Impact of Epicardial Adipose Tissue, Left Ventricular Myocardial Fat Content, and Interstitial Fibrosis on Myocardial Contractile Function

Epicardial Adipose Tissue Is Associated With Geometry Alteration and Diastolic Dysfunction in Prediabetic Cardiomyopathy

BACKGROUND

Diastolic dysfunction and alterations in cardiac geometry are early indicators of diabetic cardiomyopathy. However, the association between cardiac changes across the glucose continuum and the contribution of epicardial adipose tissue (EAT) to these changes has not yet been investigated.

PURPOSE

In this study, we aimed to investigate the EAT on cardiac diastolic function and structural alterations along the diabetic continuum using cardiac magnetic resonance imaging (CMRI).

METHODS

We enrolled individuals who were categorized into groups based on glucose tolerance status. Left ventricular structure and diastolic function were assessed using echocardiography and CMRI to determine the EAT, intramyocardial fat, and associated parameters. Multivariable logistic regression models were also used.

RESULTS

In a study of 370 patients (209 normal glucose tolerance, 82 prediabetes, 79 diabetes), those with prediabetes and diabetes showed increased heart dimensions and diastolic dysfunction, including the ratio of early mitral inflow velocity to mitral annular early diastolic velocity (7.9 ± 0.51 vs 8.5 ± 0.64 vs 10.0 ± 0.93, P = .010), left atrial volume index (28.21 ± 14.7 vs 33.2 ± 12.8 vs 37.4 ± 8.2 mL/m2, P < .001), and left ventricular peak filling rate (4.46 ± 1.75 vs 3.61 ± 1.55 vs 3.20 ± 1.30 mL/s, P < .001). EAT significantly increased in prediabetes and diabetes (26.3 ± 1.16 vs 31.3 ± 1.83 vs 33.9 ± 1.9 gm, P = .001), while intramyocardial fat did not differ significantly. Prediabetes altered heart geometry but not diastolic function (odds ratio [OR] 1.22 [1.02-1.83], P = .012; and 1.70 [0.79-3.68], P = .135). Diabetes significantly affected both heart structure and diastolic function (OR 1.42 [1.11-1.97], P = .032; and 2.56 [1.03-5.40], P = .034) after adjusting for covariates.

CONCLUSION

Elevated EAT was observed in patients with prediabetes and is associated with adverse alterations in cardiac structure and diastolic function, potentially serving as an underlying mechanism for the early onset of diabetic cardiomyopathy.

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.

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.

Predictive value of epicardial adipose tissue volume for early detection of left ventricular dysfunction in patients suspected of coronary artery disease

AIM

To investigate the relationship between epicardial adipose tissue (EAT) and myocardial strain and the severity of coronary artery disease (CAD), and to evaluate the predictive value of EAT parameters in early left ventricular (LV) diastolic dysfunction.

MATERIALS AND METHODS

One hundred seventy patients with suspected CAD who underwent both coronary computed tomography angiography and echocardiography were enrolled in 2020. LV global strains were calculated using commercial software. Epicardial adipose tissue was defined as adipose tissue between -190 HU and -30 HU in the visceral pericardium from the level of pulmonary artery bifurcation to the apical level. EAT volume and average attenuation values were measured. LV diastolic dysfunction was determined by echocardiography.

RESULTS

The mean age of the participants was 56.65 ± 12.64 years, and 57.65% were male. EAT volume and mean attenuation values were significantly correlated with CAD severity. EAT volume was significantly positively correlated with global longitudinal strain (GLS) (r=0.313, P<0.01), and EAT attenuation values were positively correlated with global circumferential strain and GLS (r=0.236, 0.164, respectively, both P<0.05). Age (β = 0.125, OR = 1.134, P<0.01) and EAT volume (β = 0.019, OR = 1.019, P=0.018) were independent predictors of LV diastolic dysfunction. Age combined with EAT volume improved the diagnostic efficacy of left ventricular diastolic dysfunction.

CONCLUSION

EAT parameters can reflect the severity of CAD. EAT volume is capable of predicting early LV diastolic dysfunction. Compared with GLS, EAT volume may be able to predict LV diastolic dysfunction earlier.

Increased epicardial adipose tissue is associated with left ventricular reverse remodeling in dilated cardiomyopathy

BACKGROUND

Epicardial adipose tissue (EAT) has been suggested to play paradoxical roles in patients with heart failure. The role of EAT in dilated cardiomyopathy (DCM) patients remains unclear. We aimed to assess the associations between the dynamic changes EAT and left ventricular reverse remodeling (LVRR) in DCM patients based on baseline and follow-up CMR.

METHODS

In this prospective study, we consecutive enrolled DCM patients with baseline and follow-up cardiac magnetic resonance (CMR) examinations. All participating patients underwent 1-2 years of guideline-directed medical therapy (GDMT) at follow-up. The EAT was measured as pericardial and epicardial fat thickness, and paracardial fat volume, while the abdominal adiposity was measured in terms of subcutaneous and visceral fat thickness. The univariable and multivariable logistic regression analyses were performed to evaluate the associations of changes in abdominal and epicardial adiposities with the presence of LVRR.

RESULTS

A total of 232 patients (mean age, 45.7 ± 15.1 years, 157 male) at baseline were enrolled. After a period of GDMT with a median duration of 15.5 months (interquartile range, 12.5-19.1 months) all participants underwent follow-up CMR with the same standardized protocol. Patients who reached LVRR showed a significant increment in EAT parameters compared to those who did not. After adjusting for age, sex, and delta changes of body mass index (BMI), the increment of pericardial fat thickness (odds ratio [OR]: 1.53; 95% confidence interval [CI]: 1.27 to 1.83; p < 0.001), epicardial fat thickness (OR: 2.10; 95% CI: 1.68 to 2.63; p < 0.001), and paracardial fat volume (OR: 1.01; 95% CI: 1.01 to 1.02; p = 0.001) were significantly associated with LVRR.

CONCLUSIONS

In DCM patients, the CMR-derived EAT parameters increased after 1-2 years of GDMT and significantly correlated with improved ventricular structure and function, independent of changes in BMI and abdominal adiposity, which may indicate the potential protective role of EAT in DCM patients.

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: ChiCTR1800017058.

Imaging and mechanisms of heart failure with preserved ejection fraction: a state-of-the-art review

Understanding of the pathophysiology of heart failure with preserved ejection fraction (HFpEF) has advanced rapidly over the past two decades. Currently, HFpEF is recognized as a heterogeneous syndrome, and there is a growing movement towards developing personalized treatments based on phenotype-guided strategies. Left ventricular dysfunction is a fundamental pathophysiological abnormality in HFpEF; however, recent evidence also highlights significant roles for the atria, right ventricle, pericardium, and extracardiac contributors. Imaging plays a central role in characterizing these complex and highly integrated domains of pathophysiology. This review focuses on established evidence, recent insights, and the challenges that need to be addressed concerning the pathophysiology of HFpEF, with a focus on imaging-based evaluations and opportunities for further research.

Heart Failure and Obesity: Unraveling Molecular Mechanisms of Excess Adipose Tissue

Obesity is an ongoing pandemic and is associated with the development of heart failure (HF), and especially HF with preserved ejection fraction. The definition of obesity is currently based on anthropometric measurements but neglects the location and molecular properties of excess fat. Important depots associated with HF development are subcutaneous adipose tissue and visceral adipose tissue, both located in the abdominal region, and epicardial adipose tissue (EAT) surrounding the myocardium. However, mechanisms linking these different adipose tissue depots to HF development are incompletely understood. EAT in particular is of great interest because of its close proximity to the heart. In this review, we therefore focus on the characteristics of different adipose tissue depots and their response to obesity. In addition, we evaluate how different mechanisms associated with EAT expansion potentially contribute to HF and in particular HF with preserved ejection fraction development.

Excessive accumulation of epicardial adipose tissue promotes microvascular obstruction formation after myocardial ischemia/reperfusion through modulating macrophages polarization

BACKGROUND

Owing to its unique location and multifaceted metabolic functions, epicardial adipose tissue (EAT) is gradually emerging as a new metabolic target for coronary artery disease risk stratification. Microvascular obstruction (MVO) has been recognized as an independent risk factor for unfavorable prognosis in acute myocardial infarction patients. However, the concrete role of EAT in the pathogenesis of MVO formation in individuals with ST-segment elevation myocardial infarction (STEMI) remains unclear. The objective of the study is to evaluate the correlation between EAT accumulation and MVO formation measured by cardiac magnetic resonance (CMR) in STEMI patients and clarify the underlying mechanisms involved in this relationship.

METHODS

Firstly, we utilized CMR technique to explore the association of EAT distribution and quantity with MVO formation in patients with STEMI. Then we utilized a mouse model with EAT depletion to explore how EAT affected MVO formation under the circumstances of myocardial ischemia/reperfusion (I/R) injury. We further investigated the immunomodulatory effect of EAT on macrophages through co-culture experiments. Finally, we searched for new therapeutic strategies targeting EAT to prevent MVO formation.

RESULTS

The increase of left atrioventricular EAT mass index was independently associated with MVO formation. We also found that increased circulating levels of DPP4 and high DPP4 activity seemed to be associated with EAT increase. EAT accumulation acted as a pro-inflammatory mediator boosting the transition of macrophages towards inflammatory phenotype in myocardial I/R injury through secreting inflammatory EVs. Furthermore, our study declared the potential therapeutic effects of GLP-1 receptor agonist and GLP-1/GLP-2 receptor dual agonist for MVO prevention were at least partially ascribed to its impact on EAT modulation.

CONCLUSIONS

Our work for the first time demonstrated that excessive accumulation of EAT promoted MVO formation by promoting the polarization state of cardiac macrophages towards an inflammatory phenotype. Furthermore, this study identified a very promising therapeutic strategy, GLP-1/GLP-2 receptor dual agonist, targeting EAT for MVO prevention following myocardial I/R injury.

Epicardial Adipose Tissue and Heart Failure, Friend or Foe?

Heart failure (HF) management guidelines recommend individualized assessments based on HF phenotypes. Adiposity is a known risk factor for HF. Recently, there has been an increased interest in organ-specific adiposity, specifically the role of the epicardial adipose tissue (EAT), in HF risk. EAT is easily assessable through various imaging modalities and is anatomically and functionally connected to the myocardium. In pathological conditions, EAT secretes inflammatory cytokines, releases excessive fatty acids, and increases mechanical load on the myocardium, resulting in myocardial remodeling. EAT plays a pathophysiological role in characterizing both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). In HFrEF, EAT volume is reduced, reflecting an impaired metabolic reservoir, whereas in HFpEF, the amount of EAT is associated with worse biomarker and hemodynamic profiles, indicating increased EAT activity. Studies have examined the possibility of therapeutically targeting EAT, and recent studies using sodium glucose cotransporter 2 inhibitors have shown potential in reducing EAT volume. However, further research is required to determine the clinical implications of reducing EAT activity in patients with HF.

New Mechanisms to Prevent Heart Failure with Preserved Ejection Fraction Using Glucagon-like Peptide-1 Receptor Agonism (GLP-1 RA) in Metabolic Syndrome and in Type 2 Diabetes: A Review

This review examines the impact of obesity on the pathophysiology of heart failure with preserved ejection fraction (HFpEF) and focuses on novel mechanisms for HFpEF prevention using a glucagon-like peptide-1 receptor agonism (GLP-1 RA). Obesity can lead to HFpEF through various mechanisms, including low-grade systemic inflammation, adipocyte dysfunction, accumulation of visceral adipose tissue, and increased pericardial/epicardial adipose tissue (contributing to an increase in myocardial fat content and interstitial fibrosis). Glucagon-like peptide 1 (GLP-1) is an incretin hormone that is released from the enteroendocrine L-cells in the gut. GLP-1 reduces blood glucose levels by stimulating insulin synthesis, suppressing islet α-cell function, and promoting the proliferation and differentiation of β-cells. GLP-1 regulates gastric emptying and appetite, and GLP-1 RA is currently indicated for treating type 2 diabetes (T2D), obesity, and metabolic syndrome (MS). Recent evidence indicates that GLP-1 RA may play a significant role in preventing HFpEF in patients with obesity, MS, or obese T2D. This effect may be due to activating cardioprotective mechanisms (the endogenous counter-regulatory renin angiotensin system and the AMPK/mTOR pathway) and by inhibiting deleterious remodeling mechanisms (the PKA/RhoA/ROCK pathway, aldosterone levels, and microinflammation). However, there is still a need for further research to validate the impact of these mechanisms on humans.

The role of diabetic foot treatment in improving left ventricular function: Insights from global longitudinal strain echocardiography

We decided to evaluate the effect of treatment of diabetic foot ulcers in improving heart function by strain echocardiography than conventional transthoracic echocardiography. This prospective cross-sectional study included patients with diabetic foot ulcer (DFU). Conventional and two-dimensional strain echocardiography performed before and after three months diabetic foot treatment. Then, we compared the echocardiographic parameters including left ventricular ejection fraction (LV-EF), left ventricular global longitudinal strain (LV-GLS). Multivariate and univariate logistic regression analysis were performed to find which variable was mainly associated with LV-GLS changes. 62 patients with DFU were conducted. After echocardiography, all patients underwent surgical or non-surgical treatments. Three months after the treatment, LV-EF was not significantly different with its' primary values (P = 0.250), but LV-GLS became significantly different (P<0.05). In the multivariate logistic regression analysis, with the increase in the grade of ulcer, LV-GLS improved by 6.3 times. Not only the treatment of DFU helps to control adverse outcomes like infection, limb loss and morbidity but also it enhances cardiac function. Of note, strain echocardiography found to be a better indicator of myocardial dysfunction than LV-EF. These findings make a strong reason for the routine assessment of cardiac function in patients with DFU.

Myocardial tissue remodeling in early adult obesity and its association with regional adipose tissue distribution and ectopic fat deposits: a prospective study

OBJECTIVES

To evaluate the left ventricular (LV) myocardial tissue characteristics in early adult obesity and its association with regional adipose tissue and ectopic fat deposition.

METHODS

Forty-nine obese adults (mean body mass index: 29.9 ± 2.0 kg/m2) and 44 healthy controls were prospectively studied. LV native and post-contrast T1 values, extracellular volume fraction (ECV), regional adipose tissue (epicardial, visceral, and subcutaneous adipose tissue (EAT, VAT, and SAT)), and ectopic fat deposition (hepatic and pancreatic proton density fat fractions (H-PDFF and P-PDFF)) based on magnetic resonance imaging were compared. The association was assessed by multivariable linear regression.

RESULTS

The obese participants showed reduced global ECV compared to the healthy controls (p < 0.05), but there was no significant difference in global native or post-contrast T1 values between the two groups. Additionally, the obese individuals exhibited higher EAT, VAT, SAT, H-PDFF, and P-PDFF than the controls (p < 0.05). ECV was associated with insulin resistance, dyslipidemia, and systolic blood pressure (SBP) (p < 0.05). Multiple linear regression demonstrated that H-PDFF and SAT were independently associated with ECV in entire population (β =  - 0.123 and - 0.012; p < 0.05).

CONCLUSIONS

Reduced myocardial ECV in patients with mild-to-moderate obesity and its relationship to SBP may indicate that cardiomyocyte hypertrophy, rather than extracellular matrix expansion, is primarily responsible for myocardial tissue remodeling in early adult obesity. Our findings further imply that H-PDFF and SAT are linked with LV myocardial tissue remodeling in this cohort beyond the growth difference and cardiovascular risk factors.

CLINICAL TRIALS REGISTRATION

Effect of lifestyle intervention on metabolism of obese patients based on smart phone software (ChiCTR1900026476).

CLINICAL RELEVANCE STATEMENT

Myocardial fibrosis in severe obesity predicts poor prognosis. We showed that cardiomyocyte hypertrophy, not myocardial fibrosis, is the main myocardial tissue characteristic of early obesity. This finding raises the possibility that medical interventions, like weight loss, may prevent cardiac fibrosis.

KEY POINTS

• Myocardial tissue characteristics in early adult obesity are unclear. • Myocardial extracellular volume fraction (ECV) can be quantitatively evaluated using T1 mapping based on cardiac magnetic resonance imaging (MRI). • Cardiac MRI-derived ECV may noninvasively evaluate myocardial tissue remodeling in early adult obesity.

Association of Epicardial Adipose Tissue With Left Ventricular Strain and MR Myocardial Perfusion in Patients With Known Coronary Artery Disease

BACKGROUND

Epicardial adipose tissue (EAT) may have a paracrine effect on coronary microcirculation and myocardium. However, it is unclear whether EAT is linked to cardiac function and perfusion.

PURPOSE

To investigate the association of EAT with left ventricular (LV) strain and myocardial perfusion in patients with coronary artery disease (CAD).

STUDY TYPE

Retrospective.

POPULATION

A total of 78 patients with CAD and 20 healthy controls. The patients were further divided into high (n = 39) and low EAT volume (n = 39) groups according to median EAT volume.

FIELD STRENGTH/SEQUENCE

A 1.5 T, balanced steady-state free precession, inversion recovery prepared echo-planar, and segmented-turbo fast low-angle shot (FLASH) phase-sensitive inversion recovery (PSIR) sequences.

ASSESSMENT

EAT volume was measured by manually tracing the epicardial border and the visceral layer of pericardium on the short-axis cine stacks. LV strain parameters included global radial (GRS), circumferential (GCS), and longitudinal peak strain (GLS). Perfusion indices included upslope, perfusion index, time-to-maximum signal intensity (TTM), and maximum signal intensity (MaxSI).

STATISTICAL TESTS

One-way analysis of variance or Kruskal-Wallis rank tests, Chi-squared or Fisher exact tests. Multivariate linear regression analyses. A P value < 0.05 was considered statistically significant.

RESULTS

The parameters of GRS GCS, GLS, upslope, perfusion index, and MaxSI were significantly lower in the patients when compared to the controls. Moreover, the high EAT volume group presented significantly longer TTM values and lower GRS, GCS, GLS, upslope, perfusion index, and MaxSI than the low EAT volume group. Multivariate linear regression analyses demonstrated that EAT was independently associated with GRS, GCS, GLS, upslope, perfusion index, TTM, and MaxSI in patients. EAT and upslope were independently associated with GRS, while EAT and perfusion index were both independently associated with GCS and GLS.

DATA CONCLUSION

EAT was associated with parameters of LV function and perfusion, and myocardial perfusion was independently associated with LV strain in patients with CAD.

EVIDENCE LEVEL

3.

TECHNICAL EFFICACY

Stage 3.

Myocardial Fibrosis and Steatosis in Patients with Aortic Stenosis: Roles of Myostatin and Ceramides

Aortic stenosis (AS) involves progressive valve obstruction and a remodeling response of the left ventriculum (LV) with systolic and diastolic dysfunction. The roles of interstitial fibrosis and myocardial steatosis in LV dysfunction in AS have not been completely characterized. We enrolled 31 patients (19 women and 12 men) with severe AS undergoing elective aortic valve replacement. The subjects were clinically evaluated, and transthoracic echocardiography was performed pre-surgery. LV septal biopsies were obtained to assess fibrosis and apoptosis and fat deposition in myocytes (perilipin 5 (PLIN5)), or in the form of adipocytes within the heart (perilipin 1 (PLIN1)), the presence of ceramides and myostatin were assessed via immunohistochemistry. After BMI adjustment, we found a positive association between fibrosis and apoptotic cardiomyocytes, as well as fibrosis and the area covered by PLIN5. Apoptosis and PLIN5 were also significantly interrelated. LV fibrosis increased with a higher medium gradient (MG) and peak gradient (PG). Ceramides and myostatin levels were higher in patients within the higher MG and PG tertiles. In the linear regression analysis, increased fibrosis correlated with increased apoptosis and myostatin, independent from confounding factors. After adjustment for age and BMI, we found a positive relationship between PLIN5 and E/A and a negative correlation between septal S', global longitudinal strain (GLS), and fibrosis. Myostatin was inversely correlated with GLS and ejection fraction. Fibrosis and myocardial steatosis altogether contribute to ventricular dysfunction in severe AS. The association of myostatin and fibrosis with systolic dysfunction, as well as between myocardial steatosis and diastolic dysfunction, highlights potential therapeutic targets.

Effect of Metabolic Dysfunction-Associated Fatty Liver Disease on Left Ventricular Deformation and Atrioventricular Coupling in Patients With Metabolic Syndrome Assessed by MRI

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) was recently recognized as an important risk factor for cardiovascular diseases.

PURPOSE

To examine the effect of MAFLD on cardiac function in metabolic syndrome by MRI.

STUDY TYPE

Retrospective.

POPULATION

One hundred seventy-nine patients with metabolic syndrome (MetS), 101 with MAFLD (MAFLD [+]) and 78 without (MAFLD [-]). Eighty-one adults without any of the components of MetS or cardiac abnormalities were included as control group.

FIELD STRENGTH/SEQUENCE

3.0 T; balanced steady-state free precession sequence.

ASSESSMENT

Left atrial (LA) strain was assessed during three phases: reservoir strain (LA-RS), conduit strain (LA-CS), and booster strain (LA-BS). Left ventricular (LV) global longitudinal (LV-GLS) strain was also derived. The left atrioventricular coupling index (LACI) was calculated as the ratio of LA end-diastolic volume (LA-EDV) and LV-EDV.

STATISTICAL TESTS

Student's t test or Mann-Whitney U test; One-way analysis of variance. A P value <0.05 was considered statistically significant.

RESULTS

Among MetS patients, individuals with MAFLD had significantly lower magnitude LV-GLS (-11.6% ± 3.3% vs. -13.8% ± 2.7%) than those without MAFLD. For LA strains, LA-RS (36.9% ± 13.7% vs. 42.9% ± 13.5%) and LA-CS (20.0% ± 10.6% vs. 24.1% ± 9.2%) were also significantly reduced in MAFLD (+) compared to MAFLD (-). The LACIs (17.2% [12.9-21.2] % vs. 15.8% [12.2-19.7] %) were significantly higher in patients with MAFLD compared to those without MAFLD. After adjustment for other clinical factors, MAFLD was found to be independently correlated with LV-GLS (β = -0.270) and LACI (β = 0.260).

DATA CONCLUSION

MAFLD had an unfavorable effect on LV myocardial strain in MetS. Moreover, LA strain and atrioventricular coupling were further impaired in patients with concomitant MAFLD compared to those without MAFLD. Last, MAFLD was independently associated with subclinical LV dysfunction and atrioventricular coupling after adjustment for other clinical factors.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: 3.

Epicardial Adipose Tissue in Myocardial Disease: From Physiology to Heart Failure Phenotypes

Epicardial adipose tissue (EAT) is increasingly being recognized as a determinant of myocardial biology. The EAT-heart crosstalk suggests causal links between dysfunctional EAT and cardiomyocyte impairment. Obesity promotes EAT dysfunction and shifts in secreted adipokines which adversely affect cardiac metabolism, induce cardiomyocyte inflammation, redox imbalance and myocardial fibrosis. Thus, EAT determines cardiac phenotype via effects on cardiac energetics, contractility, diastolic function, and atrial conduction. Vice-versa the EAT is altered in heart failure (HF), and such phenotypic changes can be detected by noninvasive imaging or incorporated in Artificial Intelligence-enhanced tools to aid the diagnosis, subtyping or risk prognostication of HF. In the present article, we summarize the links between EAT and the heart, explaining how the study of epicardial adiposity can improve the understanding of cardiac disease, serve as a source of diagnostic and prognostic biomarkers, and as a potential therapeutic target in HF to improve clinical outcomes.

Differentiating the Prognostic Determinants of Myocardial Steatosis for Heart Failure With Preserved Ejection Fraction by Cardiac Magnetic Resonance Imaging

Background Myocardial steatosis and fibrosis may play a role in the pathophysiology of heart failure with preserved ejection fraction. We therefore investigated the prognostic significance of epicardial fat (epicardial adipose tissue [EAT]) and myocardial diffuse fibrosis. Methods and Results Myocardial fibrosis, estimated as extracellular volume (ECV), and EAT were measured using cardiac magnetic resonance imaging in 163 subjects with heart failure with preserved ejection fraction. We also evaluated cardiac structure and diastolic and systolic function by echocardiography and cardiac magnetic resonance imaging. After 24 months' follow-up, 39 (24%) subjects had experienced cardiovascular events, including hospitalization for heart failure, acute coronary syndrome, and cardiovascular death. Median EAT and mean ECV were significantly higher in subjects with cardiovascular events than survivors (EAT, 35 [25-45] versus 31 [21-38], P=0.006 and ECV, 28.9±3.16% versus 27.2±3.56%, P=0.04). Subjects with high EAT (≥42 g) had increased risk of cardiovascular events (hazard ratio [HR], 2.528 [95% CI, 1.704-4.981]; P=0.032). High ECV (>29%) was also significantly associated with poorer outcomes (HR, 1.647 [95% CI, 1.263-2.548]; P=0.013). With respect to secondary end points, high EAT and high ECV were associated with increased risk of the incident acute coronary syndrome (HR, 1.982 [95% CI, 1.008-4.123]; P=0.049) and hospitalization for heart failure (HR, 1.789 [95% CI, 1.102-6.987]; P=0.033), respectively. Conclusions Our study suggested that increased epicardial fat and ECV detected by cardiac magnetic resonance imaging have an impact on cardiovascular prognosis, in particular acute coronary syndrome and hospitalization for heart failure, respectively.

Epicardial adipose tissue in patients with systemic sclerosis

Aims

Epicardial adipose tissue (EAT) has emerged as a mediator between systemic inflammatory disorders and cardiovascular disease, and may therefore play a role in the pathophysiology of cardiac involvement in systemic sclerosis (SSc). The aim of this study was to assess the correlation between EAT and left ventricular (LV) function, and to determine the prognostic value of EAT in patients with SSc.

Methods and results

Consecutive patients with SSc who underwent non-contrast thorax computed tomography and echocardiography were included. EAT mass was quantified using dedicated software. The study endpoint was all-cause mortality. A total of 230 SSc patients (age 53 ± 15 years, 14% male) were included. The median value of EAT mass was 67 g (interquartile range: 45-101 g). Patients with increased EAT mass (≥67 g) showed more impaired LV diastolic function as compared with patients with less EAT mass (<67 g), and even after adjusting for age and comorbidities, EAT mass was independently associated with LV diastolic function parameters. During a median follow-up of 8 years, 42 deaths occurred. Kaplan-Meier analysis showed that patients with increased EAT mass had higher all-cause mortality rate as compared with patients with less EAT mass (29% vs. 7%; P < 0.001). In the multivariable analysis, EAT was independently associated with all-cause mortality after adjusting for important covariates (HR: 1.006; 95% CI: 1.001-1.010).

Conclusion

In patients with SSc, EAT is independently associated with LV diastolic dysfunction and higher mortality rate.

The tyrosine kinase inhibitor Dasatinib reduces cardiac steatosis and fibrosis in obese, type 2 diabetic mice

BACKGROUND

Cardiac steatosis is an early yet overlooked feature of diabetic cardiomyopathy. There is no available therapy to treat this condition. Tyrosine kinase inhibitors (TKIs) are used as first or second-line therapy in different types of cancer. In cancer patients with diabetes mellitus, TKIs reportedly improved glycemic control, allowing insulin discontinuation. They also reduced liver steatosis in a murine model of non-alcoholic fatty liver disease. The present study aimed to determine the therapeutic effect of the second-generation TKI Dasatinib on lipid accumulation and cardiac function in obese, type 2 diabetic mice. We also assessed if the drug impacts extra-cardiac fat tissue depots.

METHODS

Two studies on 21-week-old male obese leptin receptor mutant BKS.Cg-+Leprdb/+Leprdb/OlaHsd (db/db) mice compared the effect of Dasatinib (5 mg/kg) and vehicle (10% DMSO + 90% PEG-300) given via gavage once every three days for a week or once every week for four weeks. Functional and volumetric indices were studied using echocardiography. Post-mortem analyses included the assessment of fat deposits and fibrosis using histology, and senescence using immunohistochemistry and flow cytometry. The anti-adipogenic action of Dasatinib was investigated on human bone marrow (BM)-derived mesenchymal stem cells (MSCs). Unpaired parametric or non-parametric tests were used to compare two and multiple groups as appropriate.

RESULTS

Dasatinib reduced steatosis and fibrosis in the heart of diabetic mice. The drug also reduced BM adiposity but did not affect other fat depots. These structural changes were associated with improved diastolic indexes, specifically the E/A ratio and non-flow time. Moreover, Dasatinib-treated mice had lower levels of p16 in the heart compared with vehicle-treated controls, suggesting an inhibitory impact of the drug on the senescence signalling pathway. In vitro, Dasatinib inhibited human BM-MSC viability and adipogenesis commitment.

CONCLUSIONS

Our findings suggest that Dasatinib opposes heart and BM adiposity and cardiac fibrosis. In the heart, this was associated with favourable functional consequences, namely improvement in an index of diastolic function. Repurposing TKI for cardiac benefit could address the unmet need of diabetic cardiac steatosis.

Differential expression spectrum and targeted gene prediction of tRNA-derived small RNAs in idiopathic pulmonary arterial hypertension

Background: Idiopathic pulmonary arterial hypertension (PAH) is a potentially fatal pulmonary vascular disease with an extremely poor natural course. The limitations of current treatment and the unclear etiology and pathogenesis of idiopathic PAH require new targets and avenues of exploration involved in the pathogenesis of PAH. tRNA-derived small RNAs (tsRNAs), a new type of small non-coding RNAs, have a significant part in the progress of diverse diseases. However, the potential functions behind tsRNAs in idiopathic PAH remain unknown. Methods: Small RNA microarray was implemented on three pairs of plasma of idiopathic PAH patients and healthy controls to investigate and compare tsRNAs expression profiles. Validation samples were used for real-time polymerase chain reaction (Real-time PCR) to verify several dysregulated tsRNAs. Bioinformatic analysis was adopted to determine potential target genes and mechanisms of the validated tsRNAs in PAH. Results: Microarray detected 816 statistically significantly dysregulated tsRNAs, of which 243 tsRNAs were upregulated and 573 were downregulated in PAH. Eight validated tsRNAs in the results of Real-time PCR were concordant with the small RNA microarray: four upregulated (tRF3a-AspGTC-9, 5'tiRNA-31-GluCTC-16, i-tRF-31:54-Val-CAC-1 and tRF3b-TyrGTA-4) and four downregulated (5'tiRNA-33-LysTTT-4, i-tRF-8:32-Val-AAC-2, i-tRF-2:30-His-GTG-1, and i-tRF-15:31-Lys-CTT-1). The Gene Ontology analysis has shown that the verified tsRNAs are related to cellular macromolecule metabolic process, regulation of cellular process, and regulation of cellular metabolic process. It is disclosed that potential target genes of verified tsRNAs are widely involved in PAH pathways by Kyoto Encyclopedia of Genes and Genomes. Conclusion: This study investigated tsRNA profiles in idiopathic PAH and found that the dysregulated tsRNAs may become a novel type of biomarkers and possible targets for PAH.

Effect of hypertriglyceridemia on left ventricular global longitudinal strain in patients with coronary heart disease in Jilin Province, China: a cross-sectional study

Aims

Using speckle tracking technology to investigate the effect of hypertriglyceridemia on the global longitudinal strain(GLS) of the left ventricle in patients with coronary heart disease in the early stage, and to explore the value of myocardial strain in early identification of cardiac dysfunction in patients with coronary heart disease in the pre-heart failure stage.

Methods

A cross-sectional study of 138 participants was conducted in Jilin Province, China. Basic clinical, biochemical, and echocardiographic data were obtained for all patients. Myocardial strain parameters were compared between the hypertriglyceridemia and normal triglyceride level groups and the effect of hypertriglyceridemia on early left ventricular global longitudinal strain impairment in coronary heart disease patients was evaluated.

Results

The overall longitudinal strain of the left ventricle was smaller in the hypertriglyceridemia group than in the normal triglyceride group. After the multivariate Logistic regression model adjusting for the influence of confounding factors, the results remained stable.

Conclusions

The risk of impairment of global longitudinal strain of the left ventricle in patients with coronary heart disease is positively correlated with triglyceride levels, and hypertriglyceridemia maybe an independent risk factor affecting early cardiac dysfunction in the pre-heart failure stage of patients with coronary heart disease.

The relationship between epicardial adipose tissue thickness and arrhythmias in patients with hypertension: a 3.0T cardiac magnetic resonance study

OBJECTIVES

To investigate the relationship between epicardial adipose tissue (EAT) thickness using cardiac magnetic resonance imaging (CMR) and arrhythmias in hypertensive patients.

METHODS

Fifty-four hypertensive patients with arrhythmias (HTN [arrhythmias+]), 79 hypertensive patients without arrhythmias (HTN [arrhythmias-]), and 39 normal controls were retrospectively enrolled. EAT thickness was measured on cine images. Analysis of covariance with Bonferroni's post hoc correction, Pearson or Spearman analysis, receiver operating characteristic curve, and intraclass correlation coefficient analysis were performed.

RESULTS

All hypertensive patients had impaired left ventricular (LV) and left atrial (LA) myocardial deformation, and HTN (arrhythmias+) patients displayed higher LV myocardial native T1, LA volume index, and increased EAT thickness than HTN (arrhythmias-) patients and normotensive controls. The presence of LV late gadolinium enhancement (LGE) was higher in hypertensive patients with arrhythmias than in those without arrhythmias. EAT thickness metrics significantly correlated with age, systolic blood pressure, body mass index, triglycerides and high-density lipoprotein levels, LV mass index and native T1 (all p < 0.05). EAT thickness parameters were able to differentiate hypertensive patients with arrhythmias from those without arrhythmias and normal controls, and the right ventricular free wall had the highest diagnostic performance.

CONCLUSION

An accumulation of EAT thickness could further induce cardiac remodeling, promote myocardial fibrosis, and exaggerate function in hypertensive patients with arrhythmias.

ADVANCES IN KNOWLEDGE

CMR-derived EAT thickness metrics could be a useful imaging marker for differentiating hypertensive patients with arrhythmias, which might be a potential target for the prevention of cardiac remodeling and arrhythmias.

Atrial cardiomyopathy: Current and future imaging methods for assessment of atrial structure and function

Changes in atrial size and function have historically been considered a surrogate marker of ventricular dysfunction. However, it is now recognized that atrial cardiomyopathy (ACM) may also occur as a primary myocardial disorder. Emerging evidence that ACM is a major risk factor for atrial fibrillation, heart failure, and thromboembolic stroke, has highlighted the significance of this disorder and the need for better assessment of atrial metrics in clinical practice. Key barriers in this regard include a lack of standardized criteria or hierarchy for the diagnosis of ACM and lack of consensus for the most accurate phenotyping methods. In this article we review existing literature on ACM, with a focus on current and future non-invasive imaging methods for detecting abnormalities of atrial structure and function. We discuss the relative advantages and disadvantages of transthoracic echocardiography and cardiac magnetic resonance imaging for assessing a range of parameters, including atrial size and contractile function, strain, tissue characteristics, and epicardial adipose tissue. We will also present the potential application of novel imaging methods such as sphericity index and four- or five-dimensional flow.

Epicardial fat volume assessed with cardiac magnetic resonance imaging in patients with Takotsubo cardiomyopathy

PURPOSE

The aims of our study were to investigate with cardiovascular magnetic resonance (CMR) the role of Epicardial Fat Volume (EFV) and distribution in patients with Takotsubo cardiomyopathy (TTC). Moreover, we explored EFV in patients with TTC and related this to comorbidities, cardiac biomarkers, and cardiac function.

METHODS

This retrospective study performed CMR scans in 30 consecutive TTC patients and 20 healthy controls. The absolute amount of EFV was quantified in consecutive short-axis cine stacks through the modified Simpson's rule. In addition, the left atrio-ventricular groove (LV) and right ventricle (RV) Epicardial Fat Thickness (EFT) were measured as well. Besides epicardial fat, LV myocardial strain parameters and T2 mapping measurements were obtained.

RESULTS

TTC patients and controls were of comparable age, sex, and body mass index. Compared to healthy controls, patients with TTC demonstrated a significantly increased EFV, epicardial fat mass, and EFV indexed for body 7surface area (p = 0.005; p = 0.003; p = 0.008; respectively). In a multiple regression model including age, sex, BMI, atrial fibrillation, and dyslipidemia, TTC remained an independent association with EFV (p = 0.008). Global T2 mapping and Global longitudinal strain in patients with TTC were correlated with EFV (r = 0.63, p = 0.001, and r = 0.44, p = 0.02, respectively).

CONCLUSION

Patients with TTC have increased EFV compared to healthy controls, despite a similar body mass index. The amount of epicardial fat was associated with CMR markers of myocardial inflammation and subclinical contractile dysfunction.

Pioglitazone reduces epicardial fat and improves diastolic function in patients with type 2 diabetes

AIMS

To examine the effect of pioglitazone on epicardial (EAT) and paracardial adipose tissue (PAT) and measures of diastolic function and insulin sensitivity in patients with type 2 diabetes mellitus (T2DM).

METHODS

Twelve patients with T2DM without clinically manifest cardiovascular disease and 12 subjects with normal glucose tolerance (NGT) underwent cardiac magnetic resonance imaging to quantitate EAT and PAT and diastolic function before and after pioglitazone treatment for 24 weeks. Whole-body insulin sensitivity was measured with a euglycaemic insulin clamp and the Matsuda Index (oral glucose tolerance test).

RESULTS

Pioglitazone reduced glycated haemoglobin by 0.9% (P < 0.05), increased HDL cholesterol by 7% (P < 0.05), reduced triacylglycerol by 42% (P < 0.01) and increased whole-body insulin-stimulated glucose uptake by 71% (P < 0.01) and Matsuda Index by 100% (P < 0.01). In patients with T2DM, EAT (P < 0.01) and PAT (P < 0.01) areas were greater compared with subjects with NGT, and decreased by 9% (P = 0.03) and 9% (P = 0.09), respectively, after pioglitazone treatment. Transmitral E/A flow rate and peak left ventricular flow rate (PLVFR) were reduced in T2DM versus NGT (P < 0.01) and increased following pioglitazone treatment (P < 0.01-0.05). At baseline normalized PLVFR inversely correlated with EAT (r = -0.45, P = 0.03) but not PAT (r = -0.29, P = 0.16). E/A was significantly and inversely correlated with EAT (r = -0.55, P = 0.006) and PAT (r = -0.40, P = 0.05). EAT and PAT were inversely correlated with whole-body insulin-stimulated glucose uptake (r = -0.68, P < 0.001) and with Matsuda Index (r = 0.99, P < 0.002).

CONCLUSION

Pioglitazone reduced EAT and PAT areas and improved left ventricular (LV) diastolic function in T2DM. EAT and PAT are inversely correlated (PAT less strongly) with LV diastolic function and both EAT and PAT are inversely correlated with measures of insulin sensitivity.

Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia

There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.

Sodium-glucose Cotransporter 2 Inhibitors and Pathological Myocardial Hypertrophy

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new type of oral hypoglycemic drugs that exert a hypoglycemic effect by blocking the reabsorption of glucose in the proximal renal tubules, thus promoting the excretion of glucose from urine. Their hypoglycemic effect is not dependent on insulin. Increasing data shows that SGLT2 inhibitors improve cardiovascular outcomes in patients with type 2 diabetes. Previous studies have demonstrated that SGLT2 inhibitors can reduce pathological myocardial hypertrophy with or without diabetes, but the exact mechanism remains to be elucidated. To clarify the relationship between SGLT2 inhibitors and pathological myocardial hypertrophy, with a view to providing a reference for the future treatment thereof, this study reviewed the possible mechanisms of SGLT2 inhibitors in attenuating pathological myocardial hypertrophy. We focused specifically on the mechanisms in terms of inflammation, oxidative stress, myocardial fibrosis, mitochondrial function, epicardial lipids, endothelial function, insulin resistance, cardiac hydrogen and sodium exchange, and autophagy.

Impact of body mass index and diabetes on myocardial fat content, interstitial fibrosis and function

PURPOSE

We hypothesize that both increased myocardial steatosis and interstitial fibrosis contributes to subclinical myocardial dysfunction in patients with increased body mass index and diabetes mellitus.

BACKGROUND

Increased body weight and diabetes mellitus are both individually associated with a higher incidence of heart failure with preserved ejection fraction. However, it is unclear how increased myocardial steatosis and interstitial fibrosis interact to influence myocardial composition and function.

METHODS

A total of 100 subjects (27 healthy lean volunteers, 21 healthy but overweight volunteers, and 52 asymptomatic overweight patients with diabetes) were prospectively recruited to measure left ventricular (LV) myocardial steatosis (LV-myoFat) and interstitial fibrosis (by extracellular volume [ECV]) using magnetic resonance imaging, and then used to determine their combined impact on LV global longitudinal strain (GLS) analysis by 2-dimensional (2D) speckle tracking echocardiography on the same day.

RESULTS

On multivariable analysis, both increased body mass index and diabetes were independently associated with increased LV-myoFat. In turn, increased LV-myoFat was independently associated with increased LV ECV. Both increased LV-myoFat and LV ECV were independently associated with impaired 2D LV GLS.

CONCLUSION

Patients with increased body weight and patients with diabetes display excessive myocardial steatosis, which is related to a greater burden of myocardial interstitial fibrosis. LV myocardial contractile function was determined by both the extent of myocardial steatosis and interstitial fibrosis, and was independent of increasing age. Further study is warranted to determine how weight loss and improved diabetes management can improve myocardial composition and function.

Connecting epicardial adipose tissue and heart failure with preserved ejection fraction: mechanisms, management and modern perspectives

Obesity is very common in patients with heart failure with preserved ejection fraction (HFpEF) and it has been suggested that obesity plays an important role in the pathophysiology of this disease. While body mass index defines the presence of obesity, this measure provides limited information on visceral adiposity, which is probably more relevant in the pathophysiology of HFpEF. Epicardial adipose tissue is the visceral fat situated directly adjacent to the heart and recent data demonstrate that accumulation of epicardial adipose tissue is associated with the onset, symptomatology and outcome of HFpEF. However, the mechanisms by which epicardial adipose tissue may be involved in HFpEF remain unclear. It is also questioned whether epicardial adipose tissue may be a specific target for therapy for this disease. In the present review, we describe the physiology of epicardial adipose tissue and the pathophysiological transformation of epicardial adipose tissue in response to chronic inflammatory diseases, and we postulate conceptual mechanisms on how epicardial adipose tissue may be involved in HFpEF pathophysiology. Lastly, we outline potential treatment strategies, knowledge gaps and directions for further research.

Depot-specific adipose tissue modulation by SGLT2 inhibitors and GLP1 agonists mediates their cardioprotective effects in metabolic disease

Sodium-glucose transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide 1 (GLP-1) receptor agonists are newer antidiabetic drug classes, which were recently shown to decrease cardiovascular (CV) morbidity and mortality in diabetic patients. CV benefits of these drugs could not be directly attributed to their blood glucose lowering capacity possibly implicating a pleotropic effect as a mediator of their impact on cardiovascular disease (CVD). Particularly, preclinical and clinical studies indicate that SGLT-2i(s) and GLP-1 receptor agonists are capable of differentially modulating distinct adipose pools reducing the accumulation of fat in some depots, promoting the healthy expansion of others, and/or enhancing their browning, leading to the suppression of the metabolically induced inflammatory processes. These changes are accompanied with improvements in markers of cardiac structure and injury, coronary and vascular endothelial healing and function, vascular remodeling, as well as reduction of atherogenesis. Here, through a summary of the available evidence, we bring forth our view that the observed CV benefit in response to SGLT-2i or GLP-1 agonists therapy might be driven by their ameliorative impact on adipose tissue inflammation.

Adverse association of epicardial adipose tissue accumulation with cardiac function and atrioventricular coupling in postmenopausal women assessed by cardiac magnetic resonance imaging

Background

This study aims to investigate the association of epicardial adipose tissue (EAT) accumulation with cardiac function and atrioventricular coupling in a cohort of postmenopausal women assessed by cardiac magnetic resonance imaging (CMR).

Materials and methods

Overall, 283 postmenopausal women (mean age 61.5 ± 9.1 years) who underwent CMR examination were enrolled. Participants were classified into four groups by the quartile of EAT volume. EAT volume was quantified on short-axis cine stacks covering the entire epicardium. CMR-derived cardiac structure and function, including left atrial (LA)- volume, emptying fraction, deformation, and left ventricular (LV)- mass, volume, ejection fraction, and deformation, were compared among the four groups of graded EAT volume.

Results

Left ventricular mass (LVM) and LV remodeling index were both increased in the group with the highest EAT volume, compared to those in the lowest quartile (p = 0.016 and p = 0.003). The LV global longitudinal strain (LV-GLS), circumferential strain (LV-GCS), and LA- reservoir strain (LA-RS), conduit strain (LA-CS), and booster strain (LA-BS), were all progressively decreased from the lowest quartile of EAT volume to the highest (all p &lt; 0.05). Multivariable linear regression analyses showed that EAT was independently associated with LV-GLS, LA-RS, LA-CS, and LA-BS after adjusting for body mass index and other clinical factors.

Conclusion

Epicardial adipose tissue accumulation is independently associated with subclinical LV and LA function in postmenopausal women. These associations support the role of EAT in mediating deleterious effects on cardiac structure and function.

Impact of Type 2 Diabetes Mellitus on Epicardial Adipose Tissue and Myocardial Microcirculation by MRI in Postmenopausal Women

BACKGROUND

Type 2 diabetes mellitus (T2DM) often occurs conjunctly with the menopausal transition in female patients. In addition, epicardial adipose tissue (EAT) has an unfavorable impact on the myocardium and coronary arteries under the influence of metabolic disorders.

PURPOSE

To investigate the impact of T2DM on EAT and myocardial microvascular function in postmenopausal women.

STUDY TYPE

Retrospective.

POPULATION

One-hundred sixty-one postmenopausal women divided into three groups: newly diagnosed (≤5 years) T2DM (n = 56, 58.6 ± 7.7 years), long-term (>5 years) T2DM (n = 57, 61.9 ± 7.9 years), and healthy controls (n = 48, 59.4 ± 7.4 years).

FIELD STRENGTH/SEQUENCE

3.0 T; balanced steady-state free precession and inversion recovery prepared echo-planar sequences.

ASSESSMENT

EAT volume was quantified by delineating the epicardial border and the visceral layer of pericardium on the short-axis cine stacks. Perfusion parameters including upslope, maximum signal intensity (MaxSI) and time to maximum signal intensity (TTM) were derived from the first-pass perfusion signal intensity-time curves.

STATISTICAL TESTS

One-way analysis of variance, Pearson's and Spearman correlation, and multivariable linear regression. Two-sided P < 0.05 was considered statistically significant.

RESULTS

EAT volume was significantly increased in diabetic postmenopausal women compared to the controls (48.4 ± 13.4 mL/m² [newly diagnosed T2DM] vs. 58.4 ± 17.3 mL/m² [long-term T2DM] vs. 35.8 ± 12.3 mL/m² [controls]). Regarding perfusion parameters, upslope and MaxSI were significantly reduced (2.6 ± 1.0 [newly diagnosed T2DM] vs. 2.1 ± 0.8 [long-term T2DM] vs. 3.6 ± 1.3 [controls]; and 21.4 ± 6.9 [newly diagnosed T2DM] vs. 18.7 ± 6.4 [long-term T2DM] vs. 28.4 ± 8.6 [controls]), whereas TTM was significantly increased in the T2DM groups compared to the control group (23.6 ± 8.7 [newly diagnosed T2DM] vs. 27.1 ± 9.4 [long-term T2DM] vs. 21.4 ± 6.0 [controls]). Multivariable analysis (adjusted coefficient of determination [R² ] = 0.489) showed that EAT volume (β = -0.610) and menopausal age (β = 0.433) were independently correlated with decreased perfusion upslope.

DATA CONCLUSION

Diabetic postmenopausal women had significantly higher EAT volume and more impaired microcirculation compared to the controls. Increased EAT volume and earlier menopausal age were independently associated with microvascular dysfunction in these patients.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 3.

Long-Term Changes in Cardiac Structure and Function Following Bariatric Surgery

BACKGROUND

Studies with short-term follow-up have demonstrated favorable effects of weight loss (WL) on the heart, but little information is available regarding long-term effects or effects of visceral fat reduction.

OBJECTIVES

The purpose of this study was to evaluate the effects of long-term WL following bariatric surgery on cardiac structure, function, ventricular interaction, and body composition, including epicardial adipose thickness and abdominal visceral adipose tissue (VAT).

METHODS

A total of 213 obese patients underwent echocardiography before and >180 days following bariatric surgery. Abdominal VAT area was measured by computed tomography in 52 of these patients.

RESULTS

After 5.3 years (IQR: 2.9-7.9 years), body mass index (BMI) decreased by 22%, with favorable reductions in blood pressure, fasting glucose, and left ventricular (LV) remodeling in the full sample. In the subgroup of patients with abdominal computed tomography, VAT area decreased by 30%. In all subjects, epicardial adipose thickness was reduced by 14% (both P < 0.0001) in tandem with reductions in ventricular interdependence. LV and right ventricular longitudinal strain improved following WL, but left atrial (LA) strain deteriorated, while LA volume and estimated LA pressures increased. In subgroup analysis, LV wall thickness and strain correlated more strongly with VAT than BMI at baseline, and reductions in LV mass following surgery were correlated with decreases in VAT, but not BMI.

CONCLUSIONS

In this observational study, weight loss following bariatric surgery was associated with epicardial fat reduction, reduced ventricular interaction, LV reverse remodeling, and improved longitudinal biventricular mechanics, but LA myopathy and hemodynamic congestion still progressed. Reduction in visceral fat was associated with favorable cardiac effects, suggesting this might be a key target of WL interventions.

Impact of Metabolic Syndrome on Left Ventricular Deformation and Myocardial Energetic Efficiency Compared Between Women and Men: An MRI Study

BACKGROUND

Metabolic and hemodynamic alterations in metabolic syndrome (MetS) can cause a reduced myocardial energetic efficiency (MEE). Indexed MEE (MEEi), as a simple estimate of MEE, is emerging as a novel and useful imaging parameter.

PURPOSE

To investigate the impact of MetS on MEE and systolic myocardial strain and to assess any sex difference.

STUDY TYPE

Retrospective.

POPULATION

A total of 161 patients with MetS (female: n = 82, 52.2 ± 11.7 years; male: n = 79, 51.8 ± 10.6 years) and 77 healthy subjects (female: n = 46, 52.7 ± 8.2 years; male: n = 31, 54.1 ± 11.2 years). Patients with left ventricular (LV) ejection fraction <50% were excluded.

FIELD STRENGTH/SEQUENCE

A 3.0 T; balanced steady-state free precession sequence.

ASSESSMENT

LV volumes and mass (LVM) and global longitudinal strain (GLS) were obtained by MRI. Stroke volume (SV) divided by HR was used as a surrogate measure of MEE and normalized to LVM (MEEi).

STATISTICAL TESTS

Student's t-test or Mann-Whitney U-test; Multivariable linear regression (coefficient of determination, R² ). P < 0.05 was considered statistically significant.

RESULTS

For both males and females, MEEi and GLS were lower in MetS patients than in the normal controls. Among MetS patients, men had significantly higher LVM (59.7 ± 13.4 g/m² vs. 48.8 ± 11.3 g/m² ) and significantly lower MEEi (0.68 ± 0.23 mL/g/s vs. 0.84 ± 0.23 mL/g/s) and GLS (-11.7% ± 2.8% vs. -13.9% ± 2.7%) than women. After adjustment for clinical variables, male gender (β = -0.291) was found to be inversely correlated with MEEi. Multivariable analysis showed that MEEi (β = 0.454) were independently associated with GLS (adjusted R²  = 0.454) after adjustment for clinical and other MRI parameters.

DATA CONCLUSION

MEEi was significantly impaired in MetS without overt systolic dysfunction. There was a sex difference regarding the cardiac alterations in MetS, with men having significantly lower MEEi and GLS and significantly higher LVM than women. Further, MEEi was independently associated with GLS.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 3.

Cardiovascular protection by SGLT2 inhibitors - Do anti-inflammatory mechanisms play a role?

BACKGROUND

Metabolic syndrome and related metabolic disturbances represent a state of low-grade inflammation, which accelerates insulin resistance, type 2 diabetes (T2D) and cardiovascular disease (CVD) progression. Among antidiabetic medications, sodium glucose co-transporter (SGLT) 2 inhibitors are the only agents which showed remarkable reductions in heart failure (HF) hospitalizations and major cardiovascular endpoints (MACE) as well as renal endpoints regardless of diabetes status in large randomized clinical outcome trials (RCTs). Although the exact mechanisms underlying these benefits are yet to be established, growing evidence suggests that modulating inflammation by SGLT2 inhibitors may play a key role.

SCOPE OF REVIEW

In this manuscript, we summarize the current knowledge on anti-inflammatory effects of SGLT2 inhibitors as one of the mechanisms potentially mediating their cardiovascular (CV) benefits. We introduce the different metabolic and systemic actions mediated by these agents which could mitigate inflammation, and further present the signalling pathways potentially responsible for their proposed direct anti-inflammatory effects. We also discuss controversies surrounding some of these mechanisms.

MAJOR CONCLUSIONS

SGLT2 inhibitors are promising anti-inflammatory agents by acting either indirectly via improving metabolism and reducing stress conditions or via direct modulation of inflammatory signalling pathways. These effects were achieved, to a great extent, in a glucose-independent manner which established their clinical use in HF patients with and without diabetes.

Relationship Between Epicardial Adipose Tissue and Biventricular Longitudinal Strain and Strain Rate in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Epicardial adipose tissue (EAT) has been reported to be increased in patients with type 2 diabetes mellitus (T2DM). EAT thickness may impact left ventricular (LV) diastolic function. However, the association between EAT and right ventricular (RV) function in T2DM is unclear. We hypothesized an association between EAT volume and biventricular longitudinal strain and strain rate in patients with T2DM.

MATERIALS AND METHODS

A total of 20 controls and 69 T2DM patients with preserved LV ejection fraction (EF) who underwent cardiac magnetic resonance (CMR) were included. Biventricular function was evaluated by CMR Tissue-Tracking derived strain analysis, including LV global peak systolic longitudinal strain (LVGLS), peak diastolic longitudinal strain rate (LVLSR), RVGLS and RVLSR.

RESULTS

Compared to controls, patients with T2DM had significantly higher EAT volumes with lower LVGLS, LVLSR, RVGLS and RVLSR (all p<0.05). EAT volume was significantly correlated with LVGLS, LVLSR, RVGLS and RVLSR in T2DM patients (r=-0.45, -0.39, -0.59, -0.50, all p<0.001). Multivariate linear regression analysis revealed that EAT volume was significantly associated with LVGLS (β=0.38, p=0.001), LVLSR (β=-0.35, p=0.003), RVGLS (β=0.64, p<0.001) and RVLSR (β=-0.43, p<0.001) independently of traditional risk factors in patients with T2DM.

CONCLUSION

Patients with T2DM had higher EAT levels and lower biventricular function than controls. EAT volume was independently associated with biventricular longitudinal strain and strain rate in T2DM patients.

Imaging techniques for the assessment of adverse cardiac remodeling in metabolic syndrome

Metabolic syndrome (MetS) includes different metabolic conditions (i.e. abdominal obesity, impaired glucose tolerance, hypertriglyceridemia, decreased HDL cholesterol, and/or hypertension) that concour in the development of cardiovascular disease and diabetes. MetS individuals often show adverse cardiac remodeling and myocardial dysfunction even in the absence of overt coronary artery disease or valvular affliction. Diastolic impairment and hypertrophy are hallmarks of MetS-related cardiac remodeling and represent the leading cause of heart failure with preserved ejection fraction (HFpEF). Altered cardiomyocyte function, increased neurohormonal tone, interstitial fibrosis, coronary microvascular dysfunction, and a myriad of metabolic abnormalities have all been implicated in the development and progression of adverse cardiac remodeling related to MetS. However, despite the enormous amount of literature produced on this argument, HF remains a leading cause of morbidity and mortality in such population. The early detection of initial adverse cardiac remodeling would enable the optimal implementation of effective therapies aiming at preventing the progression of the disease to the symptomatic phase. Beyond conventional imaging techniques, such as echocardiography, cardiac tomography, and magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this review, we summarize the pathophysiology of MetS-related cardiac remodeling and illustrate the relevance of state-of-the-art multimodality cardiac imaging to identify and quantify the degree of myocardial involvement, prognosticate long-term clinical outcome, and potentially guide therapeutic strategies.

The Role of Epicardial Adipose Tissue in the Development of Atrial Fibrillation, Coronary Artery Disease and Chronic Heart Failure in the Context of Obesity and Type 2 Diabetes Mellitus: A Narrative Review

Cardiovascular diseases (CVDs) are a significant burden globally and are especially prevalent in obese and/or diabetic populations. Epicardial adipose tissue (EAT) surrounding the heart has been implicated in the development of CVDs as EAT can shift from a protective to a maladaptive phenotype in diseased states. In diabetic and obese patients, an elevated EAT mass both secretes pro-fibrotic/pro-inflammatory adipokines and forms intramyocardial fibrofatty infiltrates. This narrative review considers the proposed pathophysiological roles of EAT in CVDs. Diabetes is associated with a disordered energy utilization in the heart, which promotes intramyocardial fat and structural remodeling. Fibrofatty infiltrates are associated with abnormal cardiomyocyte calcium handling and repolarization, increasing the probability of afterdepolarizations. The inflammatory phenotype also promotes lateralization of connexin (Cx) proteins, undermining unidirectional conduction. These changes are associated with conduction heterogeneity, together creating a substrate for atrial fibrillation (AF). EAT is also strongly implicated in coronary artery disease (CAD); inflammatory adipokines from peri-vascular fat can modulate intra-luminal homeostasis through an “outside-to-inside” mechanism. EAT is also a significant source of sympathetic neurotransmitters, which promote progressive diastolic dysfunction with eventual cardiac failure. Further investigations on the behavior of EAT in diabetic/obese patients with CVD could help elucidate the pathogenesis and uncover potential therapeutic targets.

Relation of Body Mass Index to Transthyretin Cardiac Amyloidosis Particularly in Black and Hispanic Patients (from the SCAN-MP Study)

Heart failure with preserved ejection fraction is a heterogeneous clinical syndrome that includes distinct subtypes with different pathophysiologies, genetics, and treatment. Distinguishing heart failure with preserved ejection fraction caused by transthyretin cardiac amyloidosis (ATTR-CA) is critical given its specific treatment. We analyzed a single-center retrospective cohort to determine the association of body mass index (BMI) with a composite of either ATTR-CA or the valine-to-isoleucine substitution (Val122Ile) variant genotype (ATTR-CA+Val122Ile). These BMI differences were prospectively evaluated in the multicenter Screening for Cardiac Amyloidosis using nuclear imaging for Minority Populations (SCAN-MP) study of Black and Hispanic patients with heart failure. The association of BMI with ATTR-CA+Val122Ile was compared by Wilcoxon rank sum analysis and combined with age, gender, and maximum left ventricle wall thickness in multivariable logistic regression. In the retrospective analysis (n = 469), ATTR-CA+Val122Ile was identified in n = 198 (40%), who had a lower median BMI (25.8 kg/m², interquartile range [IQR] 23.4 to 28.9) than other patients (27.1 kg/m², IQR 23.9 to 32.0) (p <0.001). In multivariable logistic regression, BMI <30 kg/m² (odds ratio 2.6, 95% confidence interval 1.5 to 4.5) remained independently associated with ATTR-CA+Val122Ile with a greater association in Black and Hispanic patients (odds ratio 5.8, 95% confidence interval 1.7 to 19.6). In SCAN-MP (n = 201), 17 (8%) had either ATTR-CA (n = 10) or were Val122Ile carriers (n = 7) with negative pyrophosphate scans. BMI was lower (25.4 kg/m² [IQR 24.3 to 28.2]) in ATTR-CA+Val122Ile patients than in non-amyloid patients (32.7 kg/m² [28.3 to 38.6]) (p <0.001), a finding that persisted in multivariable analysis (p = 0.002). In conclusion, lower BMI is associated with ATTR-CA+Val122Ile in heart failure with increased left ventricle wall thickness, particularly in Black and Hispanic patients, and may aid in the identification of those benefiting from ATTR-CA evaluation.

Association of Epicardial Fat with Diastolic and Vascular Functions in Children with Type 1 Diabetes

We aimed to examine the relationship between epicardial fat thickness (EFT) measured by echocardiography and cardiovascular functional parameters in children with type 1 diabetes mellitus (T1DM). The study included 50 type 1 diabetic children and 50 healthy subjects matched by sex, age, and body mass index. In addition to laboratory tests, all participants underwent transthoracic echocardiography for EFT, cardiac dimensions and left ventricular functions, and ultrasonographic examination for brachial artery flow-mediated dilation (FMD) response and carotid intima-media thickness (CIMT). Multivariate linear regression was used to analyze the relationship between EFT and CIMT, FMD, lateral mitral E' velocity, and mitral E/E' ratio. EFT was significantly increased in diabetic children compared with controls (P < 0.001). In comparison with controls diabetic children had significantly increased mitral A, decreased lateral mitral E', decreased mitral E/A ratio, decreased lateral mitral E'/A' ratio, and increased mitral E/E' ratio (P < 0.001). FMD response was significantly lower in diabetic group versus controls (P < 0.001) and CIMT was significantly increased in diabetics versus controls (P = 0.03). EFT was negatively correlated with lateral mitral E' velocity (r =  - 0.613, P < 0.001), positively correlated with mitral E/E' ratio (r = 0.60, P < 0.001), positively correlated with CIMT (r = 0.881, P < 0.001), and negatively correlated with FMD (r =  - 0.533, P < 0.001). By multivariate regression analysis, the EFT was independently and positively associated with CIMT mean and E/E' mean and negatively associated with FMD mean and E' mean. The cut-off point for EFT as predictor of endothelial dysfunction was 6.95 mm. Our findings suggest that children with T1DM have subclinical LV diastolic and vascular endothelial dysfunctions associated with increased EFT.

Assessment of Myocardial Microstructure in a Murine Model of Obesity-Related Cardiac Dysfunction by Diffusion Tensor Magnetic Resonance Imaging at 7T

Background

Obesity exerts multiple deleterious effects on the heart that may ultimately lead to cardiac failure. This study sought to characterize myocardial microstructure and function in an experimental model of obesity-related cardiac dysfunction.

Methods

Male C57BL/6N mice were fed either a high-fat diet (HFD; 60 kcal% fat, n = 12) or standard control diet (9 kcal% fat, n = 10) for 15 weeks. At the end of the study period, cardiac function was assessed by ultra-high frequency echocardiography, and hearts were processed for further analyses. The three-dimensional myocardial microstructure was examined ex vivo at a spatial resolution of 100 × 100 × 100 μm3 by diffusion tensor magnetic resonance imaging (DT-MRI) at 7T. Myocardial deformation, diffusion metrics and fiber tract geometry were analyzed with respect to the different myocardial layers (subendocardium/subepicardium) and segments (base/mid-cavity/apex). Results were correlated with blood sample analyses, histopathology, and gene expression data.

Results

HFD feeding induced significantly increased body weight combined with a pronounced accumulation of visceral fat (body weight 42.3 ± 5.7 vs. 31.5 ± 2.2 g, body weight change 73.7 ± 14.8 vs. 31.1 ± 6.6%, both P &lt; 0.001). Obese mice showed signs of diastolic dysfunction, whereas left-ventricular ejection fraction and fractional shortening remained unchanged (E/e’ 41.6 ± 16.6 vs. 24.8 ± 6.0, P &lt; 0.01; isovolumic relaxation time 19 ± 4 vs. 14 ± 4 ms, P &lt; 0.05). Additionally, global longitudinal strain was reduced in the HFD group (−15.1 ± 3.0 vs. −20.0 ± 4.6%, P = 0.01), which was mainly driven by an impairment in basal segments. However, histopathology and gene expression analyses revealed no myocardial fibrosis or differences in cardiomyocyte morphology. Mean diffusivity and eigenvalues of the diffusion tensor were lower in the basal subepicardium of obese mice as assessed by DT-MRI (P &lt; 0.05). The three-dimensional fiber tract arrangement of the left ventricle (LV) remained preserved.

Conclusion

Fifteen weeks of high-fat diet induced alterations in myocardial diffusion properties in mice, whereas no remodeling of the three-dimensional myofiber arrangement of the LV was observed. Obese mice showed reduced longitudinal strain and lower mean diffusivity predominantly in the left-ventricular base, and further investigation into the significance of this regional pattern is required.

Diabetes Mellitus and Heart Failure With Preserved Ejection Fraction: Role of Obesity

Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.

Cardiac remodeling and subclinical left ventricular dysfunction in adults with uncomplicated obesity: a cardiovascular magnetic resonance study

BACKGROUND

Obesity often exists alongside comorbidities and increases the risk of heart failure and cardiovascular mortality. However, the specific effects of obesity on cardiac structure and function have not been clarified. This study set out to evaluate left ventricular (LV) geometric and functional changes using cardiovascular magnetic resonance imaging (CMR) in adults with uncomplicated obesity.

METHODS

Forty-eight patients with uncomplicated obesity [body mass index (BMI) mean ± SD: 29.8±2.1 kg/m2] and 25 healthy controls were included in this study. CMR was used to assess LV geometry, global systolic function, and strains, and to quantify epicardial adipose tissue (EAT). Body composition was measured by dual X-ray absorptiometry.

RESULTS

Compared with healthy controls, patients with obesity had increased LV size, mass, and myocardial thickness, and impaired myocardial contractility, with lower global radial, circumferential, and longitudinal peak strains (PS), and circumferential and longitudinal peak diastolic strain rates (PDSR; all P<0.05). Multivariable linear regression showed that BMI was independently associated with LV maximum myocardial thickness (LVMMT) (β=0.197, P=0.016). Visceral adipose tissue (VAT) was independently associated with LV global longitudinal PS (β=-2.684, P=0.001), and both longitudinal (β=-0.192, P=0.002) and circumferential (β=-0.165, P=0.014) PDSR. Homeostasis model assessment of insulin resistance (HOMA-IR) was mildly correlated with BMI (r=0.327) and body fat percentage (BF%) (r=0.295) in patients with obesity (all P<0.05). HOMA-IR was independently associated with LV global circumferential PS (β=-0.276, P=0.04) and PDSR (β=-0.036, P=0.026).

CONCLUSIONS

Extensive LV geometric remodeling and marked changes in cardiac strains were observed in adults with obesity. Tissue tracking with CMR can reveal subclinical impaired ventricular function with preserved LV ejection fraction in such patients. BMI was independently related to LV remodeling in obesity. HOMA-IR and VAT are potentially superior to BMI as predictors of subclinical dysfunction, assessed by strain, in obesity.

TRIAL REGISTRY

This study has been registered with the Chinese Clinical Trial Registry (ID: ChiCTR1900026476; Effect of lifestyle intervention on metabolism of obese patients based on smart phone software).

Obesity, inflammation, and heart failure: links and misconceptions

Obesity has been linked with heart failure (HF) with preserved left ventricular (LV) ejection fraction (HFpEF). This link has been attributed to obesity-induced metabolic and inflammatory disturbances leading to HFpEF. However, HF is a syndrome in which disease evolvement is associated with a dynamic unraveling of functional and structural changes leading to unique disease trajectories, creating a spectrum of phenotypes with overlapping distinct characteristics extending beyond the LV ejection fraction (LVEF). In this regard, despite quantitative differences between the two extremes (HFpEF and HF with reduced LVEF, HFrEF), there is important overlap between the phenotypes along the entire spectrum. In this paper, we describe the systemic pro-inflammatory state that is present throughout the HF spectrum and emphasize that obesity intertwines with HF beyond the LVEF construct.

Epicardial adipose tissue in obesity-related cardiac dysfunction

Obesity is associated with the development of heart failure and is a major risk factor for heart failure with preserved ejection fraction (HFpEF). Epicardial adipose tissue (EAT) is a unique visceral fat in close proximity to the heart and is of particular interest to the study of cardiac disease. Small poorly differentiated adipocytes with altered lipid:water content are associated with a proinflammatory secretome and may contribute to the pathophysiology observed in HFpEF. Multimodality imaging approaches can be used to quantify EAT volume and characterise EAT composition. Current research studies remain unclear as to the magnitude of effect that EAT plays on myocardial dysfunction and further work using multimodality imaging techniques is ongoing. Pharmacological interventions, including glucagon-like peptide 1 receptor agonists and sodium-dependent glucose linked transporter 2 inhibitors have shown promise in attenuating the deleterious metabolic and inflammatory changes seen in EAT. Clinical studies are ongoing to explore whether these therapies exert their beneficial effects by modifying this unique adipose deposit.

Role of Epicardial Adipose Tissue in Cardiovascular Diseases: A Review

Cardiovascular diseases (CVDs) are the leading causes of death worldwide. Epicardial adipose tissue (EAT) is defined as a fat depot localized between the myocardial surface and the visceral layer of the pericardium and is a type of visceral fat. EAT is one of the most important risk factors for atherosclerosis and cardiovascular events and a promising new therapeutic target in CVDs. In health conditions, EAT has a protective function, including protection against hypothermia or mechanical stress, providing myocardial energy supply from free fatty acid and release of adiponectin. In patients with obesity, metabolic syndrome, or diabetes mellitus, EAT becomes a deleterious tissue promoting the development of CVDs. Previously, we showed an adverse modulation of gene expression in pericoronary adipose tissue in patients with coronary artery disease (CAD). Here, we summarize the currently available evidence regarding the role of EAT in the development of CVDs, including CAD, heart failure, and atrial fibrillation. Due to the rapid development of the COVID-19 pandemic, we also discuss data regarding the association between EAT and the course of COVID-19. Finally, we present the potential therapeutic possibilities aiming at modifying EAT's function. The development of novel therapies specifically targeting EAT could revolutionize the prognosis in CVDs.

Metformin: Expanding the Scope of Application-Starting Earlier than Yesterday, Canceling Later

Today the area of application of metformin is expanding, and a wealth of data point to its benefits in people without carbohydrate metabolism disorders. Already in the population of people leading an unhealthy lifestyle, before the formation of obesity and prediabetes metformin smooths out the adverse effects of a high-fat diet. Being prescribed at this stage, metformin will probably be able to, if not prevent, then significantly reduce the progression of all subsequent metabolic changes. To a large extent, this review will discuss the proofs of the evidence for this. Another recent important change is a removal of a number of restrictions on its use in patients with heart failure, acute coronary syndrome and chronic kidney disease. We will discuss the reasons for these changes and present a new perspective on the role of increasing lactate in metformin therapy.

Fragmented QRS in inferior leads is associated with non-alcholic fatty liver disease, body-mass index, and interventricular septum thickness in young men

OBJECTIVE

Fragmented QRS (fQRS) has been shown to be related to coronary heart disease, heart failure, hypertension, cardiac arrhythmia, and metabolic syndrome. Although fQRS in lateral leads is shown to be associated with a poor outcome in patients with a known cardiac disease, the knowledge about the significance and prevalence of fQRS in inferior leads is scarce. This study aimed to investigate the prevalence and predictors of fQRS in inferior leads in healthy young men.

METHODS

A total of 1,155 men underwent electrocardiography (ECG), hepatic ultrasonography, and routine biochemical tests. A total of 210 eligible men with fQRS in inferior leads (group 1) and 770 eligible men without fQRS in inferior leads (group 2) were compared with each other in terms of clinical, demographic, and laboratory parameters.

RESULTS

The prevalence of fQRS in inferior leads was found to 21.4%. Body mass index (BMI), systolic blood pressure (BP), creatinine, and alanine aminotransferase levels; non-alcoholic fatty liver disease (NAFLD) percentage; and interventricular septum thickness (IVST) were significantly greater in group 1 than those in group 2. BMI, IVST, NAFLD, creatinine, ALT, and systolic BP were entered in a model of multiple regression analyses to predict fQRS, a dependent variable. NAFLD was the best independent predictor of fQRS (β=6.115, p=0.001). BMI (β=1.448, p=0.014) and IVST (β=1.058, p=0.029) were the other independent predictors of fQRS in inferior leads.

CONCLUSION

This study demonstrated the association of fQRS in inferior leads with NAFLD, BMI, and IVST in young men.