Meta-Analysis of Relation of Epicardial Adipose Tissue Volume to Left Atrial Dilation and to Left Ventricular Hypertrophy and Functions

doi:10.1016/j.amjcard.2018.10.020

The American Journal of Cardiology

Volume 123, Issue 3, 1 February 2019, Pages 523-531

https://doi.org/10.1016/j.amjcard.2018.10.020 Get rights and content

Many studies have explored the hypothesis that epicardial adipose tissue (EAT) accumulation adversely affects cardiac remodeling. We assessed, through a systematic review and meta-analysis, whether EAT is linked to left atrial (LA) and left ventricular (LV) structure and function, irrespective of global or abdominal visceral adiposity. We searched MEDLINE, Scopus, and Web of Science for studies evaluating the association of EAT volume quantified by computed tomography with cardiac morphology and function. We used DerSimonian and Laird random-effects models to summarize the adjusted-effect of 10 ml variation of EAT on LA size, LV mass, LV diastolic and systolic functions parameters, and presence of diastolic dysfunction. We quantified heterogeneity using I² statistic. We included 19 studies. Quantitative analysis by cardiac parameters, including LA dimension (n = 2,719), LV mass (n = 2,519), diastolic function (n = 3,741), and systolic function (n = 2,037) showed that EAT was associated with LA dilation (pooled B-coefficient: 0.12 mm; 95% confidence interval [CI] 0.08 to 0.17; I²: 97%), LV hypertrophy (pooled B-coefficient: 1.21 g; 95% CI 0.63 to 1.79; I²: 77%), diastolic dysfunction (odds ratio: 1.35; 95% CI 1.16 to 1.57; I²: 0%), higher E/E′ ratio (pooled B-coefficient: 0.28 cm/s; 95% CI 0.08 to 0.49; I²: 67%), lower E′ velocity (pooled B-coefficient: −0.16 cm/s; 95% CI −0.22 to −0.09; I²: 43%), and E/A ratio (pooled B-coefficient: −0.01; 95% CI −0.02 to −0.001; I²: 70%), independently of body mass index. There was no association between EAT and LV systolic function. In conclusion, EAT volume measured by computed tomography was independently associated with LA dilation, LV hypertrophy, and diastolic dysfunction.

Section snippets

Methods

We conducted the present study according to the protocols specified in the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement. The study protocol was registered in PROSPERO (ID: CRD42017080849). We searched MEDLINE, Scopus, and Web of Science for publications reporting association measures between EAT and parameters of cardiac structure and function using the following expression: ([“Epicardial adipose tissue” OR “Epicardial fat” OR “Pericardial adipose tissue” OR

Results

Systematic review flowchart is depicted in Figure 1. A total of 19 reports matched our search criteria.⁹^,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23 In them, 17 studies reported the association with total EAT volume9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21^,24, 25, 26 and 6 studies investigated the association with periatrial EAT.9, 13^,20, 21, 22, 23 The former studies included 8,838 subjects, in which cardiac morphology and function were assessed by transthoracic echocardiography

Discussion

In this review, we pooled adjusted association measures of the volume of EAT by CT and cardiac structure and function. We observed a small, but BMI-independent, effect of EAT on LA dilation, LV hypertrophy, and LV diastolic dysfunction; no associations were found between EAT and systolic function.

Obesity may worsen myocardial remodeling by several mechanisms namely, activation of the renin-angiotensin system and autonomic nervous system, which altogether increase peripheral arterial resistance

Disclosures

The authors have declared no competing interests.

References (35)

T. Mazurek et al.
Relation of proinflammatory activity of epicardial adipose tissue to the occurrence of atrial fibrillation
Am J Cardiol
(2014)
M.A. Tabl et al.
The relation between total epicardial fat volume assessed by cardiac CT and the presence of atrial fibrillation
Egypt Heart J
(2016)
A.C.T. Ng et al.
Epicardial adipose tissue volume and left ventricular myocardial function using 3-dimensional speckle tracking echocardiography
Can J Cardiol
(2016)
R. Fontes-Carvalho et al.
Influence of epicardial and visceral fat on left ventricular diastolic and systolic functions in patients after myocardial infarction
Am J Cardiol
(2014)
J.L. Cavalcante et al.
Association of epicardial fat, hypertension, subclinical coronary artery disease, and metabolic syndrome with left ventricular diastolic dysfunction
Am J Cardiol
(2012)
T. Khawaja et al.
Epicardial fat volume in patients with left ventricular systolic dysfunction
Am J Cardiol
(2011)
M.O. Al Chekakie et al.
Pericardial fat is independently associated with human atrial fibrillation
J Am Coll Cardiol
(2010)
A.A. Mahabadi et al.
Association of epicardial adipose tissue and left atrial size on non-contrast CT with atrial fibrillation: the Heinz Nixdorf Recall study
Eur Heart J Cardiovasc Imaging
(2014)
M. Obokata et al.
Evidence supporting the existence of a distinct obese phenotype of heart failure with preserved ejection fraction
Circulation
(2017)
S.N. Hatem et al.
Epicardial adipose tissue and atrial fibrillation
Cardiovasc Res
(2014)

T. Haffar et al.

Lipotoxic palmitate impairs the rate of beta-oxidation and citric acid cycle flux in rat neonatal cardiomyocytes

Cell Physiol Biochem

(2016)

J. Mancio et al.

Epicardial adipose tissue volume assessed by computed tomography and coronary artery disease: a systematic review and meta-analysis

Eur Heart J Cardiovasc Imaging

(2018)

S.W. Rabkin

The relationship between epicardial fat and indices of obesity and the metabolic syndrome: a systematic review and meta-analysis

Metab Syndr Relat Disord

(2014)

C.L. Hung et al.

An observational study of the association among interatrial adiposity by computed tomography measure, insulin resistance, and left atrial electromechanical disturbances in heart failure

Medicine

(2016)

Y.H. Lai et al.

Excessive interatrial adiposity is associated with left atrial remodeling, augmented contractile performance in asymptomatic population

Echo Res Pract

(2016)

C.S. Fox et al.

Pericardial fat, intrathoracic fat, and measures of left ventricular structure and function: the Framingham Heart Study

Circulation

(2009)

C.L. Hung et al.

An observational study of the association among interatrial adiposity by computed tomography measure, insulin resistance, and left atrial electromechanical disturbances in heart failure

Medicine

(2016)

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Epicardial Adipose Tissue in Myocardial Disease: From Physiology to Heart Failure Phenotypes
2023, Current Problems in Cardiology
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.
Riboflavin ameliorates pathological cardiac hypertrophy and fibrosis through the activation of short-chain acyl-CoA dehydrogenase
2023, European Journal of Pharmacology
Short-chain acyl-CoA dehydrogenase (SCAD), the rate-limiting enzyme for fatty acid β-oxidation, has a negative regulatory effect on pathological cardiac hypertrophy and fibrosis. FAD, a coenzyme of SCAD, participates in the electron transfer of SCAD-catalyzed fatty acid β-oxidation, which plays a crucial role in maintaining the balance of myocardial energy metabolism. Insufficient riboflavin intake can lead to symptoms similar to short-chain acyl-CoA dehydrogenase (SCAD) deficiency or flavin adenine dinucleotide (FAD) gene abnormality, which can be alleviated by riboflavin supplementation. However, whether riboflavin can inhibit pathological cardiac hypertrophy and fibrosis remains unclear. Therefore, we observed the effect of riboflavin on pathological cardiac hypertrophy and fibrosis. In vitro experiments, riboflavin increased SCAD expression and the content of ATP, decreased the free fatty acids content and improved PE-induced cardiomyocytes hypertrophy and AngⅡ-induced cardiac fibroblasts proliferation by increasing the content of FAD, which were attenuated by knocking down the expression of SCAD using small interfering RNA. In vivo experiments, riboflavin significantly increased the expression of SCAD and the energy metabolism of the heart to improve TAC induced pathological myocardial hypertrophy and fibrosis in mice. The results demonstrate that riboflavin improves pathological cardiac hypertrophy and fibrosis by increasing the content of FAD to activate SCAD, which may be a new strategy for treating pathological cardiac hypertrophy and fibrosis.
Epicardial adipose tissue volume is not an independent predictor of atrial fibrillation recurrence after catheter ablation
2023, Revista Espanola de Cardiologia
Estudios previos han sugerido que el tejido adiposo epicárdico (TAE) podría ejercer un efecto paracrino en el miocardio. Sin embargo, pocos estudios han evaluado su papel en el riesgo de recurrencia de la fibrilación auricular (FA). El objetivo de ese estudio fue evaluar la asociación entre el volumen de TAE y su atenuación con el riesgo de recurrencia de FA tras la ablación de FA.
Se incluyó un total de 350 pacientes consecutivos sometidos a ablación de FA - mediana de edad 57 años [RIC 48-65], 21% FA persistente. La grasa epicárdica se cuantificó mediante tomografía computarizada multidetector utilizando el software Syngo.via Frontier-Cardiac Risk Assessment, midiendo el volumen tejido adiposo pericárdico (VTAP), el volumen de TAE y la atenuación de TAE posterior a la aurícula izquierda. La recurrencia de FA se definió como cualquier episodio documentado de FA, aleteo auricular, o taquicardia auricular más de 3 meses después del procedimiento.
Tras una mediana de seguimiento de 34 meses [rango de 12 a 57 meses], 114 pacientes (33%) tuvieron recurrencia de FA. La regresión de Cox univariable mostró que los pacientes con un volumen de TAE ≥ 80 ml tenían un mayor riesgo de recurrencia de FA (HR = 1,65; IC95%, 1,14-2,39; p = 0,007). Sin embargo, después del ajuste multivariable, el volumen de TAE no fue un predictor independiente de recurrencia de FA (HR = 1,24; IC95%, 0,83-1,87; p = 0,3). Se observaron resultados similares con VTAP. Los pacientes con menor atenuación de TAE no tenían un mayor riesgo de recurrencia de FA (prueba de rango logarítmico p = 0,75).
Los parámetros de TAE, incluida la evaluación del volumen de TAE, VTAP y la atenuación de TAE, no fueron predictores independientes de recurrencia de FA después de la ablación con catéter.
Previous studies have suggested that epicardial adipose tissue (EAT) could exert a paracrine effect in the myocardium. However, few studies have assessed its role in the risk of atrial fibrillation (AF) recurrence. This study aimed to evaluate the association between EAT volume, and its attenuation, with the risk of AF recurrence after AF ablation.
A total of 350 consecutive patients who underwent AF ablation were included. The median age was 57 [IQR 48-65] years and 21% had persistent AF. Epicardial fat was quantified by multidetector computed tomography using Syngo.via Frontier-Cardiac Risk Assessment software, measuring pericardial fat volume (PATV), EAT volume, and attenuation of EAT posterior to the left atrium. AF recurrence was defined as any documented episode of AF, atrial flutter, or atrial tachycardia more than 3 months after the procedure.
After a median follow-up of 34 [range, 12-57] months, 114 patients (33%) had AF recurrence. Univariable Cox regression showed that patients with an EAT volume ≥ 80 mL had an increased risk of AF recurrence (HR, 1.65; 95%CI, 1.14-2.39; P = .007). However, after multivariable adjustment, EAT volume did not remain an independent predictor of AF recurrence (HR, 1.24; 95%CI, 0.83-1.87; P = .3). Similar results were observed with PATV. Patients with lower attenuation of EAT did not have a higher risk of AF recurrence (log-rank test, P = .75).
EAT parameters including the evaluation of EAT volume, PATV and EAT attenuation were not independent predictors of AF recurrence after catheter ablation.
Structural Cardiac Remodeling in Atrial Fibrillation
2021, JACC: Cardiovascular Imaging
This study sought to evaluate preablation computed tomography angiography (CTA) for atrial and epicardial features to predict atrial fibrillation (AF) recurrence after ablation.
Structural atrial remodeling is a process associated with occurrence or persistence of AF. Different anatomical imaging features have been proposed to influence atrial remodeling both negatively and positively as substrate for AF.
Patients with nonvalvular AF underwent cardiac CTA before pulmonary vein isolation at 2 high-volume centers. Left atrial (LA) and right atrial volumes, LA wall thickness (LAWT), and epicardial adipose tissue volume and attenuation were evaluated. Additional subanalyses of electroanatomical maps were made. Follow-up was performed for at least 12 months, including subanalysis of repeated cardiac CTA studies. Interrater variability was assessed.
Of 732 patients, 270 (36.9%) had AF recurrence after a mean of 7 months. CT analysis revealed larger indexed LA volume (47.3 mL/m² vs 43.6 mL/m²; P = 0.0001) and higher mean anterior (1.91 mm vs 1.65 mm; P < 0.0001) and posterior (1.61 mm vs 1.39 mm; P = 0.001) LAWT in patients with AF recurrence. Epicardial adipose tissue volume in patients with AF recurrence was higher (144.5 mm³ vs 128.5 mm³; P < 0.0001) and further progressed significantly in a subset of 85 patients after 2 years (+11.8 mm² vs −3.5 mm²; P = 0.041). Attenuation levels were lower, indicating a higher lipid component associated with AF recurrence (−69.1 HU vs −67.5 HU; P = 0.001). A total of 103 atrial voltage maps were highly predictive of AF recurrence and showed good discriminatory power for patients with low voltage >50% and LAWT (1.55 ± 0.5 mm vs 1.81 ± 0.6 mm; P = 0.032). Net reclassification improvement (NRI) showed a significant incremental benefit (NRI = 0.279; P < 0.0001) when adding LAWT to established risk models.
Atrial wall thickness, epicardial fat volume, and attenuation are associated with AF recurrence in patients undergoing ablation therapy.
Association between epicardial adipose tissue and blood pressure: A systematic review and meta-analysis
2021, Nutrition, Metabolism and Cardiovascular Diseases
Citation Excerpt :
In the past decade, epicardial fat was recognized as a cardiometabolic active tissue. Its confirmed association with coronary heart disease [37,38], AF and diastolic HF had also triggered the interest in exploring its relationship with other cardiovascular and cardiometabolic diseases [4,39], such as diabetes mellitus (DM) and hypertension [40–42]. Meta-analysis by Li et al. concluded that DM patients were presented with higher epicardial fat value regardless of DM subtype [43].
Epicardial adipose tissue has been reported to be associated with the development of cardiometabolic disease. Whether this is true for hypertension and non-dipper blood pressure remains controversial. Here, we conducted a systemic review and meta-analysis to evaluate the association between EAT and blood pressure.
Pubmed, Embase, and Web of Science were searched for relevant papers. Studies reported on the difference of EAT thickness between hypertensive and normotensive patients, or those recorded odds ratio (OR) between EAT and hypertension were included. The standard mean difference (SMD) and ORs were extracted and pooled using a random-effects model respectively. We further assessed the effect of EAT on circadian rhythm of blood pressure by combining multiple-adjusted ORs for non-dipper blood pressure. Seven studies with an overall sample of 1089 patients reported the mean difference of EAT thickness between hypertensive and normotensive patients, and the hypertensive patients had higher EAT (SMD = 1.07; 95% CI: 0.66–1.48; I2 = 89.2%) compared with controls. However, the pooled association between EAT and hypertension from two studies was not significant (OR = 1.65, 95%CI 0.62–4.68; I2 = 87.5%). The summary risk effect of EAT on non-dipper blood pressure from six studies comprising1208 patients showed that each 1 mm increment of EAT was associated with a 2.55-fold risk of non-dipper blood pressure.
Hypertensive patients tend to present higher EAT thickness near the right ventricular wall and increased EAT thickness might be associated with high risk of non-dipper blood pressure. Future researches are warranted to determine the causal link between EAT and hypertension and the underlying mechanism.
Automatic epicardial adipose tissue segmentation in pulmonary computed tomography venography using nnU-Net
2023, Quantitative Imaging in Medicine and Surgery

View all citing articles on Scopus

: Funding: Mancio J is supported by the Fundação Portuguesa para a Ciência e Tecnologia (SFRH/BD/104369/2014) and by the Sociedade Portuguesa de Cardiologia (“Bolsa de investigação João Porto”). This report is a result of the project DOCnet (NORTE-01-0145-FEDER-000003) supported by the Norte Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement, through the European Regional Development Fund (ERDF).

: PROSPERO Registration: This study protocol was registered with PROSPERO (ID: CRD42017080849) Porto (Portugal).

¹: JM and DA contributed equally to this work and are joint first authors.

View full text

Meta-Analysis of Relation of Epicardial Adipose Tissue Volume to Left Atrial Dilation and to Left Ventricular Hypertrophy and Functions

Section snippets

Methods

Results

Discussion

Disclosures

Am J Cardiol

Egypt Heart J

Can J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Association of epicardial adipose tissue and left atrial size on non-contrast CT with atrial fibrillation: the Heinz Nixdorf Recall study

Eur Heart J Cardiovasc Imaging

Evidence supporting the existence of a distinct obese phenotype of heart failure with preserved ejection fraction

Circulation

Epicardial adipose tissue and atrial fibrillation

Cardiovasc Res

Lipotoxic palmitate impairs the rate of beta-oxidation and citric acid cycle flux in rat neonatal cardiomyocytes

Cell Physiol Biochem

Epicardial adipose tissue volume assessed by computed tomography and coronary artery disease: a systematic review and meta-analysis

Eur Heart J Cardiovasc Imaging

The relationship between epicardial fat and indices of obesity and the metabolic syndrome: a systematic review and meta-analysis

Metab Syndr Relat Disord

An observational study of the association among interatrial adiposity by computed tomography measure, insulin resistance, and left atrial electromechanical disturbances in heart failure

Medicine

Excessive interatrial adiposity is associated with left atrial remodeling, augmented contractile performance in asymptomatic population

Echo Res Pract

Pericardial fat, intrathoracic fat, and measures of left ventricular structure and function: the Framingham Heart Study

Circulation

An observational study of the association among interatrial adiposity by computed tomography measure, insulin resistance, and left atrial electromechanical disturbances in heart failure

Medicine