Epicardial fat thickness correlates with carotid intima-media thickness, arterial stiffness, and cardiac geometry in children and adolescents

Visceral fat and cardiometabolic future in children and adolescents: a critical update

Cardiovascular disease (CVD) is a process whose pathogenetic mechanisms start very early in life. Recently, the importance of visceral adipose tissue (VAT) has been highlighted in the development of CVD. VAT does not always depend on body mass index (BMI) and has been implicated in unfavorable metabolic activity and cardiovascular adverse events. Abnormally high deposition of VAT is associated with metabolic syndrome, obesity-associated phenotype, and cardiometabolic risk factors. Although the importance of visceral fat has not been studied broadly or extensively in long-term studies in children and adolescents, it appears that it does not have the same behavior as in adults, it is related to the appearance of cardiac risk factors. In adolescents, it plays a role in the pathogenesis of CVD that occur later in adulthood. Excess body weight and adiposity may lead to the development of early myocardial and pathological coronary changes in childhood. The purpose of this review is to summarize the risk factors, the clinical significance, and the prognostic role of visceral obesity in children and adolescents. In addition, extensive reference is made to the most commonly used techniques for the evaluation of VAT in clinical settings. IMPACT: Visceral obesity, plays an important role in cardiovascular health from very early in an individual's life. Visceral adipose tissue (VAT) distribution is not entirely related to body mass index (BMI) and provides additional prognostic information. There is a need to pay more attention to the assessment of VAT in young people, to develop methods that would go beyond the measurement of only BMI in clinical practice and to identify individuals with excess visceral adiposity and perhaps to monitor its changes.

Evaluation of subclinical atherosclerosis and cardiac functions in children of mothers with gestational diabetes and maternal obesity

BACKGROUND AND AIMS

We aimed to evaluate the effects of maternal obesity or gestational diabetes on body composition, lipid, and glucose metabolism, arterial morphology, and functions in children, and to investigate these effects in terms of cardiometabolic diseases.

METHODS

The study group was composed of 48 children who had a history of gestational diabetes or maternal obesity, and the control group was composed of 33 children. Echocardiographic assessments were performed. Socio-economic status and education level of mothers were obtained.

RESULTS

In the study group, carotid intima-media thickness, epicardial adipose tissue thickness, and arterial stiffness values were found to be significantly higher compared to the control group (p < 0.001, p < 0.001, p = 0.003, respectively), while arterial distensibility and arterial strain values were found to be significantly lower (p = 0.003, p = 0.008, respectively). Among the children who had similar body mass index in both groups, children in the study group had higher carotid intima-media thickness and epicardial adipose tissue thickness values. Arterial stiffness values were significantly reduced (p = 0.028) and arterial distensibility and strain values were significantly increased (p = 0.039, p = 0.033, respectively) in the children whose mothers had gestational diabetes and high socio-economic status. Left ventricular mass and left ventricular end-diastolic internal thickness were found to be significantly increased in the children who had obese and unemployed mothers (p = 0.04, p = 0.03, respectively).

CONCLUSION

Low socio-economic status was found to be associated with increased maternal obesity and gestational diabetes. Poor socio-economic status, poor glycaemic control and being overweight during pregnancy indicate negative cardiometabolic outcomes for children in the long term.

Incremental Value of Noncontrast Chest Computed Tomography-derived Parameters in Predicting Subclinical Carotid Atherosclerosis: From the PERSUADE Study

PURPOSE

To investigate the incremental value of noncontrast chest computed tomography (CT)-derived parameters, such as coronary artery calcium score (CACS) and epicardial adipose tissue volume (EATv), in predicting subclinical carotid atherosclerosis above traditional risk factors in community-based asymptomatic populations of northern China.

MATERIALS AND METHODS

A total of 2195 community-based asymptomatic individuals were enrolled from Jidong Oilfield in accordance with the PERSUADE study. CACS and EATv were measured on noncontrast chest CT. Demographics and ideal cardiovascular health score (ICHS) were collected through questionnaires. We recalculated the ideal cardiovascular health risk score (ICHRS) (ICHRS=14-ICHS) and standardized the parameters as log-CACS and body mass index adjusted EATv (i-EATv). Subclinical carotid atherosclerosis was assessed by Doppler sonography and defined as any prevalence of average carotid intima-media thickness ≥1.00 mm, appearance of carotid plaque, and carotid arterial stenosis in the areas of extracranial carotid arteries on both sides.

RESULTS

A total of 451 (20.55%) individuals presented subclinical carotid atherosclerosis. CACS and EATv were significantly greater in the subclinical group, while ICHS was lower. In multivariate logistic regression, ICHRS (odds ratio [OR]=1.143, 95% confidence interval [CI]: 1.080-1.210, P <0.001), log-CACS (OR=1.701, 95% CI: 1.480-1.955, P <0.001), and i-EATv (OR=1.254, 95% CI: 1.173-1.341, P <0.001) were found to be independent risk predictors for subclinical carotid atherosclerosis. In receiver-operating characteristic curve analysis, when combined with male sex and age level, the area under the curve of the ICHRS basic model increased from 0.627 (95% CI: 0.599-0.654) to 0.757 (95% CI: 0.732-0.781) ( P <0.0001). Further adding log-CACS and i-EATv, the area under the curve demonstrated a statistically significant improvement (0.788 [95% CI: 0.765-0.812] vs. 0.757 [95% CI: 0.732-0.781], P <0.0001).

CONCLUSION

Noncontrast chest CT-derived parameters, including CACS and EATv, could provide significant incremental improvement for predicting subclinical carotid atherosclerosis beyond the conventional risk assessment model based on ICHRS.

Determinants of Arterial Stiffness in Patients with Morbid Obesity. The Role of Echocardiography and Carotid Ultrasound Imaging

Background and objective: Morbid obesity is accompanied by an increased cardiovascular (CV) risk, which justifies a multidisciplinary, integrative approach. Arterial stiffness has a well-defined additional role in refining individual CV risk. Given that echocardiography and carotid ultrasound are usual methods for CV risk characterization, we aimed to identify the imaging parameters with a predictive value for early-onset arterial stiffness. Material and methods: We conducted a study in which 50 patients (divided into two equal groups with morbid obesity and without obesity), age and gender matched, untreated for cardiovascular risk factors, were addressed to bariatric surgery or non-inflammatory benign pathology surgery. Before the surgical procedures, we evaluated demographics, anthropometric data and biochemical parameters including adipokines (chemerin, adiponectin). Arterial stiffness was evaluated using the Medexpert ArteriographTM TL2 device. Transthoracic echocardiography and carotid ultrasound were also performed. We also analyzed adipocyte size and vascular wall thickness in intraoperative biopsies. Results: Left ventricle (LV) mass index (p = 0.2851), LV ejection fraction (LVEF) (p = 0.0073), epicardial adipose tissue thickness (p = 0.0001) as echocardiographic parameters and carotid intima–media thickness (p = 0.0033), relative wall thickness (p = 0.0295), wall to lumen thickness ratio (p = 0.0930) and carotid cross-sectional area (p = 0.0042) as ultrasound parameters were significant measures in our groups and were assessed in relation to adipocyte size, blood vessel wall thickness and adipokines serum levels. Statistical analysis revealed directly proportional relationships between LV mass index (p = 0.008), carotid systolic thickness of the media (p = 0.009), diastolic thickness of the media (p = 0.007), cross-sectional area (p = 0.001) and blood vessel wall thickness. Carotid relative wall thickness positively correlates with adipocyte size (p = 0.023). In patients with morbid obesity, chemerin and adiponectin/chemerin ratio positively correlates with carotid intima–media thickness (p = 0.050), systolic thickness of the media (p = 0.015) and diastolic thickness of the media (p = 0.001). The multiple linear regression models revealed the role of epicardial adipose tissue thickness and carotid cross-sectional area in predicting adipocyte size which in turn is an independent factor for arterial stiffness parameters such as pulse wave velocity, subendocardial viability ratio and aortic augmentation index. Conclusions: Our results suggest that epicardial adipose tissue thickness, carotid intima–media thickness, relative wall thickness and carotid cross-sectional area might be useful imaging parameters for early prediction of arterial stiffness in patients with morbid obesity.

Role of obesity and blood pressure in epicardial adipose tissue thickness in children

BACKGROUND

Elevated body mass index (BMI) has been associated with cardiac changes, such as higher epicardial adipose tissue (EAT) thickness. This fat has been identified as a predictive factor of cardiovascular diseases during adulthood. However, few studies have tested the association of multiple cardiovascular risk factors (high weight or blood pressure) with EAT in adolescents and children. Therefore, the main objective of this current research was to determine the impact of BMI, overweight, obesity, and blood pressure on EAT thickness in children.

METHODS

A descriptive cross-sectional study focused on elementary and high school students aged 6-16 years was carried out by utilizing diverse measurements and instruments, such as echocardiography.

RESULTS

EAT thickness (N = 228) was linked to sex (more predominant in boys 2.3 ± 0.6; p = 0.044), obesity (2.3 ± 0.6; p < 0.001), and hypertension (2.6 ± 0.6; p = 0.036). The logistic regression indicated that age, sex, and BMI seemed to be more relevant factors in EAT thickness in children (adjusted R square = 0.22; p < 0.001).

CONCLUSIONS

This paper examined the associations of sex, age, and cardiovascular risk factors (arthrometric measures and blood pressure) with EAT thickness, indicating that it is necessary to assess whether the findings are associated with future events.

IMPACT

Excessive weight gain and blood pressure in the early stages of life have been associated with adipose tissue. This increase in weight and blood pressure has been attributed to alterations in the epicardial adipose tissue linked to anthropometric markers in adults, but no related study has been implemented in Spanish children. This study revealed how higher epicardial adipose tissue is linked to body mass index, other anthropometric parameters, and blood pressure in Spanish children. These measurements are related to high epicardial adipose tissue thickness, which in early stages does not imply pathology but increases the risk of developing cardiovascular diseases.

Carotid intima-media and epicardial adipose tissue thickness in adult patients with epilepsy taking anti-seizure medication and its long-term significance

OBJECTIVES

We investigated epicardial adipose tissue thickness (EATT), carotid intima-media thickness (CIMT), and lipid profile in adult patients with epilepsy (PWE) taking anti-seizure medication(s) (ASM) and compared with those of the healthy population. We also investigated whether duration of follow-up and number of ASM(s) (mono- vs. polytherapy) affect these risk factors.

METHODS

Twenty PWE older than 18 years of age were recruited at the outpatient epilepsy clinic and compared to twenty controls. Patients who were 18 years old and younger, those with cardiovascular risk factors, and patients with follow-up duration less than 2 years were excluded from the study.

RESULTS

Epicardial adipose tissue thickness and CIMT were thicker compared to controls. While patients' low-density lipoprotein (LDL) levels were higher than controls, and high-density lipoprotein (HDL) levels were lower, the levels were in normal ranges. Those patients with duration of follow-up more than five years had thicker EATT. The 5-year LDL was in normal ranges while HDL was abnormally low. Number of ASM(s) was not associated with increased risks of atherosclerosis. Increased CIMT in patients taking ASM(s) was independent of their lipid profile.

CONCLUSION

Anti-seizure medications contribute to accelerated atherosclerosis in people with epilepsy. Chronic use of ASMs may increase this chance. It is appropriate to use ASM(s) with lower chances of atherosclerosis in people with epilepsy and encourage them to change their lifestyle in order to modify cardiovascular risk factors. Meantime, it is reasonable to assess the risk of atherosclerosis periodically in these patients by noninvasive methods including lipid profile, CIMT, and EATT.

Pericardial adipose tissue, cardiac structures, and cardiovascular risk factors in school-age children

Aims 

We examined the associations of pericardial adipose tissue with cardiac structures and cardiovascular risk factors in children.

Methods and results 

We performed a cross-sectional analysis in a population-based cohort study among 2892 children aged 10 years (2404 normal weight and 488 overweight/obese). Pericardial adipose tissue mass was estimated by magnetic resonance imaging (MRI) and indexed on height³. Left ventricular mass (LVM) and left ventricular mass-to-volume ratio (LMVR) were estimated by cardiac MRI. Cardiovascular risk factors included android adipose tissue percentage obtained by Dual-energy X-ray absorptiometry, blood pressure and glucose, insulin, cholesterol, and triglycerides concentrations. Adverse outcomes were defined as values above the 75 percentile. Median pericardial adipose tissue index was 3.6 (95% range 1.6–7.1) among normal weight and 4.7 (95% range 2.0–8.9) among overweight children. A one standard deviation (1 SD) higher pericardial adipose tissue index was associated with higher LMVR [0.06 standard deviation scores, 95% confidence interval (CI) 0.02–0.09], increased odds of high android adipose tissue [odd ratio (OR) 2.08, 95% CI 1.89–2.29], high insulin concentrations (OR 1.17, 95% CI 1.06–1.30), an atherogenic lipid profile (OR 1.22, 95% CI 1.11–1.33), and clustering of cardiovascular risk factors (OR 1.56, 95% CI 1.36–1.79). Pericardial adipose tissue index was not associated with LVM, blood pressure, and glucose concentrations. The associations showed largely the same directions but tended to be weaker among normal weight than among overweight children.

Conclusion 

Pericardial adipose tissue is associated with cardiac adaptations and cardiovascular risk factors already in childhood in both normal weight and overweight children.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Aim

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

Materials and methods

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

Results

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

Conclusion

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

Imaging of body composition in children

Overweight and obesity in children and adolescents have become a worldwide public health concern with an ever-increasing prevalence. An excessive accumulation of intraabdominal fat tissue increases the risk of developing insulin resistance, diabetes, and cardiovascular diseases in adulthood. Body composition has a role in metabolism regulation in children and adolescents with differences between genders and age groups. Until recently, Air Displacement Plethysmography and Dual-energy X-ray Absorptiometry (DXA) have been the most common techniques used to assess body composition in children. Ultrasound (US) is an accurate, readily available, and radiation-free technique to quantify intra-abdominal fat in adults, but its use in children has not yet been validated. Computed tomography (CT) is a reliable tool to assess body composition, but its use in children should be avoided due to the significant radiation burden. Quantitative Magnetic Resonance Imaging (qMRI) provides an accurate measurement of body composition, through the quantification of the visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and brown adipose tissue (BAT), as well as lean mass. Furthermore, qMRI provides other significant estimates such as the Proton Density Fat-Fraction of the fat tissue. This review article aims to briefly describe the state of art of the advanced imaging techniques to provide a quantitative assessment of body composition in children and adolescents.

Ultrasound imaging, a stethoscope for body composition assessment

Dysregulation of the human's energy balance, mediated by non-performing endocrine organs (liver, skeletal muscle and adipose tissue, above all), can be related to human metabolic disorders characterized by an impaired body composition (BC), such as obesity and sarcopenia. While it is possible to monitor the BC and its variations at different levels, the tissue-organ composition studies have been proven to provide the most clinically applicable information. Ultrasonography (US), a fast, non-invasive, low-cost and widely available technique, holds great potential in the study of BC, as it can directly measure muscles, organs, visceral and subcutaneous fat tissue in different sections of the abdomen and body, overcoming some limits of anthropometric evaluation and other imaging techniques. Purpose of this review article is to explore the technical aspects and the applied methods of US examination to assess the potential clinical role of this technique in the context of BC characterization, investigating four pivotal topics [abdominal fat compartments, subcutaneous adipose tissue (SAT), skeletal muscle, liver].

Childhood Obesity: Does it Have Any Effect on Young Arteries?

Prevalence of overweight (OW) and obesity (O) in children and adolescents has been increased in the past three decades. Increased arterial stiffness measuring by aortic pulse wave velocity (PWV_ao) might be detected in OW/O children and adolescents. The aim of our study was to compare the arterial function parameters (AFPs), such as PWV_ao; aortic augmentation index (Aix_ao); aortic systolic blood pressure (SBP_ao) and brachial systolic blood pressure (SBP_brach) measured simultaneously in O/OW patients and healthy subjects. In our study 6,816 subjects (3,668 boys) aged 3-18 years were recruited and categorized by their body mass index (BMI) into normal weight (N), OW and O groups regarding their age and sex. AFPs were measured by a non-invasive, occlusive-oscillometric device. 19.9% (n = 1,356) of the population were OW/O, 911 (516 boys) were OW and 445 (272 boys) were O. After accounting for the effect of covariates, PWV_ao did not differ significantly between N (5.9 ± 0.8 m/s) and OW patients (5.9 ± 0.8 m/s); and N (6.0 ± 0.7 m/s) and O patients (6.0 ± 0.8 m/s). Aix_ao was significantly lower in OW (9.3 ± 7.4% vs. 7.6 ± 7.0%, p < 0.00001) and in O patients (9.7 ± 8.1% vs. 6.6 ± 7.2%, p < 0.00001) compared to controls. No significant difference was found regarding SBP_ao values between controls and OW and O groups (N = 110.7 ± 12.4 mmHg vs. OW = 110.3 ± 11.9 mmHg; N = 115.6 ± 14.0 mmHg vs. O = 114.3 ± 12.8 mmHg). According to our results we may conclude that the unchanged PWV_ao in O/OW subjects might be due to the compensatory decrease in Aix_ao, referring to enhanced vasodilatory status in the studied population.

Perirenal and epicardial fat and their association with carotid intima-media thickness in children

Recent data suggest that subclinical atherosclerosis is more related to visceral adipose tissue distribution than to overall fat mass. Both perirenal fat and epicardial fat are visceral fat depots surrounding the kidneys and the myocardium, respectively, which can be easily assessed by ultrasound. Their clinical relevance in children is largely unknown. This review describes studies relating perirenal and epicardial fat to cardiovascular disease or carotid intima-media thickness (cIMT), a well-established surrogate for subclinical atherosclerosis, and discusses this in context with our own data from children. In adults, both perirenal and epicardial fat are useful biological markers of visceral obesity. The former has been related to hypertension in overweight subjects and with atherosclerosis in patients with human immunodeficiency virus. The latter was associated with several metabolic syndrome components and with calcification of the carotid artery. In healthy prepubertal children, both epicardial and perirenal fat thickness, rather than total body fat mass, were related to cIMT. Ultrasonography measures of perirenal and epicardial fat are related to atherosclerosis in adults and may be convenient tools for the assessment of cardiometabolic risk in children.

The presbycardia phenotype: Cardiac remodeling and valvular degeneration in nonagenarians

BACKGROUND

Nonagenarians (NON) are a growing segment of the population and have a high prevalence of cardiac disease. Many findings encountered on their echocardiograms are also found in younger individuals with valvular or myocardial disease. Therefore, the purpose of this study was to describe this distinct echocardiographic phenotype.

METHODS

We identified our study population by querying our echo database to identify unique septuagenarians (SEPT) and nonagenarians (NON) who underwent a transthoracic echocardiogram (TTE) from January 1, 2010 to December 31, 2014. Exclusion criteria were LVEF < 50%, any akinetic wall segment, aortic stenosis, moderate-severe AR and/or severe MR, coronary revascularization within 60 days of study echo, and prior valve surgery.

RESULTS

The mean age of SEPT was 73.0 ± 2.0 and NON was 92.0 ± 2.1 (P < 0.001). There was no gender difference between groups. NON had significantly smaller LV end-diastolic diameters than SEPT (41.6 ± 5.7 mm vs 48.0 ± 7.0 mm, P < 0.001). NON had a greater relative wall thickness (0.51 ± 0.10 vs 0.40 ± 0.08, P < 0.001) and more frequently had concentric remodeling or hypertrophy. NON had higher E/Ea ratios and estimated LA pressures (P < 0.01). 48% of NON had moderate-severe mitral annular calcification compared to 25.0% of SEPT (P < 0.01).

CONCLUSIONS

Herein, we provide the first comprehensive echocardiographic description of 'presbycardia'; concentric LVH, asymmetric septal hypertrophy, mitral and aortic valve calcification, and increased epicardial fat thickness. This pattern of findings may be increasingly seen as the population ages.

Epicardial adipose tissue as a metabolic transducer: role in heart failure and coronary artery disease

Obesity and diabetes are strongly associated with metabolic and cardiovascular disorders including dyslipidemia, coronary artery disease, hypertension, and heart failure. Adipose tissue is identified as a complex endocrine organ, which by exerting a wide array of regulatory functions at the cellular, tissue and systemic levels can have profound effects on the cardiovascular system. Different terms including "epicardial," "pericardial," and "paracardial" have been used to describe adipose tissue deposits surrounding the heart. Epicardial adipose tissue (EAT) is a unique and multifaceted fat depot with local and systemic effects. The functional and anatomic proximity of EAT to the myocardium enables endocrine, paracrine, and vasocrine effects on the heart. EAT displays a large secretosome, which regulates physiological and pathophysiological processes in the heart. Perivascular adipose tissue (PVAT) secretes adipose-derived relaxing factor, which is a "cocktail" of cytokines, adipokines, microRNAs, and cellular mediators, with a potent effect on paracrine regulation of vascular tone, vascular smooth muscle cell proliferation, migration, atherosclerosis-susceptibility, and restenosis. Although there are various physiological functions of the EAT and PVAT, a phenotypic transformation can lead to a major pathogenic role in various cardiovascular diseases. The equilibrium between the physiological and pathophysiological properties of EAT is very delicate and susceptible to the influences of intrinsic and extrinsic factors. Various adipokines secreted from EAT and PVAT have a profound effect on the myocardium and coronary arteries; targeting these adipokines could be an important therapeutic approach to counteract cardiovascular disease.

Early cardiac abnormalities in obese children and their relationship with adiposity

OBJECTIVES

Childhood obesity rates are increasing as well as chronic disease and cardiovascular risk factors for patients at young ages. In this study, we evaluate the correlation between cardiac parameters, body mass index (BMI), and other body composition indicators in children and adolescents.

METHODS

In this cross-sectional study, we evaluated anthropometric measurements, bioelectrical impedance parameters, and echocardiographic measurements including the left ventricular mass (LVM), LVM index (LVMI), and left atrial diameter (LAD) in children and adolescents ages 7 to 15 y. We performed linear and multivariate regression analyses and analyzed the correlations between cardiac parameters, BMI, and other body composition parameters.

RESULTS

We analyzed 96 children and adolescents and found 40.6% to be obese and 29.2% overweight. LVMI and LAD indexed to height were significantly higher in individuals who were obese. LVMI increased significantly with increasing BMI (r = 0.717; P < 0.001), waist circumference (r = 0.670; P < 0.001), waist-to-height ratio (r = 0.650; P < 0.001), and body surface (r = 0.570; P < 0.001). Only BMI was significant in the multivariate analysis. LVMI was directly and positively correlated with fat mass (FM) and percentage of visceral and abdominal FM and negatively correlated with percentage of lean body mass. LAD was significantly correlated with body surface (r = 0.728; P < 0.001), BMI (r = 0.611; P < 0.001), waist circumference (r = 0.614; P < 0.001), and waist-to-height ratio (r = 0.341; P < 0.01). When indexed to height, LAD was only correlated with BMI and waist-to-height ratio.

CONCLUSIONS

Obesity is associated with cardiac disturbances at a very early age and these changes are closely related to the degree of adiposity. Cardiac structural parameters are significantly correlated with BMI and waist circumference in pediatric patients ages 7 to 15 y.

Association between endothelial dysfunction, epicardial fat and subclinical atherosclerosis during menopause

BACKGROUND

Menopausal transition is critical for the development of early, subclinical vascular damage. Multiple factors, such as atherosclerosis, increased epicardial fat, and endothelial dysfunction can play a role. Hence, the objective of this study was the comparison of epicardial adipose tissue and carotid intima media thickness in order to establish the best predictor of carotid stiffness in middle-aged women with endothelial dysfunction.

METHODS

A total of 43 healthy women aged 40-59 years old with endothelial dysfunction previously demonstrated by flow mediated dilation were recruited to have anthropometric, biochemical, hormonal and ultrasound determinations of carotid intima media thickness and epicardial fat thickness.

RESULTS

Carotid arterial stiffness parameters (local pulse wave velocity [4.7±0.7 vs 4.8±0.5 vs 5.6±0.5m/s, respectively, p<0.001], pressure strain elastic modulus [55.2±13.4 vs 59.2±11.8 vs 81.9±15.6kPa, respectively, p<0.001], arterial stiffness index β [4.4±1.4 vs 5.0±1.1 vs 6.4±1.3, respectively, p<0.001]) and epicardial fat thickness (2.98±1.4 vs 3.28±1.9 vs 4.70±1.0mm, respectively, p=0.007) showed a significant and proportional increase in the group of late post-menopausal women when compared to early post-menopausal and pre-menopausal groups, respectively. Among body fat markers, epicardial fat was the strongest predictor of local pulse wave velocity, independent of age.

CONCLUSIONS

In menopausal women with endothelial dysfunction, menopausal transition is associated with increased carotid arterial stiffness and epicardial fat thickness, independent of age. Ultrasound measured epicardial fat was a better independent predictor of arterial stiffness than carotid intima media thickness in these women.

Clinical importance of epicardial adipose tissue

Different visceral fat compartments have several systemic effects and may play a role in the development of both insulin resistance and cardiovascular diseases. In the last couple of years special attention has been paid to the epicardial adipose tissue (EAT), which can be quantified by non-invasive cardiac imaging techniques. The epicardial fat is a unique fat compartment between the myocardium and the visceral pericardium sharing a common embryologic origin with the visceral fat depot. Epicardial adipose tissue has several specific roles, and its local effects on cardiac function are incorporated in the complex pathomechanism of coronary artery disease. Importantly, EAT may produce several adipocytokines and chemokines that may influence - through paracrine and vasocrine effects - the development and progression of coronary atherosclerosis. Epicardial adipose tissue volume has a relatively strong genetic dependence, similarly to other visceral fat depots. In this article, the anatomical and physiological as well as pathophysiological characteristics of the epicardial fat compartment are reviewed.

Assessment of early atherosclerosis and left ventricular dysfunction in children with 21-hydroxylase deficiency

AIM

We analysed 25 children with 21-hydroxylase deficiency who received glucocorticoid and/or mineralocorticoid treatment for at least 12 months to determine the effects of the disease and its treatment on vascular structures and ventricular function.

METHODS

Twenty-five patients with 21-hydroxylase-deficient congenital adrenal hyperplasia (CAH) and 25 control subjects were enrolled into this observational, cross-sectional study. The patients were investigated in terms of fasting blood glucose and insulin; fasting serum lipid profile; serum 17-hydroxyprogesterone; dehydroepiandrosterone sulphate; androstenedione; and adrenocorticotropic hormone. M-mode tracings of the wall motion of major arteries were obtained to measure carotid intima-media thickness (cIMT), as well as elasticity and distensibility of the aorta and carotid artery. Conventional and relatively new tissue Doppler imaging techniques were employed to assess ventricular systolic and diastolic functions.

RESULTS

The median age and weight of patients were 9·4 years (1·5-16·75) and 35·5 kg (7·5-76·3), respectively. The median duration of treatment was 52·2 months. Tissue Doppler imaging measurements revealed left ventricular diastolic impairment in the patient group compared to the controls. Carotid intima-media thickness, stiffness index, elastic modulus of the aorta and carotid artery were significantly higher; meanwhile, aortic distensibility and carotid distensibility were lower in the patient group, all of which indicates the presence of subclinical atherosclerosis. BMI was found to be an independent variable for cIMT (ß: 0·5, P = 0·01) and aortic stiffness index (ß: 0·52, P < 0·001).

CONCLUSION

Cardiovascular function and the elastic properties of major arteries are disturbed in children and adolescents with 21-hydroxylase-deficient CAH.

An increase in epicardial adipose tissue is strongly associated with carotid-intima media thickness and atherosclerotic plaque, but LDL only with the plaque

Objective:

Carotid intima-media thickness (CIMT) is reliable marker of subclinical atherosclerosis and cardiovascular events. Until today, there was no study that investigated whether epicardial adipose tissue (EAT), which is a surrogate for lipid depot in a special visceral tissue or circulating lipids, is more important for CIMT and atherosclerotic plaque.

Methods:

Our study, having cross-sectional and prospective observational design, included 252 patients who were admitted to our outpatient clinic. EAT identified as an echo-free space under the pericardial layer on 2-dimensional echocardiography, was measured perpendicularly in front of the right ventricular free wall at end-systole.

Results:

EAT significantly correlated with CIMT (r=0.623, p<0.001). CIMT was significantly increased with rising EAT thickness (0.72±0.15 mm, 0.85±0.16 mm, and 0.95±0.12 mm in patients with EAT <5 mm, 5–7, and >7 mm, p<0.001, respectively). Multiple linear regression analysis revealed that age (Beta: 0.406, p<0.001), male gender (Beta: 0.244, p<0.001), and EAT (Beta: 0.450, p<0.001) as independent correlates of CIMT. Otherwise, in logistic regression analysis, only EAT (OR, 1.386; 95% CI, 1.203–1.597, p<0.001) and LDL cholesterol (OR, 1.013; 95% CI, 1.002–1.013, p=0.02) were independent predictors for presence of carotid plaque.

Conclusion:

Our study showed that EAT has a relationship with both CIMT and the presence of carotid plaque, but LDL is independently related to the plaque. This finding suggests that EAT thickness may be a risk factor and biomarker, playing an important role beginning from early stages of atherosclerosis, unlike LDL cholesterol, which appear to have a role in later stages of atherosclerosis.

Increased Epicardial Fat Thickness Correlates with Aortic Stiffness and N-Terminal Pro-Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Patients

Epicardial fat, a metabolically active tissue, has emerged as a risk factor and active player in metabolic and cardiovascular diseases. We investigated epicardial fat thickness in patients who had sustained an acute ischemic stroke, and we evaluated the relationship of epicardial fat thickness with other prognostic factors. We enrolled 61 consecutive patients (age, ≥18 yr) who had sustained a first acute ischemic stroke and had been admitted to our hospital within 24 hours of the onset of stroke symptoms. The control group comprised 82 consecutive sex- and age-matched patients free of past or current stroke who had been admitted to our cardiology clinics. Blood samples were taken for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at admission. Aortic stiffness indices and epicardial fat thickness were measured by means of transthoracic echocardiography within the first 48 hours. In comparison with the control group, the patients with acute ischemic stroke had significantly higher epicardial fat thickness (4.8 ± 0.9 vs 3.8 ± 0.7 mm; P <0.001), lower aortic distensibility (2.5 ± 0.8 vs 3.4 ± 0.9 cm(2) ·dyn(-1); P <0.001) and lower aortic strain (5.5% ± 1.9% vs 6.4% ± 1.8%; P=0.003). We found a significant association between epicardial fat thickness, NT-proBNP levels, and arterial dysfunction in patients who had sustained acute ischemic stroke. Increased epicardial fat thickness might be a novel risk factor and might enable evaluation of subclinical target-organ damage in these patients.

Ultrasound: Which role in body composition?

Ultrasound is a non-invasive, fast, relatively inexpensive and available tool for estimating adiposity in clinical practice, and in several research settings. It does not expose patients to ionizing radiation risks, making the method ideal for the evaluation, and for follow-up studies. Several parameters and indexes based on adipose tissue thickness have been introduced and tested, and these have been correlated with clinical and laboratoristic parameters. Moreover, ultrasound can also be directed to the estimation of adipose tissue and intracellular fat indirectly, at cellular-molecular level: an opportunity for many radiologists who already and sometimes unconsciously perform "body composition" assessment when looking at the liver, at muscle as well as at other organs. However, standardized procedure and parameters are needing to improve accuracy and reproducibility. The purposes of this review are: 1) to provide a complete overview of the most used and shared measurements of adiposity; 2) to analyze technical conditions, accuracy, and clinical meaning of ultrasound in the study of body composition; 3) to provide some elements for the use of ultrasound in the evaluation of intra-cellular lipids accumulation, in two hot spots: liver and skeletal muscle.

Epicardial adipose tissue thickness in children and adolescents with cardiometabolic risk factors

OBJECTIVE

To assess the relationship of epicardial adipose tissue (EAT) thickness with cardiometabolic risk factors (CRFs) in children and adolescents.

METHODS

Seventy-seven subjects of both sexes aged 7-18 years were selected. Medical history, clinical parameters, and glucose, insulin, and lipid levels were collected. EAT thickness was measured using transthoracic echocardiography. Study subjects were divided into two groups based on whether they had less than two or two or more CRFs.

RESULTS

The group with two or more CRFs had higher EAT thickness, insulin, and HOMA-IR values (P<.05). EAT thickness showed a statistically significant positive correlation with body mass index (BMI) (r=0.561, P=.0001), waist circumference (r=.549, P=.0001), systolic blood pressure (SBP) (r=.256, P=.028), insulin (r=0.408, P=.0001), and HOMA-IR (r=.325, P=.005). However, these correlations were not significant after adjustment for BMI. The cut-off point for EAT thickness as predictor of two or more CRFs was 3.17mm. The risk (odds ratio) of having two or more CRFs if EAT thickness was >3.17mm was 3.1 (95% CI: 1.174-8.022). BMI was the independent variable that most affected EAT thickness and the presence of two or more CRFs.

CONCLUSION

In this group of children and adolescents, the relationship of EAT thickness with CRFs was found to be dependent on BMI.

Increased arterial stiffness in South Dakota American Indian children

Arterial stiffness has been observed in white American obese children, yet there are no data in American Indian youth, who are affected disproportionately by the cardiovascular consequences of childhood obesity and its accompanying risk factors. The purpose of this study was to determine the association of childhood overweight-obesity and cardiometabolic risk factors with arterial stiffness in South Dakota white American and American Indian children. Thirty-six (28 white American and 8 American Indian) children (age, 13 ± 1 years; grades 6-8) from a rural South Dakota elementary and middle school were studied: 18 had a healthy weight (body mass index (BMI), 19.5 ± 1.9 kg/m(2)) and 18 were overweight-obese (BMI, 26.8 ± 3.5 kg/m(2)). Arterial stiffness was assessed using applanation tonometry via pulse wave analysis to determine carotid-radial pulse wave velocity (crPWV) and aortic augmentation index (AIx). There were no differences (P = 0.94) in crPWV between healthy weight (7.1 ± 1.4 m/s) and overweight-obese (7.3 ± 1.0 m/s) children, even after controlling for risk factors. However, crPWV was markedly elevated (P = 0.002) in overweight-obese American Indian children (7.7 ± 1.1 m/s) compared with white American children (6.8 ± 0.5 m/s), and these differences remained after controlling for blood pressure and more severe obesity in the American Indians. An obesity-matched subgroup analysis indicated that crPWV (7.7 ± 1.1 vs 6.8 ± 0.4 m/s) remained significantly greater in the American Indians (P = 0.03). There were no between-group differences in aortic AIx. These findings indicate an adverse influence of American Indian ethnicity on arterial stiffening in children with elevated adiposity. Arterial stiffness in American Indian children may accelerate early adulthood vascular disease.

Local and systemic effects of the multifaceted epicardial adipose tissue depot

Epicardial adipose tissue is a unique and multifaceted fat depot with local and systemic effects. This tissue is distinguished from other visceral fat depots by a number of anatomical and metabolic features, such as increased fatty acid metabolism and a unique transcriptome enriched in genes that are associated with inflammation and endothelial function. Epicardial fat and the heart share an unobstructed microcirculation, which suggests these tissues might interact. Under normal physiological conditions, epicardial fat has metabolic, thermogenic (similar to brown fat) and mechanical (cardioprotective) characteristics. Development of pathological conditions might drive the phenotype of epicardial fat such that it becomes harmful to the myocardium and the coronary arteries. The equilibrium between protective and detrimental effects of this tissue is fragile. Expression of the epicardial-fat-specific transcriptome is downregulated in the presence of severe and advanced coronary artery disease. Improved local vascularization, weight loss and targeted medications can restore the protective physiological functions of epicardial fat. Measurements of epicardial fat have several important applications in the clinical setting: accurate measurement of its thickness or volume is correlated with visceral adiposity, coronary artery disease, the metabolic syndrome, fatty liver disease and cardiac changes. On account of this simple clinical assessment, epicardial fat is a reliable marker of cardiovascular risk and an appealing surrogate for assessing the efficacy of drugs that modulate adipose tissues.

Evidence for contemporary arterial stiffening in obese children and adolescents using pulse wave velocity: A systematic review and meta-analysis

INTRODUCTION

Pulse wave velocity (PWV) and augmentation index (AI) may provide information on future cardiovascular risk. Reports are conflicting on whether obese children show evidence of raised PWV and AI.

METHODS

Systematic review and meta-analysis of published studies using EMBASE, Web-of-Science and PUBMED databases for studies reporting PWV and AI in obese versus non-obese controls(<age 18 years). Studies were pooled in meta-analyses to generate weighted mean differences (WMD) using random effects methodology. Analyses were repeated by method, quality grade and anatomical region.

RESULTS

383 studies were found in initial searches and 81 were assessed in detail; 14 studies (6677 total participants, 1120 obese and 5557 non-obese) were suitable for meta-analysis for PWV, and 5 studies (728 participants obese and 317 non-obese) for AI. Across all studies, obese children had higher PWV than non-obese children (WMD 0.45(95% confidence interval 0.10 to 0.81 ms(-)(1))). This difference was not significant when only studies with low/medium risk of bias were included. Obese subjects had higher PWV measured directly at the carotid (WMD 0.51 (0.35-0.67 ms(-)(1))) and aorta (WMD 1.33 (0.36-2.31)). No significant differences were found for AI. Heterogeneity was high in all analyses(I(2) > 90% in PWV and AI meta-analyses).

CONCLUSION

There is moderate evidence that obese children have increased arterial stiffening, especially in central arteries. This supports concerns about future CVD risk in obese children. Developing effective obesity interventions must remain a health priority.

Obesity and Arterial Stiffness in Children

Objective—

Childhood obesity is associated with risk factors for cardiovascular disease. Arterial stiffness is considered one of the earliest detectable measures of vascular damage. There is controversy in the literature regarding the effects of childhood obesity on arterial stiffness. The objective of this study is to systematically review the literature and to conduct a meta-analysis comparing measures of central arterial stiffness in children and adolescents with obesity to healthy body mass index controls.

Approach and Results—

Literature searches were conducted using databases (eg, MEDLINE, EMBASE) and citations cross-referenced. Studies assessing central pulse wave velocity or β-stiffness index were included. A random effects meta-analysis of the standardized mean difference and 95% confidence intervals in arterial stiffness between children with obesity and control children was performed for each arterial stiffness measure. A total of 523 studies were identified. Fifteen case–control studies were included, with 2237 children/adolescents (1281 with obesity, 956 healthy body mass index controls) between 5 and 24 years of age. All studies measuring carotid and aortic β-stiffness index and 10/12 studies measuring central pulse wave velocity reported greater arterial stiffness in children/adolescents with obesity compared with controls. A random effects meta-analysis was performed revealing a significant effect of obesity on pulse wave velocity (standardized mean difference=0.718; 95% confidence interval=0.291–1.415), carotid β-stiffness index (0.862; 0.323–1.402), and aortic β stiffness index (1.017; 0.419–1.615).

Conclusion—

These findings indicate that child/adolescent obesity is associated with greater arterial stiffness. However, further research is needed to address confounders, such as pubertal status, that may affect this relationship in children. In the future, these techniques may be useful in risk stratification and guiding clinical management of obese children to optimize cardiovascular outcomes.

Epicardial fat thickness: threshold values and lifestyle association in male adolescents

BACKGROUND

Obese adolescents with high proportion of visceral fat are at higher risk of developing the metabolic syndrome.

OBJECTIVES

The study aims to investigate if echocardiographic epicardial fat thickness (EF) could be predictive of visceral obesity (VO) early in life and to provide EF threshold values specific for male adolescents. Further aim was to investigate the association between EF, lifestyle and metabolic disease familiarity.

METHODS

Anthropometric data were collected from 102 normal weight and overweight, healthy male adolescents (mean age: 14.91 ±  1.98 years); bioelectrical impedance analysis and transthoracic echocardiogram were performed in the same sample. Each participant fulfilled a validated self-administered lifestyle questionnaire.

RESULTS

We found higher EF values in sedentary adolescents (P < 0.05), in those who never eat fruit and vegetables (P < 0.05), and in those with overweight mothers (P < 0.05). The strongest independent predictor of EF was waist circumference (P < 0.0001). Using the waist to height ratio as a marker of VO, logistic regression analysis revealed that 1 mm EF gain is responsible for seven times higher VO risk (P < 0.0001). Receiver Operating Characteristic (ROC) analysis showed that the optimal cut-off for EF thickness associated to youth VO is 3.2 mm.

CONCLUSION

Ultrasonography EF measurement might be a second-level assessment tool, useful to detect early cardiometabolic damage stage.