotoxicity of noble metal-based NPs in biological disease conditions.

Aerobic exercise decreases the number and transcript expression of inflammatory M1 macrophages and CD8+ T cells in the epicardial adipose tissue of female pigs

Background

Epicardial adipose tissue (EAT) regulates coronary artery function via lipid metabolism and immune cell recruitment. Increased EAT is a risk factor for coronary artery disease (CAD), but aerobic exercise mitigates CAD. The effect of aerobic exercise on immune cells in EAT is unknown. We hypothesized that aerobic exercise creates an anti-inflammatory environment characterized by increased M2 macrophages and up-regulation of anti-inflammatory cytokine transcripts in EAT.

Methods

Female Yucatan pigs (n=7) were allocated to sedentary or exercised groups. To mimic CAD, a coronary artery was chronically occluded or remained non-occluded. EAT samples were processed for bulk and single nuclei transcriptomic sequencing.

Results

Sub-clustering identified immune, endothelial, smooth muscle, adipocytes, adipocyte progenitor cells (APSCs), and neuronal cells, with adipocytes and APSCs being dominant. Non-occluded sedentary EAT had the largest percentage of M1 macrophages and CD8+ T cells. Irrespective of occlusion, sedentary EAT had the largest fraction of cells expressing genes in the tumor necrosis factor (TNF) superfamily. Irrespective of occlusion, exercise upregulated peroxisome proliferator-activated receptor (PPAR) gamma (G) expression and enriched PPAR signaling pathways in adipocytes, macrophages, and T cells. However, PPARG expression was lowest in CD8+ T cells from non-occluded exercised EAT. The greatest number of significant cell-cell communications between adipocytes and immune cells via growth factors and adhesion molecules occurred in occluded sedentary EAT.

Conclusion

Aerobic exercise mitigates the proinflammatory nature of EAT in CAD via modulation of immune cell subpopulations, decreased TNF superfamily and increased PPARG gene expression, and decreased growth factor communication between adipocytes and immune cells.

Visceral adiposity: A major mediator of the relationship between epicardial adiposity and cardiorespiratory fitness in adults

BACKGROUND AND AIMS

Epicardial adiposity has been positively associated with visceral adipose tissue (VAT). Few studies have examined the association between cardiorespiratory fitness (CRF) and epicardial adiposity. Furthermore, whether this relationship was independent of VAT remains unexplored. Our purpose was to investigate the contribution of VAT in the relationships between CRF, physical activity (PA) and epicardial adipose tissue (EAT) in asymptomatic women and men.

METHODS AND RESULTS

We examined the associations between EAT and VAT measured by magnetic resonance imaging, CRF measured by cardiopulmonary exercise testing, and PA assessed using pedometers and a 3-day PA journal in 239 apparently healthy adults (43 % women). Participants were compared according to EAT tertiles and CRF level in both sexes. Participants with the highest EAT level presented more VAT (p < 0.001), lower CRF (p < 0.01), and a more deteriorated cardiometabolic health score (p < 0.01) than those with the lowest EAT level. CRF was negatively associated with EAT in both sexes (p < 0.01). No significant relationship was found with PA (p = NS). Stepwise multivariable regression analyses showed that VAT explained most of the variance in EAT in women and men. Mediation analyses confirmed that VAT was a mediator of the association between CRF and EAT in both sexes.

CONCLUSION

In women and men, VAT appears as a major mediator of the association between CRF and EAT thereby suggesting that managing VAT by improving CRF could help in the prevention of cardiometabolic disorders related to excess EAT.

Effect of smoking behaviour and related blood DNA methylation on visceral adipose tissues

BACKGROUND

Recent studies have found that tobacco smoking is associated with fat distribution, yet limited research has focused on its relationship with visceral adipose tissues (VATs). Furthermore, the cellular and molecular mechanisms underlying the interactions among smoking, epigenetic modifications, and VATs remain unknown.

METHOD

We performed univariable Mendelian randomization (MR) analysis to elucidate the causal relationship between smoking behaviours and VATs, including epicardial and pericardial adipose tissue (EPAT), liver fat (LF), and pancreas fat (PF). This approach could minimize the impact of confounders and reverse causality through utilizing genetic variants to proxy the smoking behaviours. Mediation MR analysis were conducted to detect potential mediators. Additionally, summary-data-based MR (SMR) and colocalization analysis were performed to explore the association between smoking-related DNA methylation and VATs.

RESULTS

We identified a convincing association between smoking initiation and increased EPAT (beta: 0.15, 95% CI: 0.06, 0.23, p = 7.01 × 10-4) and LF area (beta: 0.15, 95% CI = 0.05, 0.24, p = 2.85 × 10-3), respectively. Further mediation analysis suggested type 2 diabetes mellitus (T2DM) as a potential mediator within these co-relationships. When further exploring the associations between the smoking related DNA methylation and VATs, we identified that WT1 methylation at cg05222924 was significantly linked to a lower EPAT area (beta: -0.12, 95% CI: -0.16, -0.06, PFDR = 2.24 × 10-3), while GPX1 methylation at cg18642234 facilitated the deposition of EPAT (beta: 0.15, 95% CI: 0.10, 0.20, PFDR = 1.66 × 10-4).

CONCLUSION

Our study uncovered a significant causal effect between smoking and VATs, with T2DM identified as a potential mediator. Further investigation into DNA methylation yielded novel insights into the pathogenic role of smoking on EPAT.

Liraglutide effects on epicardial adipose tissue micro-RNAs and intra-operative glucose control

BACKGROUND AND AIM

Epicardial adipose tissue (EAT) plays a role in coronary artery disease (CAD). EAT has regional distribution throughout the heart and each location may have a different genetic profile and function. Glucagon like peptide-1 receptor analogs (GLP-1RAs) reduce cardiovascular risk. However, the short-term effects of GLP-1RA on microRNA (miRNA) profile of each EAT location is unknown. Objective was to evaluate if EAT miRNAs were different between coronary (CORO-EAT), left atrial EAT (LA-EAT) and subcutaneous fat (SAT), and liraglutide can modulate EAT miRNAs expression.

METHODS AND RESULTS

This was a 12-week randomized, double-blind, placebo-controlled study in 38 patients with type 2 diabetes (T2DM) and coronary artery disease (CAD) who were started on either liraglutide or placebo for a minimum of 4 up to 12 weeks prior to coronary artery by-pass grafting (CABG). Fat samples were collected during CABG. miR16, miR155 and miR181a were significantly higher in CORO-EAT and in LA-EAT than SAT (p < 0.01 and p < 0.05) in overall patients. miR16 and miR181-a were significantly higher in CORO-EAT than SAT (p < 0.01), and miR155 and miR181a were higher in LA-EAT than SAT (p < 0.05) in the liraglutide group. Liraglutide-treated patients had better intra-op glucose control than placebo (146 ± 21 vs 160 ± 21 mg/dl, p < 0.01).

CONCLUSIONS

Our study shows that CORO- and LA-miRNAs profiles were significantly different than SAT miRNAs in overall patients and miRNAs were significantly higher in CORO-EAT and LA-EAT than SAT in the liraglutide group. Pre-op liraglutide was also associated with better intra operative glucose control than placebo independently of weight loss.

Coronary artery calcifications are not associated with epicardial adipose tissue volume and attenuation on computed tomography in 1,945 individuals with various degrees of glucose disorders

Background

The quantification of coronary artery calcifications (CAC) is a mainstay in radiological assessment of coronary atherosclerosis and cardiovascular risk, but reflect advanced, possibly late-stage changes in the arteries. Increased volume and changes in attenuation of the epicardial adipose tissue (EAT) on computed tomography (CT) have been linked to adverse cardiovascular events, and these changes in the EAT might reflect earlier stages of the processes leading to clinically manifest atherosclerosis. The relationship between EAT and CAC is subject to a knowledge gap, especially in individuals with no previously known coronary artery disease.

Methods

Fully automated EAT analysis with an artificial intelligence-based model was performed in a population sample enriched for pre-diabetics, comprising a total of 1,945 individuals aged 50-64 years, where non-contrast CT images, anthropometric and laboratory data was available on established cardiovascular risk factors. Uni- and multivariable linear regression, gradient-boosting and correlation analyses were performed to determine the explanatory value of EAT volume and attenuation data with regards to CAC data.

Results

Neither EAT volume nor EAT attenuation was associated with the presence or severity of CAC, when adjusting for established cardiovascular risk factors, and had only weak explanatory value in gradient-boosting and correlation analyses. Age was the strongest predictor of CAC in both sexes.

Conclusion

No independent association was found between CAC and total EAT volume or attenuation. Importantly, these findings do not rule out early stage or local effects on coronary atherosclerosis from the EAT immediately surrounding the coronary arteries.