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Waddell HMM, Moore MK, Herbert-Olsen MA, Stiles MK, Tse RD, Coffey S, Lamberts RR, Aitken-Buck HM. Identifying sex differences in predictors of epicardial fat cell morphology. Adipocyte 2022; 11:325-334. [PMID: 35531882 PMCID: PMC9122305 DOI: 10.1080/21623945.2022.2073854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/12/2022] Open
Abstract
Predictors of overall epicardial adipose tissue deposition have been found to vary between males and females. Whether similar sex differences exist in epicardial fat cell morphology is currently unknown. This study aimed to determine whether epicardial fat cell size is associated with different clinical measurements in males and females. Fat cell sizes were measured from epicardial, paracardial, and appendix adipose tissues of post-mortem cases (N= 118 total, 37 females). Epicardial, extra-pericardial, and visceral fat volumes were measured by computed tomography from a subset of cases (N= 70, 22 females). Correlation analyses and stepwise linear regression were performed to identify predictors of fat cell size in males and females. Median fat cell sizes in all depots did not differ between males and females. Body mass index (BMI) and age were independently predictive of epicardial, paracardial, and appendix fat cell sizes in males, but not in females. Epicardial and appendix fat cell sizes were associated with epicardial and visceral fat volumes, respectively, in males only. In females, paracardial fat cell size was associated with extra-pericardial fat volume, while appendix fat cell size was associated with BMI only. No predictors were associated with epicardial fat cell size in females at the univariable or multivariable levels. To conclude, no clinical measurements were useful surrogates of epicardial fat cell size in females, while BMI, age, and epicardial fat volume were independent, albeit weak, predictors in males only.
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Affiliation(s)
- Helen M. M. Waddell
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Matthew K. Moore
- Department of Medicine, HeartOtago, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Morgan A. Herbert-Olsen
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Martin K. Stiles
- Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Rexson D. Tse
- Department of Forensic Pathology, LabPLUS, Auckland City Hospital, Auckland, New Zealand
| | - Sean Coffey
- Department of Medicine, HeartOtago, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Department of Cardiology, Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
| | - Regis R. Lamberts
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Hamish M. Aitken-Buck
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
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Aitken-Buck HM, Moharram M, Babakr AA, Reijers R, Van Hout I, Fomison-Nurse IC, Sugunesegran R, Bhagwat K, Davis PJ, Bunton RW, Williams MJA, Stiles MK, Jones PP, Coffey S, Lamberts RR. Relationship between epicardial adipose tissue thickness and epicardial adipocyte size with increasing body mass index. Adipocyte 2019; 8:412-420. [PMID: 31829077 PMCID: PMC6948959 DOI: 10.1080/21623945.2019.1701387] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Macroscopic deposition of epicardial adipose tissue (EAT) has been strongly associated with numerous indices of obesity and cardiovascular disease risk. In contrast, the morphology of EAT adipocytes has rarely been investigated. We aimed to determine whether obesity-driven adipocyte hypertrophy, which is characteristic of other visceral fat depots, is found within EAT adipocytes. EAT samples were collected from cardiac surgery patients (n = 49), stained with haematoxylin & eosin, and analysed for mean adipocyte size and non-adipocyte area. EAT thickness was measured using echocardiography. A significant positive relationship was found between EAT thickness and body mass index (BMI). When stratified into standardized BMI categories, EAT thickness was 58.7% greater (p = 0.003) in patients from the obese (7.3 ± 1.8 mm) compared to normal (4.6 ± 0.9 mm) category. BMI as a continuous variable significantly correlated with EAT thickness (r = 0.56, p < 0.0001). Conversely, no correlation was observed between adipocyte size and either BMI or EAT thickness. No difference in the non-adipocyte area was found between BMI groups. Our results suggest that the increased macroscopic EAT deposition associated with obesity is not caused by adipocyte hypertrophy. Rather, alternative remodelling via adipocyte proliferation might be responsible for the observed EAT expansion.
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Affiliation(s)
- Hamish M. Aitken-Buck
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Mohammed Moharram
- Department of Medicine, HeartOtago, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Aram A Babakr
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Robin Reijers
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Isabelle Van Hout
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Ingrid C. Fomison-Nurse
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Ramanen Sugunesegran
- Department of Cardiothoracic Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Krishna Bhagwat
- Department of Cardiothoracic Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Phillip J Davis
- Department of Cardiothoracic Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Richard W. Bunton
- Department of Cardiothoracic Surgery, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Michael J. A. Williams
- Department of Medicine, HeartOtago, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Martin K. Stiles
- Department of Cardiology, Waikato District Health Board, Hamilton, New Zealand
- Waikato Clinical School, University of Auckland, Hamilton, New Zealand
| | - Peter P. Jones
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Sean Coffey
- Department of Medicine, HeartOtago, Dunedin School of Medicine, Dunedin Hospital, Dunedin, New Zealand
| | - Regis R. Lamberts
- Department of Physiology, HeartOtago, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
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3
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Christensen RH, von Scholten BJ, Hansen CS, Jensen MT, Vilsbøll T, Rossing P, Jørgensen PG. Epicardial adipose tissue predicts incident cardiovascular disease and mortality in patients with type 2 diabetes. Cardiovasc Diabetol 2019; 18:114. [PMID: 31470858 PMCID: PMC6716926 DOI: 10.1186/s12933-019-0917-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/21/2019] [Indexed: 02/03/2023] Open
Abstract
Background Cardiac fat is a cardiovascular biomarker but its importance in patients with type 2 diabetes is not clear. The aim was to evaluate the predictive potential of epicardial (EAT), pericardial (PAT) and total cardiac (CAT) fat in type 2 diabetes and elucidate sex differences. Methods EAT and PAT were measured by echocardiography in 1030 patients with type 2 diabetes. Follow-up was performed through national registries. The end-point was the composite of incident cardiovascular disease (CVD) and all-cause mortality. Analyses were unadjusted (model 1), adjusted for age and sex (model 2), plus systolic blood pressure, body mass index (BMI), low-density lipoprotein (LDL), smoking, diabetes duration and glycated hemoglobin (HbA1c) (model 3). Results Median follow-up was 4.7 years and 248 patients (191 men vs. 57 women) experienced the composite end-point. Patients with high EAT (> median level) had increased risk of the composite end-point in model 1 [Hazard ratio (HR): 1.46 (1.13; 1.88), p = 0.004], model 2 [HR: 1.31 (1.01; 1.69), p = 0.038], and borderline in model 3 [HR: 1.32 (0.99; 1.77), p = 0.058]. For men, but not women, high EAT was associated with a 41% increased risk of CVD and mortality in model 3 (p = 0.041). Net reclassification index improved when high EAT was added to model 3 (19.6%, p = 0.035). PAT or CAT were not associated with the end-point. Conclusion High levels of EAT were associated with the composite of incident CVD and mortality in patients with type 2 diabetes, particularly in men, after adjusting for CVD risk factors. EAT modestly improved risk prediction over CVD risk factors.
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Affiliation(s)
- Regitse H Christensen
- Center for Inflammation and Metabolism/Center for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark. .,Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | | | | | - Magnus T Jensen
- Department of Cardiology, Glostrup-Rigshospitalet, Glostrup, Denmark.,Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Tina Vilsbøll
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter G Jørgensen
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark
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Choi JH. The Relation of Epicardial Fat Thickness, Neutrophil to Lymphocyte Ratio and Circadian Rhythm of Blood Pressure. J Cardiovasc Ultrasound 2017; 24:272-273. [PMID: 28090252 PMCID: PMC5234335 DOI: 10.4250/jcu.2016.24.4.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jae Hyuk Choi
- Division of Cardiology, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Kim BJ, Cho KI, Choi JH, Park DH, Yu GI, Im SI, Kim HS, Heo JH, Cha TJ. Epicardial Fat Thickness and Neutrophil to Lymphocyte Ratio are Increased in Non-Dipper Hypertensive Patients. J Cardiovasc Ultrasound 2016; 24:294-302. [PMID: 28090257 PMCID: PMC5234339 DOI: 10.4250/jcu.2016.24.4.294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 11/29/2016] [Accepted: 11/30/2016] [Indexed: 11/22/2022] Open
Abstract
Background In this study, we aimed to investigate the relationship between echocardiographic epicardial fat thickness (EFT), neutrophil to lymphocyte ratio (NLR; an important inflammatory marker), and diurnal blood pressure (BP) changes in patients with recently diagnosed essential hypertension. Methods A total of 647 patients underwent echocardiography and 24 hours of ambulatory BP monitoring. EFT was measured by echocardiography, while NLR was measured by dividing the neutrophil count by the lymphocyte count. Patients were categorized into three groups according to BP pattern: the normotensive group, the dipper group, and the non-dipper group. Results The mean EFT was highest in the non-dipper group (non-dipper group, 7.3 ± 3.0 mm; dipper group, 6.1 ± 2.0 mm; control group, 5.6 ± 2.0 mm; p < 0.001). NLR was also highest in the non-dipper group (non-dipper, 2.75 ± 2.81; dipper, 2.01 ± 1.32; control, 1.92 ± 1.11; p < 0.001). EFT was significantly correlated with age (r = 0.160, p < 0.001) and NLR (r = 0.353, p < 0.001). Furthermore, an EFT ≥ 7.0 mm was associated with the non-dipper BP pattern with 51.3% sensitivity and 71.6% specificity [95% confidence interval (CI) = 0.56–0.65, p < 0.001]. In a multivariate analysis, EFT [adjusted odds ratio (OR) = 3.99, 95% CI = 1.22–13.10, p = 0.022] and NLR (OR = 1.34, 95% CI = 1.05–1.71, p = 0.018) were independent parameters that distinguished a non-dipper pattern after adjustment for cardiovascular risk factors. Conclusion EFT and NLR are independently associated with impaired diurnal BP profiles in hypertensive individuals. EFT (as measured by echocardiography) and NLR appear to be helpful in stratifying cardiometabolic risk.
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Affiliation(s)
- Bong Joon Kim
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoung Im Cho
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ji Hun Choi
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Dong Hyun Park
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ga In Yu
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Il Im
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hyun Su Kim
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jeong Ho Heo
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Tae-Joon Cha
- Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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6
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Çetin S, Vural MG, Gündüz H, Akdemir R, Fırat H. Epicardial fat thickness regression with continuous positive airway pressure therapy in patients with obstructive sleep apnea: assessment by two-dimensional echocardiography. Wien Klin Wochenschr 2016; 128:187-92. [PMID: 26964554 DOI: 10.1007/s00508-016-0975-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 02/11/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a common syndrome in patients with metabolic syndrome (MetS). Epicardial fat thickness (EFT), an indicator of visceral adiposity, is a novel parameter for studying patients with OSA. Our aim was to investigate the effects of continuous positive airway pressure therapy (CPAP) therapy on EFT. METHODS A total of 162 subjects (68 women and 94 men) were included and divided into three groups: Group I: Apnea-hypopnea index (AHI) < 5 (n = 45), Group II: AHI 5-15 (n = 22), and Group III: AHI > 15 (n = 95). All participants underwent full-night polysomnography and transthoracic echocardiography. There were 28 symptomatic patients with AHI > 15 who received compliant CPAP therapy for 24 weeks. RESULTS MetS was more frequent, and systolic blood pressure (SBP), diastolic blood pressure (DBP), blood glucose were higher in Group III compared with I (p < 0.05). High-density lipoprotein (HDL) levels were lower in Group III compared with I (p < 0.05). Triglyceride levels and waist circumference were higher in Group III compared with I and II (p < 0.05). EFT was higher in Group III compared with I and higher in Group II compared with I (p < 0.05). EFT was predicted by MetS and AHI. After CPAP therapy high-sensitive C-reactive protein (hsCRP) and EFT were reduced (p < 0.05). CONCLUSION EFT was significantly higher in patients with AHI > 15 and predicted by MetS and AHI. CPAP therapy reduced hsCRP levels and EFT.
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Affiliation(s)
- Süha Çetin
- Department of Cardiology, Kudret Private Hospital, GMK Bulvarı Nr. 81, Ankara, Turkey.
| | - Mustafa Gökhan Vural
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Hüseyin Gündüz
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Ramazan Akdemir
- Department of Cardiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Hikmet Fırat
- Pulmonology Clinic, Ministery of Health Dışkapı Yıldırım Beyazıt Research and Educational Hospital, Ankara, Turkey
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7
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Selthofer-Relatić K, Bošnjak I. Myocardial fat as a part of cardiac visceral adipose tissue: physiological and pathophysiological view. J Endocrinol Invest 2015; 38:933-9. [PMID: 25770455 DOI: 10.1007/s40618-015-0258-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 02/08/2015] [Indexed: 01/07/2023]
Abstract
Thoracic fat includes extra-pericardial (outside the visceral pericardium) and intra-pericardial (inside the visceral pericardium) adipose tissue. It is called ectopic adipose tissue although it is a normal anatomical structure. Intra-pericardial adipose tissue, which is predominantly composed of epicardial and pericoronary adipose tissue, has a significant role in cardiovascular system function. It provides metabolic-mechanical support to the heart and blood vessels in physiological conditions, while it represents metabolic-cardiovascular risk in case of qualitative and quantitative structural changes in the tissue: it correlates with coronary atherosclerotic disease, left ventricular mass, left atrium enlargement and atrial fibrillation presence. In the last decade there has been mounting evidence of fat cells presence in the myocardium of healthy (non-diseased) persons as well as in persons with both cardiovascular and non-cardiovascular diseases. Thus, it is necessary to clarify the incidence, aetiology, physiological role of fat cells in the myocardium, as well as the clinical significance of pathological fatty infiltration of the myocardium.
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Affiliation(s)
- K Selthofer-Relatić
- Department for Cardiovascular Medicine, University Hospital Centre Osijek, Osijek, Croatia,
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8
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Hua N, Chen Z, Phinikaridou A, Pham T, Qiao Y, LaValley MP, Bigornia SJ, Ruth MR, Apovian CM, Ruberg FL, Hamilton JA. The influence of pericardial fat upon left ventricular function in obese females: evidence of a site-specific effect. J Cardiovasc Magn Reson 2014; 16:37. [PMID: 24884541 PMCID: PMC4046092 DOI: 10.1186/1532-429x-16-37] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 05/12/2014] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although increased volume of pericardial fat has been associated with decreased cardiac function, it is unclear whether this association is mediated by systemic overall obesity or direct regional fat interactions. We hypothesized that if local effects dominate, left ventricular (LV) function would be most strongly associated with pericardial fat that surrounds the left rather than the right ventricle (RV). METHODS Female obese subjects (n = 60) had cardiovascular magnetic resonance (CMR) scans to obtain measures of LV function and pericardial fat volumes. LV function was obtained using the cine steady state free precession imaging in short axis orientation. The amount of pericardial fat was determined volumetrically by the cardiac gated T1 black blood imaging and normalized to body surface area. RESULTS In this study cohort, LV fat correlated with several LV hemodynamic measurements including cardiac output (r = -0.41, p = 0.001) and stroke volume (r = -0.26, p = 0.05), as well as diastolic functional parameters including peak-early-filling rate (r = -0.38, p = 0.01), early late filling ratio (r = -0.34, p = 0.03), and time to peak-early-filling (r = 0.34, p = 0.03). These correlations remained significant even after adjusting for the body mass index and the blood pressure. However, similar correlations became weakened or even disappeared between RV fat and LV function. LV function was not correlated with systemic plasma factors, such as C-reactive protein (CRP), B-type natriuretic peptide (BNP), Interleukin-6 (IL-6), resistin and adiponectin (all p > 0.05). CONCLUSIONS LV hemodynamic and diastolic function was associated more with LV fat as compared to RV or total pericardial fat, but not with systemic inflammatory markers or adipokines. The correlations between LV function and pericardial fat remained significant even after adjusting for systemic factors. These findings suggest a site-specific influence of pericardial fat on LV function, which could imply local secretion of molecules into the underlying tissue or an anatomic effect, both mechanisms meriting future evaluation.
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Affiliation(s)
- Ning Hua
- The Department of Physiology and Biophysics, Boston University School of Medicine, Boston, MA, USA
| | - Zhongjing Chen
- The Department of Physiology and Biophysics, Boston University School of Medicine, Boston, MA, USA
| | - Alkystis Phinikaridou
- The Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, UK
| | - Tuan Pham
- The Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Ye Qiao
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Michael P LaValley
- The Department of Biostatistics, Boston University School of Medicine, Boston, MA, USA
| | - Sherman J Bigornia
- The Department of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston, MA, USA
| | - Megan R Ruth
- The Department of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston, MA, USA
| | - Caroline M Apovian
- The Department of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- The Department of Medicine, Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA, USA
- The Department of Radiology, Boston University School of Medicine, Boston, MA, USA
| | - James A Hamilton
- The Department of Physiology and Biophysics, Boston University School of Medicine, Boston, MA, USA
- The Department of Biomedical Engineering, Boston University, Boston, MA, USA
- The Department of Radiology, Boston University School of Medicine, Boston, MA, USA
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9
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Epicardial Adipose Tissue: New Kid on the Block. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0383-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Lin HH, Lee JK, Yang CY, Lien YC, Huang JW, Wu CK. Accumulation of epicardial fat rather than visceral fat is an independent risk factor for left ventricular diastolic dysfunction in patients undergoing peritoneal dialysis. Cardiovasc Diabetol 2013; 12:127. [PMID: 24001037 PMCID: PMC3766214 DOI: 10.1186/1475-2840-12-127] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/10/2013] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Symptoms of heart failure with preserved left ventricular systolic function are common among patients undergoing peritoneal dialysis (PD). Epicardial fat (EpF) is an ectopic fat depot with possible paracrine or mechanical effects on myocardial function. The aim of our current study is to assess the association between EpF and Left ventricular diastolic dysfunction (LVDD) in patients undergoing PD and to clarify the relationships among EpF, inflammation, and LVDD in this population. METHODS This was a cross-sectional study of 149 patients with preserved left ventricular systolic function who were undergoing PD. LVDD was diagnosed (according to the European Society of Cardiology guidelines) and EpF thickness measured by echocardiography. The patients without LVDD were used as controls. The serum inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) was measured. The location and amount of adipose tissue were assessed by computed tomography (CT) at the level of the fourth lumbar vertebra. RESULTS Subjects with LVDD had higher levels of hsCRP, more visceral and peritoneal fat, and thicker EpF (all p < 0.001) than controls. Visceral adipose tissue, hsCRP, and EpF all correlated significantly (p < 0.05) with LVDD. Multivariate regression analysis rendered the relationship between visceral adipose tissue and LVDD insignificant, whereas EpF was the most powerful determinant of LVDD (odds ratio = 2.41, 95% confidence interval = 1.43-4.08, p < 0.01). EpF thickness also correlated significantly with the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/e'; r = 0.27, p < 0.01). CONCLUSION EpF thickness is significantly independently associated with LVDD in patients undergoing PD and may be involved in its pathogenesis.
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Affiliation(s)
- Heng-Hsu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital No, 7, Chung-Shan South Road Taipei 100, Taipei, Taiwan.
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Morelli M, Gaggini M, Daniele G, Marraccini P, Sicari R, Gastaldelli A. Ectopic fat: the true culprit linking obesity and cardiovascular disease? Thromb Haemost 2013; 110:651-60. [PMID: 23884194 DOI: 10.1160/th13-04-0285] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/22/2013] [Indexed: 01/14/2023]
Abstract
Obesity is a major risk factor for cardiovascular disease and its complications. However, not all fat depots share the same characteristics. Recent studies have found that ectopic rather than subcutaneous fat accumulation is associated with increased cardiometabolic risk. However, ectopic fat accumulation can be seen initially as a protective mechanism against lipotoxicity. Subsequently the adipose tissue becomes dysfunctional, thus inducing systemic metabolic alterations (through release of cytokines) or specific organ dysfunctions. The purpose of this review is to summarise the current available data on the impact of excess adiposity vs ectopic fat in the development of cardio-metabolic diseases.
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Affiliation(s)
- Mariangela Morelli
- Amalia Gastaldelli, PhD, Head of Cardiometabolic Risk Unit, Institute of Clinical Physiology, via Moruzzi 1, 56100 Pisa, Italy, Tel.: +39 050 3152680/79, Fax: +39 050 3152166, E-mail:
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12
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Aortic valve sclerosis is a high predictive marker of systemic endothelial dysfunction in hypertensive patients. Herz 2013; 38:915-21. [DOI: 10.1007/s00059-013-3763-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 01/13/2013] [Accepted: 01/14/2013] [Indexed: 12/25/2022]
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13
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Increased bioactive lipids content in human subcutaneous and epicardial fat tissue correlates with insulin resistance. Lipids 2012; 47:1131-41. [PMID: 23054552 PMCID: PMC3501177 DOI: 10.1007/s11745-012-3722-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 09/18/2012] [Indexed: 12/19/2022]
Abstract
Obesity is a risk factor for metabolic diseases. Intramuscular lipid accumulation of ceramides, diacylglycerols, and long chain acyl-CoA is responsible for the induction of insulin resistance. These lipids are probably implicated in obesity-associated insulin resistance not only in skeletal muscle but also in fat tissue. Only few data are available about ceramide content in human subcutaneous adipose tissue. However, there are no data on DAG and LCACoA content in adipose tissue. The aim of our study was to measure the lipids content in human SAT and epicardial adipose tissue we sought to determine the bioactive lipids content by LC/MS/MS in fat tissue from lean non-diabetic, obese non-diabetic, and obese diabetic subjects and test whether the lipids correlate with HOMA-IR. We found, that total content of measured lipids was markedly higher in OND and OD subjects in both types of fat tissue (for all p < 0.001) as compared to LND group. In SAT we found positive correlation between HOMA-IR and C16:0-Cer (r = 0.79, p < 0.001) and between HOMA-IR and C16:0/18:2 DAG (r = 0.56, p < 0.001). In EAT we found a strong correlation between C16:0-CoA content and HOMA-IR (r = 0.73, p < 0.001). The study showed that in obese and obese diabetic patients, bioactive lipids content is greater in subcutaneous and epicardial fat tissue and the particular lipids content positively correlates with HOMA-IR.
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Snel M, Jonker JT, Schoones J, Lamb H, de Roos A, Pijl H, Smit JWA, Meinders AE, Jazet IM. Ectopic fat and insulin resistance: pathophysiology and effect of diet and lifestyle interventions. Int J Endocrinol 2012; 2012:983814. [PMID: 22675355 PMCID: PMC3366269 DOI: 10.1155/2012/983814] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Revised: 01/16/2012] [Accepted: 01/17/2012] [Indexed: 12/15/2022] Open
Abstract
The storage of triglyceride (TG) droplets in nonadipose tissues is called ectopic fat storage. Ectopic fat is associated with insulin resistance and type 2 diabetes mellitus (T2DM). Not the triglycerides per se but the accumulation of intermediates of lipid metabolism in organs, such as the liver, skeletal muscle, and heart seem to disrupt metabolic processes and impair organ function. We describe the mechanisms of ectopic fat depositions in the liver, skeletal muscle, and in and around the heart and the consequences for each organs function. In addition, we systematically reviewed the literature for the effects of diet-induced weight loss and exercise on ectopic fat depositions.
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Affiliation(s)
- M. Snel
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J. T. Jonker
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J. Schoones
- Walaeus Library, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - H. Lamb
- Department of Radiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - A. de Roos
- Department of Radiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - H. Pijl
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J. W. A. Smit
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - A. E. Meinders
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - I. M. Jazet
- Departments of Endocrinology & Metabolism and General Internal Medicine, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- *I. M. Jazet:
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Sengul C, Cevik C, Ozveren O, Duman D, Eroglu E, Oduncu V, Tanboga HI, Can MM, Akgun T, Dindar I. Epicardial Fat Thickness Is Associated with Non-Dipper Blood Pressure Pattern in Patients with Essential Hypertension. Clin Exp Hypertens 2011; 34:165-70. [DOI: 10.3109/10641963.2011.577488] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
AbstractEpicardial adipose tissue (EAT) is metabolically active tissue that accumulates around the coronary arteries. Epicardial fat is a rich source of free fatty acids and may contribute to local inflammatory load by increased synthesis of inflammatory cytokines. Direct passage of bioactive molecules into the coronary arteries due to close contact with the vascular wall and the lack of fascia may contribute to the pathogenesis of coronary artery disease. Direct correlation between visceral fat and EAT defines the latter as an indirect marker of intra-abdominal visceral adiposity. EAT is related to anthropometric and clinical features of the metabolic syndrome (MS) and to hepatic transaminases as markers of steatohepatitis. An increase in EAT thickness is related to an increase in left ventricular mass and is correlated with atrial enlargement and impairment in diastolic filling in obesity. Echocardiographic study of EAT is an easy and reliable imaging indicator of visceral adiposity and cardiovascular risk. EAT is an independent factor strongly correlated with significant coronary stenosis. A level of EAT above an established average value can be considered a predictive marker of cardiovascular risk. We review the most recent studies proving the specific active role of EAT in the development of cardiac disease.
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Pezeshkian M, Rashidi MR, Varmazyar M, Hanaee J, Darbin A, Nouri M. Influence of a high cholesterol regime on epicardial and subcutaneous adipose tissue fatty acids profile in rabbits. Metab Syndr Relat Disord 2011; 9:403-9. [PMID: 21612505 DOI: 10.1089/met.2011.0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We have shown that the fatty acid profile of epicardial adipose tissue (EAT) in patients with obstructed coronary vessels is different from that of the subcutaneous adipose tissue (SAT). The diversity and amount of fatty acids in the adipose tissue can be affected by the component of the lipids in diet. As a result, this study investigated the influence of a high cholesterol regime on EAT and subcutaneous adipose tissue fatty acids profile in rabbits. METHODS Sixteen New Zealand white rabbits were randomly divided into two equal groups. The control group received a normal standard diet, whereas the test group was fed with the high cholesterol regime for 2 months. At the end of this period, the rabbits were anesthetized, 1-5 mg of EAT and SAT were removed, and their fatty acids content was determined. RESULTS The high cholesterol regime caused a significant increase in low-density lipoprotein (LDL) and triglycerides levels and a marked decrease in high-density lipoprotein (HDL) concentration. After 2 months, in the EAT, fatty acids 16:0 and 18:1t and saturated fatty acid (SFA) showed a significant increase (P<0.05), whereas, fatty acids 12:0, 18:1, 18:2, and 18:3, monounsaturated fatty acid (MUFA), polyunsaturated fatty acid (PUFA), ω3, and ω6 had a significant decrease (P<0.05). In SAT, fatty acids 18:3, 20:4, 22:6, MUFA, and ω3 decreased and PUFA, SFA, and ω6 significantly increased (P<0.05). CONCLUSION Consumption of a high cholesterol regime for 2 months resulted in a significant increase in atherogenic fatty acids and a decrease in antiatherogenic ones in the EAT. EAT is very sensitive to lipid changes of the regime comparing to SAT.
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Affiliation(s)
- Masood Pezeshkian
- Cardiovascular Research Center, School of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
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Doesch C, Haghi D, Flüchter S, Suselbeck T, Schoenberg SO, Michaely H, Borggrefe M, Papavassiliu T. Epicardial adipose tissue in patients with heart failure. J Cardiovasc Magn Reson 2010; 12:40. [PMID: 20624277 PMCID: PMC2914772 DOI: 10.1186/1532-429x-12-40] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Accepted: 07/12/2010] [Indexed: 12/13/2022] Open
Abstract
PURPOSE The aim of this study was to evaluate the extent of epicardial adipose tissue (EAT) and its relationship with left ventricular (LV) parameters assessed by cardiovascular magnetic resonance (CMR) in patients with congestive heart failure (CHF) and healthy controls. BACKGROUND EAT is the true visceral fat deposited around the heart which generates various bioactive molecules. Previous studies found that EAT is related to left ventricular mass (LVM) in healthy subjects. Further studies showed a constant EAT to myocardial mass ratio in normal, ischemic and hypertrophied hearts. METHODS CMR was performed in 66 patients with CHF due to ischemic cardiomyopathy (ICM), or dilated cardiomyopathy (DCM) and 32 healthy controls. Ventricular volumes, dimensions and LV function were assessed. The amount of EAT was determined volumetrically and expressed as mass indexed to body surface area. Additionally, the EAT/LVM and the EAT/left ventricular remodelling index (LVRI) ratios were calculated. RESULTS Patients with CHF had less indexed EAT mass than controls (22 +/- 5 g/m2 versus 34 +/- 4 g/m2, p < 0.0001). In the subgroup analysis there were no significant differences in indexed EAT mass between patients with ICM and DCM (21 +/- 4 g/m2 versus 23 +/- 6 g/m2, p = 0.14). Linear regression analysis showed that with increasing LV end-diastolic diameter (LV-EDD) (r = 0.42, p = 0.0004) and LV end-diastolic mass (LV-EDM) (r = 0.59, p < 0.0001), there was a significantly increased amount of EAT in patients with CHF. However, the ratio of EAT mass/LV-EDM was significantly reduced in patients with CHF compared to healthy controls (0.54 +/- 0.1 versus 0.21 +/- 0.1, p < 0.0001). In CHF patients higher indexed EAT/LVRI-ratios in CHF patients correlated best with a reduced LV-EF (r = 0.49, p < 0.0001). CONCLUSION Patients with CHF revealed significantly reduced amounts of EAT. An increase in LVM is significantly related to an increase in EAT in both patients with CHF and controls. However, different from previous reports the EAT/LVEDM-ratio in patients with CHF was significantly reduced compared to healthy controls. Furthermore, the LV function correlated best with the indexed EAT/LVRI ratio in CHF patients. Metabolic abnormalities and/or anatomic alterations due to disturbed cardiac function and geometry seem to play a key role and are a possible explanation for these findings.
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Affiliation(s)
- Christina Doesch
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dariusch Haghi
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Stephan Flüchter
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Tim Suselbeck
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Stefan O Schoenberg
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Henrik Michaely
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Martin Borggrefe
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Theano Papavassiliu
- 1st Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany
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Nelson AJ, Worthley MI, Psaltis PJ, Carbone A, Dundon BK, Duncan RF, Piantadosi C, Lau DH, Sanders P, Wittert GA, Worthley SG. Validation of cardiovascular magnetic resonance assessment of pericardial adipose tissue volume. J Cardiovasc Magn Reson 2009; 11:15. [PMID: 19416534 PMCID: PMC2684106 DOI: 10.1186/1532-429x-11-15] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Accepted: 05/05/2009] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pericardial adipose tissue (PAT) has been shown to be an independent predictor of coronary artery disease. To date its assessment has been restricted to the use of surrogate echocardiographic indices such as measurement of epicardial fat thickness over the right ventricular free wall, which have limitations. Cardiovascular magnetic resonance (CMR) offers the potential to non-invasively assess total PAT, however like other imaging modalities, CMR has not yet been validated for this purpose. Thus, we sought to describe a novel technique for assessing total PAT with validation in an ovine model. METHODS 11 merino sheep were studied. A standard clinical series of ventricular short axis CMR images (1.5T Siemens Sonata) were obtained during mechanical ventilation breath-holds. Beginning at the mitral annulus, consecutive end-diastolic ventricular images were used to determine the area and volume of epicardial, paracardial and pericardial adipose tissue. In addition adipose thickness was measured at the right ventricular free wall. Following euthanasia, the paracardial adipose tissue was removed from the ventricle and weighed to allow comparison with corresponding CMR measurements. RESULTS There was a strong correlation between CMR-derived paracardial adipose tissue volume and ex vivo paracardial mass (R2 = 0.89, p < 0.001). In contrast, CMR measurements of corresponding RV free wall paracardial adipose thickness did not correlate with ex vivo paracardial mass (R2 = 0.003, p = 0.878). CONCLUSION In this ovine model, CMR-derived paracardial adipose tissue volume, but not the corresponding and conventional measure of paracardial adipose thickness over the RV free wall, accurately reflected paracardial adipose tissue mass. This study validates for the first time, the use of clinically utilised CMR sequences for the accurate and reproducible assessment of pericardial adiposity. Furthermore this non-invasive modality does not use ionising radiation and therefore is ideally suited for future studies of PAT and its role in cardiovascular risk prediction and disease in clinical practice.
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Affiliation(s)
- Adam J Nelson
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Matthew I Worthley
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Peter J Psaltis
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Angelo Carbone
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Benjamin K Dundon
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Rae F Duncan
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Cynthia Piantadosi
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Dennis H Lau
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Prashanthan Sanders
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Gary A Wittert
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
| | - Stephen G Worthley
- Cardiovascular Research Centre, Royal Adelaide Hospital & Disciplines of Medicine and Physiology, University of Adelaide, Adelaide, SA, Australia
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Baker AR, da Silva NF, Quinn DW, Harte AL, Pagano D, Bonser RS, Kumar S, McTernan PG. Human epicardial adipose tissue expresses a pathogenic profile of adipocytokines in patients with cardiovascular disease. Cardiovasc Diabetol 2006; 5:1. [PMID: 16412224 PMCID: PMC1352345 DOI: 10.1186/1475-2840-5-1] [Citation(s) in RCA: 485] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Accepted: 01/13/2006] [Indexed: 02/06/2023] Open
Abstract
Introduction Inflammation contributes to cardiovascular disease and is exacerbated with increased adiposity, particularly omental adiposity; however, the role of epicardial fat is poorly understood. Methods For these studies the expression of inflammatory markers was assessed in epicardial fat biopsies from coronary artery bypass grafting (CABG) patients using quantitative RT-PCR. Further, the effects of chronic medications, including statins, as well as peri-operative glucose, insulin and potassium infusion, on gene expression were also assessed. Circulating resistin, CRP, adiponectin and leptin levels were determined to assess inflammation. Results The expression of adiponectin, resistin and other adipocytokine mRNAs were comparable to that in omental fat. Epicardial CD45 expression was significantly higher than control depots (p < 0.01) indicating significant infiltration of macrophages. Statin treated patients showed significantly lower epicardial expression of IL-6 mRNA, in comparison with the control abdominal depots (p < 0.001). The serum profile of CABG patients showed significantly higher levels of both CRP (control: 1.28 ± 1.57 μg/mL vs CABG: 9.11 ± 15.7 μg/mL; p < 0.001) and resistin (control: 10.53 ± 0.81 ng/mL vs CABG: 16.8 ± 1.69 ng/mL; p < 0.01) and significantly lower levels of adiponectin (control: 29.1 ± 14.8 μg/mL vs CABG: 11.9 ± 6.0 μg/mL; p < 0.05) when compared to BMI matched controls. Conclusion Epicardial and omental fat exhibit a broadly comparable pathogenic mRNA profile, this may arise in part from macrophage infiltration into the epicardial fat. This study highlights that chronic inflammation occurs locally as well as systemically potentially contributing further to the pathogenesis of coronary artery disease.
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Affiliation(s)
- Adam R Baker
- Unit for Diabetes and Metabolism, Warwick Medical School, University of Warwick, Clinical Sciences Research Institute, UHCW Campus, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Nancy F da Silva
- Unit for Diabetes and Metabolism, Warwick Medical School, University of Warwick, Clinical Sciences Research Institute, UHCW Campus, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - David W Quinn
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, B15 2TH, UK
| | - Alison L Harte
- Unit for Diabetes and Metabolism, Warwick Medical School, University of Warwick, Clinical Sciences Research Institute, UHCW Campus, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Domenico Pagano
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, B15 2TH, UK
| | - Robert S Bonser
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, B15 2TH, UK
| | - Sudhesh Kumar
- Unit for Diabetes and Metabolism, Warwick Medical School, University of Warwick, Clinical Sciences Research Institute, UHCW Campus, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Philip G McTernan
- Unit for Diabetes and Metabolism, Warwick Medical School, University of Warwick, Clinical Sciences Research Institute, UHCW Campus, Clifford Bridge Road, Coventry, CV2 2DX, UK
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