Elsevier

Progress in Cardiovascular Diseases

Volume 78, May–June 2023, Pages 27-33
Progress in Cardiovascular Diseases

Epicardial fat links obesity to cardiovascular diseases

https://doi.org/10.1016/j.pcad.2023.04.006Get rights and content

Abstract

Patients with obesity have been historically associated with higher risk to develop cardiovascular diseases (CVD). However, regional, visceral, organ specific adiposity seems to play a stronger role in the development of those cardiovascular diseases than obesity by itself. Epicardial adipose tissue is the visceral fat depot of the heart with peculiar anatomy, regional differences, genetic profile and functions. Due to its unobstructed contiguity with heart and intense pro inflammatory and pro arrhythmogenic activities, epicardial fat is directly involved in major obesity-related CVD complications, such as coronary artery disease (CAD), atrial fibrillation (AF) and heart failure (HF). Current and developing imaging techniques can measure epicardial fat thickness, volume, density and inflammatory status for the prediction and stratification of the cardiovascular risk in both symptomatic and asymptomatic obese individuals. Pharmacological modulation of the epicardial fat with glucagon like peptide-1 receptor (GLP1R) analogs, sodium glucose transporter-2 inhibitors, and potentially dual (glucose-dependent insulinotropic polypeptide -GLP1R) agonists, can reduce epicardial fat mass, resume its original cardio-protective functions and therefore reduce the cardiovascular risk. Epicardial fat assessment is poised to change the traditional paradigm that links obesity to the heart.

Section snippets

From obesity to the adipocyte

The perception of the role of obesity in cardiovascular diseases (CVD) has substantially changed in the past years. While the general statement that obese subjects are at higher CVD risk than individuals with normal body weight is still correct, visceral fat is now considered a stronger cardio-metabolic risk factor than overall obesity.1 Subjects with visceral fat accumulation are certainly at greater risk to develop CVD than individuals with prevalent peripheral adiposity.2 However, the exact

Epicardial fat between physiology and pathology

Epicardial adipose tissue has recently been on the spotlight for its multifaceted functions, pathogenic roles, and clinical measurability in, but not limited to, obesity-related CVD.4, 5, 6, 7 At the first glance, epicardial fat could be considered as an ectopic fat accumulation of the heart. However, this definition does not fully describe the variety of aspects of this visceral fat depot. In fact, epicardial fat has both physiological and pathological properties.4, 5, 6, 7 Under physiological

Epicardial fat and obesity cardiac changes

Epicardial fat mass increases with the degree of visceral adiposity and contributes to the structural and functional cardiac changes that are observed in obese persons. Obesity is associated with changes in cardiac morphology and function that can progressively lead to a pathological and maladaptive cardiac remodeling and ultimately cause heart failure (HF), as summarized in Table 1.14 Morbidly obese subjects commonly present with increased left ventricular (LV) mass, abnormal LV and right

Measuring epicardial fat in CVD

The need of measurable and trackable risk factors is compelling in the clinical care of obesity.20 Measuring epicardial fat can provide information for the stratification and prediction of cardiac abnormalities in high risk obese subjects. A methodology through which epicardial fat can be visualized and measured using standard two-dimensional echocardiography was first developed by Iacobellis' group.21,22 Epicardial fat thickness can be visualized and measured with two-dimensional guided M-mode

Epicardial fat and CAD

Obese individuals, especially those with predominant visceral fat accumulation, are at higher risk of suffering and dying for CAD. While the causes are complex and multifactorial, epicardial fat is a novel contributing and causative factor. Epicardial fat thickness and volume are higher in subjects with CAD, independent of obesity as defined by body mass indices categories.33 The interplay between epicardial fat, obesity and CAD is stronger when body fat distribution and visceral adiposity are

Epicardial fat in obesity AF

AF is associated with increased CVD morbidity and mortality. Obesity is as important independent risk factor for AF.43 The Framingham Heart Study reported a 4% increased risk in incident AF per unit increase in body mass index in both men and women.44 Weight loss and lifestyle modifications reduce the risk of AF, as recently reported.45 Weight loss was associated with lower AF symptom burden scores, symptom severity scores, and number of AF episodes.45 Weight loss and lifestyle modifications

Epicardial fat and obesity HF

HF is a serious complication of the morbid and visceral obesity. The peripheral obesity phenotype with more prevalent subcutaneous fat accumulation can be associated with the so called “obesity paradox” and lower prevalence of HF.59 Epicardial fat has been suggested to have a role in HF, particularly in patients with HF with preserved ejection fraction (HFpEF).60,61 Epicardial fat volume is significantly higher in patients with HFpEF than in healthy individuals, whereas findings are less

Targeting epicardial fat

Modifiable and trackable risk factors are desirable for cardiovascular risk prediction and monitoring therapeutic responsiveness. Epicardial fat is clinically measurable and well-responsive to interventions modulating the adipose tissue. Weight loss can rapidly reduce epicardial fat thickness in morbidly obese subjects receiving pre-operative meal replacement diet.68 Epicardial fat reduction was greater and faster than other body fat indices, and independently associated with the improvement in

Conclusions and perspectives

Whilst it is known that patients with obesity present with peculiar cardiac abnormalities that can progressively lead to CVD, the mechanisms which underline these abnormalities are partially unknown. Visceral, organ specific adiposity is evidently the principal pathogenic factor and therapeutic target. Epicardial fat, an important visceral/ectopic fat depot, can directly, mechanically and functionally modulate the obese heart. Epicardial fat represents a novel and modifiable risk CVD factor

Declaration of Competing Interest

None.

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