Epicardial adipose tissue in contemporary cardiology

Effect of smoking behaviour and related blood DNA methylation on visceral adipose tissues

BACKGROUND

Recent studies have found that tobacco smoking is associated with fat distribution, yet limited research has focused on its relationship with visceral adipose tissues (VATs). Furthermore, the cellular and molecular mechanisms underlying the interactions among smoking, epigenetic modifications, and VATs remain unknown.

METHOD

We performed univariable Mendelian randomization (MR) analysis to elucidate the causal relationship between smoking behaviours and VATs, including epicardial and pericardial adipose tissue (EPAT), liver fat (LF), and pancreas fat (PF). This approach could minimize the impact of confounders and reverse causality through utilizing genetic variants to proxy the smoking behaviours. Mediation MR analysis were conducted to detect potential mediators. Additionally, summary-data-based MR (SMR) and colocalization analysis were performed to explore the association between smoking-related DNA methylation and VATs.

RESULTS

We identified a convincing association between smoking initiation and increased EPAT (beta: 0.15, 95% CI: 0.06, 0.23, p = 7.01 × 10-4) and LF area (beta: 0.15, 95% CI = 0.05, 0.24, p = 2.85 × 10-3), respectively. Further mediation analysis suggested type 2 diabetes mellitus (T2DM) as a potential mediator within these co-relationships. When further exploring the associations between the smoking related DNA methylation and VATs, we identified that WT1 methylation at cg05222924 was significantly linked to a lower EPAT area (beta: -0.12, 95% CI: -0.16, -0.06, PFDR = 2.24 × 10-3), while GPX1 methylation at cg18642234 facilitated the deposition of EPAT (beta: 0.15, 95% CI: 0.10, 0.20, PFDR = 1.66 × 10-4).

CONCLUSION

Our study uncovered a significant causal effect between smoking and VATs, with T2DM identified as a potential mediator. Further investigation into DNA methylation yielded novel insights into the pathogenic role of smoking on EPAT.

The prognostic value of epicardial and pericoronary adipose tissue in heart failure with preserved ejection fraction using coronary computed tomography angiography

OBJECTIVES

To assess the prognostic significance of epicardial adipose tissue volume (EATv) and pericoronary adipose tissue attenuation (PCATa) in patients with heart failure with preserved ejection fraction (HFpEF).

METHODS

This retrospective study was based on HFpEF and controls who underwent coronary CT angiography (CCTA) screening to rule out coronary disease. Comparisons of EATv and PCATa were made between HFpEF patients and a control group, using statistical analyses including Kaplan-Meier and Cox regression to assess prognostic significance.

RESULTS

A total of 224 patients were retrospectively analysed. The EATv was 56.1 ± 11.9 cm3 and PCATa in the right coronary artery (PCATa-RCA) was -74.7 HU ± 3.82 in HFpEF patients, which increased significantly compared with controls. Among them, 112 HFpEF patients (mean age: 71.9 ± 8.5 years; 40% male) were followed up for a median of 27 ± 0.6 months (range 2-47 months). EATv and PCATa-RCA were predictive of outcome with an optimal threshold of 56.29 cm3 and -71.17 HU, respectively. In Kaplan-Meier analysis, the high EATv and PCATa-RCA attenuation had significantly higher rates of composite outcomes (log-rank test, all P < .01). EATv and PCATa-RCA were independently predictive of outcome following adjustment for confounding variables (EATv: hazard ratio [HR] 1.03; 95% CI (1.01-1.06); P < .01, PCTAa-RCA: HR 1.44; 95% CI 1.27-1.62; P < .001)).

CONCLUSIONS

Increased EATv and PCATa-RCA are associated with worse clinical outcomes in HFpEF patients.

ADVANCES IN KNOWLEDGE

This study highlights the potential of CCTA-derived adipose tissue metrics as novel, non-invasive biomarkers for risk stratification in HFpEF.

Epicardial fat tissue, a hidden enemy against the early recovery of left ventricular systolic function after transcatheter aortic valve implantation

Background

Epicardial fat tissue (EFT) is an active organ that can affect cardiac function and structure through endocrine, paracrine, and proinflammatory mechanisms. We hypothesized that greater thickness of EFT may harm the recovery of left ventricular (LV) systolic function in patients with severe aortic stenosis (AS) and reduced LV ejection fraction (EF ≤ 50 %) undergoing transcatheter aortic valve implantation (TAVI).

Methods

A sixty six patients with severe AS and 20 % ≥ LVEF ≤ 50 % who underwent TAVI were included. Patients were categorized into two groups based on LV systolic function recovery 30 days after TAVI defined by ≥ 20 % relative increase in LV Global longitudinal strain (GLS) from baseline. EFT was determined by ECG-gated contrast-enhanced multidetector computed tomography (MDCT).

Results

Forty-five patients (68.0 %) showed LV systolic function recovery. EFT showed no significant correlation with the baseline LV-GLS but was associated with less likelihood of LV systolic function recovery (OR 0.7, 95 % CI 0.50 - 0.98, P = 0.04). In the multivariate analysis, higher LVMI (OR 1.05, 95 % CI 1.00-1.10, P = 0.02), lower LV-GLS (OR 0.55, 95 % CI 0.40-0.82, P = 0.002), and thinner EFT (OR 0.38, 95 % CI 0.20-0.73, P = 0.003) were independently associated with LV systolic function recovery after TAVI.

Conclusion

EFT extent is associated with LV systolic function recovery in AS patients with impaired LVEF undergoing TAVI and therefore may help in risk stratification and management of these patients.

CMR assessment of epicardial edipose tissue in relation to myocardial inflammation and fibrosis in patients with new-onset atrial arrhythmias after STEMI

BACKGROUND

Previous studies have shown that epicardial edipose tissue(EAT) appears to be associated with myocardial inflammation and fibrosis, but this is not clear in patients with new-onset atrial arrhythmias after STEMI. The present study focused on using CMR to assess the association of epicardial fat with myocardial inflammation and fibrosis and its predictive value in patients with new-onset atrial arrhythmias after STEMI.

METHODS

This was a single-centre, retrospective study. We consecutively selected patients who completed CMR during their hospitalisation for PCI after STEMI from May 2019-January 2023, and then underwent regular follow-up, grouped by the presence or absence of new atrial arrhythmias, and enrolled patients were divided into atrial arrhythmia and non-atrial arrhythmia groups.

RESULTS

In the atrial arrhythmia group, age, heart rate, Peak hs-TnT, PeakNT-proBNP, EATV, LAES, LAED, T1 native, T1*, ECV, and T2 were higher than those in the non-atrial arrhythmia group, and LVEF was lower than those in the non-atrial arrhythmia group. EATV showed a positive and significant correlation with T1native, T1*, ECV, and T2. (T1 native: r = 0.476,p < 0.001; ECV: r = 0.529,p < 0.001; T1*: r = 0.467,p < 0.001; T2: r = 0.538,p < 0.001). Multifactorial logistic regression analysis showed age, LVEF, EATV, T1*,ECV, T2 as independent risk factors for atrial arrhythmia. (p < 0.05) ROC analysis showed that the AUC for age was 0.568; AUC for LVEF was 0.656; AUC for EATV was 0.768; AUC for ECV was 0.705; AUC for T1* was 0.612; and AUC for T2 was 0.772.

CONCLUSION

In patients with STEMI, EAT is associated with myocardial inflammation, fibrosis. Age, LVEF, EATV, T1*,ECV, T2 are independent risk factors for new onset atrial arrhythmias and have good predictive value.

Epicardial adipose tissue, cardiac damage, and mortality in patients undergoing TAVR for aortic stenosis

Computed tomography (CT)-derived Epicardial Adipose Tissue (EAT) is linked to cardiovascular disease outcomes. However, its role in patients undergoing Transcatheter Aortic Valve Replacement (TAVR) and the interplay with aortic stenosis (AS) cardiac damage (CD) remains unexplored. We aim to investigate the relationship between EAT characteristics, AS CD, and all-cause mortality. We retrospectively included consecutive patients who underwent CT-TAVR followed by TAVR. EAT volume and density were estimated using a deep-learning platform and CD was assessed using echocardiography. Patients were classified according to low/high EAT volume and density. All-cause mortality at 4 years was compared using Kaplan-Meier and Cox regression analyses. A total of 666 patients (median age 81 [74-86] years; 54% female) were included. After a median follow-up of 1.28 (IQR 0.53-2.57) years, 11.7% (n = 77) of patients died. The EAT volume (p = 0.017) decreased, and density increased (p < 0.001) with worsening AS CD. Patients with low EAT volume (< 49cm3) and high density (≥-86 HU) had higher all-cause mortality (log-rank p = 0.02 and p = 0.01, respectively), even when adjusted for age, sex, and clinical characteristics (HR 1.71, p = 0.02 and HR 1.73, p = 0.03, respectively). When CD was added to the model, low EAT volume (HR 1.67 p = 0.03) and CD stages 3 and 4 (HR 3.14, p = 0.03) remained associated with all-cause mortality. In patients with AS undergoing TAVR, CT-derived low EAT volume, and high density were independently associated with increased 4-year mortality and worse CD stage. Only EAT volume remained associated when adjusted for CD.

Diagnostic Potential of CTRP5 and Chemerin for Coronary Artery Disease: A Study by Coronary Computed Tomography Angiography

Background/Objectives: As an endocrine organ, adipose tissue produces adipokines that influence coronary artery disease (CAD). The objective of this study was to assess the potential value of CTRP5 and chemerin in differentiating coronary computed tomography angiography (CCTA)-confirmed coronary artery disease (CAD) versus non-CAD. Secondarily, within the CCTA-confirmed CAD group, the aim was to investigate the relationship between the severity and extent of CAD, as determined by coronary artery calcium score (CACS), and the levels of CTRP5 and chemerin. Methods: Consecutive individuals with chest pain underwent CCTA to evaluate coronary artery anatomy and were divided into two groups. The CCTA-confirmed CAD group included patients with any atherosclerotic plaque (soft, mixed, or calcified) regardless of calcification, while the non-CAD group consisted of individuals without plaques on CCTA, with zero CACS, and without ischemia on stress ECG. Secondarily, in the CCTA-confirmed CAD group, the severity and extent of CAD were evaluated using CACS. Blood samples were collected and stored at -80 °C for analysis of CTRP5 and chemerin levels via ELISA. Results: Serum CTRP5 and chemerin levels were significantly higher in the CAD group compared to the non-CAD group (221.83 ± 103.81 vs. 149.35 ± 50.99 ng/mL, p = 0.003 and 105.02 ± 35.62 vs. 86.07 ± 19.47 ng/mL, p = 0.005, respectively). Receiver operating characteristic (ROC) analysis showed that a CTRP5 cutoff of 172.30 ng/mL had 70% sensitivity and 73% specificity for identifying CAD, while a chemerin cutoff of 90.46 ng/mL had 61% sensitivity and 62% specificity. A strong positive correlation was observed between CTRP5 and chemerin, but neither adipokine showed a correlation with the Agatston score, a measure of CAD severity and extent, nor with coronary artery stenosis as determined by CCTA. Conclusions: CTRP5 and chemerin were significantly elevated in the CCTA-confirmed CAD group compared to the non-CAD group, with CTRP5 showing greater sensitivity and specificity. However, neither adipokine was linked to CAD severity and extent, differing from findings based on invasive coronary angiography (ICA). CTRP5 may serve as a promising "all-or-none biomarker" for CAD presence.

Mineral composition and ratios in aortic valves, serum, and epicardial fat among patients with aortic stenosis undergoing aortic valve replacement

Aortic stenosis (AS) is a leading cause of surgical intervention in adults with acquired heart disease, driven by an aging population and advancements in diagnostic and treatment approaches. This study aimed to investigate levels of macroelements (Ca, K, Na, Mg, and P) in aortic valve tissues, serum, and epicardial fat in patients undergoing aortic valve replacement due to degenerative disease. Elemental composition was determined using inductively coupled plasma mass spectrometry. Analyses revealed a distinct accumulation of Ca and P in aortic valve tissues, not correlated to and exceeding that in epicardial adipose tissue, suggesting localized mineralization. Significant relationships between serum and aortic valve element concentrations were found, with serum K and Mg levels inversely correlated with Ca and P deposition and Ca/P ratio in the valve, highlighting their potential role as calcification inhibitors. Moreover, serum and valvular Na/K ratios were positively correlated. Furthermore, patient age was associated with increased Ca, Mg, Na, P levels, and Ca/P ratio in valve tissues, reinforcing age as a risk factor for valvular calcification. Creatinine and lipoprotein (a) levels correlated positively with valvular K content and Ca/P ratio, respectively, while high-density lipoprotein cholesterol concentration was positively associated with Ca, Mg, and P content in epicardial fat. Patients with increased transvalvular systolic pressure gradient revealed higher valvular Na content. Future longitudinal research should address mineralization across earlier disease stages, exploring additional trace elements and molecular contributors to advance understanding of calcification mechanisms, ultimately aiding in developing biomarkers or therapeutic strategies for postponing or preventing AS onset.

Unmasking the Epicardial Adipose Tissue-Left Atrial Strain Nexus in HFpEF: A Potential Echocardiographic Signature of Cardiac Adaptation

PURPOSE

This study aims to investigate the relationship between epicardial adipose tissue (EAT) and left atrial function in patients with preserved ejection fraction heart failure (HFpEF).

METHODS

We conducted a cross-sectional study involving 113 patients diagnosed with HFpEF and 48 control subjects without heart failure. Echocardiography was performed to assess EAT thickness and left atrial function was quantified using Autostrain left atrium (LA), including left atrial strain during reservoir phase (LASr), left atrial strain during conduit phase (LAScd), and left atrial strain during contraction phase (LASct). Clinical and biochemical parameters were correlated with EAT and LA strain using regression analyses and generating receiver operating characteristic (ROC) curves for left atrial strain parameters.

RESULTS

EAT thickness was significantly greater in the HFpEF group (8.0 ± 1.0 mm) compared to the control group (5.0 ± 0.7 mm). HFpEF group exhibited poorer left ventricle diastolic function, indicated by lower e' velocity, E/A ratio, and higher E/e' values. Left atrial strain parameters, including LASr (22.4 ± 9.1%), LAScd (11.9 ± 6.9%), and LASct (10.5 ± 3.9%), were all lower in the HFpEF. EAT thickness was positively correlated with NT-proBNP, triglycerides, and fasting blood glucose. Multivariate analysis revealed significant associations between EAT and LA strain parameters even after adjusting for potential confounders. ROC curve analysis indicated that LASr had the highest diagnostic accuracy for HFpEF. Additionally, left atrial strain parameters were strongly correlated with left ventricular diastolic function.

CONCLUSION

Patients with HFpEF exhibit increased EAT thickness and reduced left atrial function. The thickening of EAT is associated with a decrease in left atrial strain. LA strain, particularly LASr, may serve as a sensitive indicator for early detection of left ventricular diastolic dysfunction in HFpEF.

Low breast density is associated with epicardial adipose tissue volume and coronary artery disease

PURPOSE

Epicardial adipose tissue volume (EATv), is well correlated with coronary artery disease (CAD), however not reported clinically. Breast density, measured on mammography, has shown promise as a reflector of cardiometabolic risk, with less dense breasts indicating greater proportion of adipose tissue. We aimed to evaluate the association between breast density, EATv and CAD.

METHOD

Retrospective, cross-sectional study including 153 women who had both clinically indicated coronary computed tomography angiogram (CCTA) and mammography. EATv was quantified using semi-automated software. Breast density was visually assessed by standard 4-level BI-RADS grading (low: BI-RADS A-B, high: BI-RADS CD). CAD was categorised as presence/absence of coronary artery plaque and severity was quantified using CAD-RADS score.

RESULTS

Among 153 patients (mean age 62 ± 10), 103 (67.3 %) had low breast density (high breast adiposity). Low breast density patients were older, had greater rates of hypertension, higher mean BMI (p < 0.001) and EATv (106.6 ± 43.0 ml vs 81.0 ± 31.6 ml, p < 0.001). EATv was predictive of low breast density (OR: 1.02[1.01-1.03], p = 0.006), independent of age and hypertension. Low breast density was strongly associated with presence of CAD (prevalence 75 % vs 48 %, OR: 3.21[1.58-6.53], p = 0.001) independent of EATv, and modifiable (OR: 2.69[1.24-5.92], p = 0.012) and non-modifiable (OR: 2.42[1.04-5.85], p = 0.047) cardiovascular risk factors. Low breast density made up a higher proportion of mild (76.5 %), moderate (73.9 %) and severe (80.0 %) CAD.

CONCLUSIONS

Low breast density is associated with higher EATv and independently associated with CAD presence beyond EATv and other cardiovascular risk factors. Mammographic breast density may therefore have value as an early risk identification tool for CAD in women.

Perivascular adipose tissue: a central player in the triad of diabetes, obesity, and cardiovascular health

Perivascular adipose tissue (PVAT) is a dynamic tissue that affects vascular function and cardiovascular health. The connection between PVAT, the immune system, obesity, and vascular disease is complex and plays a pivotal role in the pathogenesis of vascular diseases such as atherosclerosis, hypertension, and vascular inflammation. In cardiometabolic diseases, PVAT becomes a significant source of proflammatory adipokines, leading to increased infiltration of immune cells, in cardiometabolic diseases, PVAT becomes a significant source of proinflammatory adipokines, leading to increased infiltration of immune cells, promoting vascular smooth muscle cell proliferation and migrationpromoting vascular smooth muscle cell proliferation and migration. This exacerbates vascular dysfunction by impairing endothelial cell function and promoting endothelial activation. Dysregulated PVAT also contributes to hemodynamic alterations and hypertension through enhanced sympathetic nervous system activity and impaired vasodilatory capacity of PVAT-derived factors. Therapeutic interventions targeting key components of this interaction, such as modulating PVAT inflammation, restoring adipokine balance, and attenuating immune cell activation, hold promise for mitigating obesity-related vascular complications. Lifestyle interventions, pharmacological agents targeting inflammatory pathways, and surgical approaches aimed at reducing PVAT mass or improving adipose tissue function are potential therapeutic avenues for managing vascular diseases associated with obesity and PVAT dysfunction.

Epicardial adipose tissue: a new link between type 2 diabetes and heart failure-a comprehensive review

Diabetic cardiomyopathy is a unique cardiomyopathy that is common in diabetic patients, and it is also a diabetic complication for which no effective treatment is currently available. Moreover, relevant studies have revealed that a link exists between type 2 diabetes and heart failure and that abnormal thickening of EAT is inextricably linked to the development of diabetic heart failure. Numerous clinical studies have demonstrated that EAT is implicated in the pathophysiologic process of diabetic myocardial disease. In this overview, we will introduce the physiology, pathophysiology of the disease and potential therapeutic strategies, knowledge gaps, and future directions of the role of epicardial adipose tissue in type 2 diabetes mellitus and heart failure to promote the development of novel therapeutic approaches to improve the prognosis of patients with diabetic cardiomyopathy.

SGLT2 inhibition and adipose tissue metabolism: current outlook and perspectives

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as important agents for the treatment of type 2 diabetes mellitus (T2DM). SGLT2 inhibitors have been associated with improved cardiovascular outcomes, not only through their immediate hemodynamic effects-such as glycosuria and (at least temporary) increased natriuresis-but also due to their multifaceted impact on metabolism. Recently, studies have also focused on the effects of SGLT2 inhibitors on adipose tissue. Aside from the well-documented effects on human adiposity, SGLT2i have shown, both in vitro and in murine models, the ability to reduce fat mass, upregulate genes related to browning of white adipose tissue, influence adipocyte size and fatty acid oxidation, and improve oxidative stress and overall metabolic health. In humans, even though data are still limited, recent evidence seems to confirm that the SGLT2i effects observed in cardiovascular outcome trials could be partially explained by their impact on adipose tissue. This review aims to clarify the impact of SGLT2i on adipose tissue, highlighting their role in metabolic health and their potential to transform treatment strategies for T2DM beyond glucose metabolism.

Effect of physical exercise on metabolism in patients with atrial fibrillation

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, is closely linked to metabolic dysfunctions, including obesity, diabetes, and dyslipidemia. These lead to pathological changes in myocardial metabolism and mitochondrial energy metabolism, thereby aggravating AF's incidence and severity. This review introduces the role of metabolic dysfunctions in exacerbating AF, assesses the therapeutic potential of physical exercise and investigates it as a non-pharmacological intervention to alleviate these metabolic disturbances. Evidence suggests that regular physical activity not only enhances metabolic profiles but also reduces the frequency of AF episodes and improves overall cardiovascular health. At the same time, the review emphasizes the need for individualized exercise regimens, individualized to the metabolic and cardiac conditions of each patient to optimize benefits and minimize risks. Additionally, it calls for more basic studies and large-scale clinical trials to establish and refine evidence-based exercise guidelines specific to AF management.

Visceral fat as the main tomographic risk factor for COVID-19 mortality

BACKGROUND

Obesity is a risk factor for COVID-19 mortality; a BMI >35 increases the risk of death up to 12-fold; two previous studies have examined the association between visceral fat quantified by tomography and the risk of severe COVID-19, but not its association with mortality.

OBJECTIVE

Examine whether tomographic findings differentiated data from patients who died of COVID-19 pneumonia from those who survived in a cohort of patients at a tertiary hospital.

METHODS

This was a case-control study (1:1) in which we recruited data from patients at a tertiary care hospital in Mexico. Cases (N = 213) were data from patients with COVID-19 pneumonia discharged due to death, and controls (N = 216) were data from patients discharged due to improvement. All had chest computed tomography (CT) scans in the Picture Archiving and Communication System (PACS) platform. Multivariate analysis was used to identify tomographic variables associated with mortality, and odds ratios were calculated. As tomographic variables, we refer to the total severity score, the total percentage of pulmonary involvement, the pattern of involvement, the location of the lesions, and subcutaneous and visceral fat.

RESULTS

A total of 429 sets of data from Mexican patients were analyzed, with an overall age of 57 years (18-93). Sixty-three percent were male, and arterial hypertension was the most common comorbidity in 48.3 %. An odds ratio (OR) of 8.79 (95 % CI 1.44-53.73) was found for visceral fat and mortality; the rest of the tomographic variables did not show a statistically significant association.

CONCLUSION

Visceral fat was the most significant tomographic risk factor for mortality in patients with COVID-19 pneumonia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: ChiCTR1800017058.

Ischemia-induced expression status of cofilin 1, CRSP2, HSP90, HSP27, and IL8 in epicardial adipose tissue and single cell transcriptomic profiling of stromal cells

Epicardial adipose tissue (EAT) is a rich source of EAT-derived stromal cells (EATDS), which possess regenerative potential. CRSP2, HSP27, IL8, HSP90, and Cofilin 1 were detected in the secretome of left ventricular stromal cells under ischemia challenge. However, the association of these genes in the EAT and EATDS remain understudied. We aim to assess the status of cofilin 1, CRSP2, HSP27, IL8, and HSP90 in the EAT of myocardial infarction (MI) and coronary artery bypass graft (CABG) swine models and in vitro stimulated ischemic EATDS. Expression status of these proteins in EAT were assessed by immunostaining, and in EATDS using qRT-PCR, immunostaining, and Western blot. EATDS phenotyping was performed using sc-RNAseq analysis. Cofilin 1 was increased while the other four genes were decreased in the CABG. IL8 and HSP90 were increased, while CRSP2, HSP27, and cofilin 1 were decreased in the MI group. Similar trend was displayed in the expression of these genes in EATDS. Additionally, EATDS displayed versatile phenotypes at single cell resolution based on the differential expression of various gene signatures. The findings revealed novel insights into EAT/EATDS biology and further understanding regarding the EATDS sub-phenotypes would open novel avenues in translational cardiology.

Novel therapeutic agents for cardiometabolic risk mitigation in heart transplant recipients

Heart transplant (HT) recipients experience high rates of cardiometabolic disease. Novel therapies targeting hyperlipidemia, diabetes, and obesity, including proprotein convertase subtilisin/kexin inhibitors, sodium-glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 agonists, are increasingly used for cardiometabolic risk mitigation in the general population. However, limited data exist to support the use of these agents in patients who have undergone heart transplantation. Herein, we describe the mechanisms of action and emerging evidence supporting the use of novel pharmacologic agents in the post-HT setting for cardiometabolic risk mitigation and review evidence supporting their ability to modulate immune pathways associated with atherogenesis, epicardial adipose tissue, and coronary allograft vasculopathy.

Identification of patients with unstable angina based on coronary CT angiography: the application of pericoronary adipose tissue radiomics

Objective

To explore whether radiomics analysis of pericoronary adipose tissue (PCAT) captured by coronary computed tomography angiography (CCTA) could discriminate unstable angina (UA) from stable angina (SA).

Methods

In this single-center retrospective case-control study, coronary CT images and clinical data from 240 angina patients were collected and analyzed. Patients with unstable angina (n = 120) were well-matched with those having stable angina (n = 120). All patients were randomly divided into training (70%) and testing (30%) datasets. Automatic segmentation was performed on the pericoronary adipose tissue surrounding the proximal segments of the left anterior descending artery (LAD), left circumflex coronary artery (LCX), and right coronary artery (RCA). Corresponding radiomic features were extracted and selected, and the fat attenuation index (FAI) for these three vessels was quantified. Machine learning techniques were employed to construct the FAI and radiomic models. Multivariate logistic regression analysis was used to identify the most relevant clinical features, which were then combined with radiomic features to create clinical and integrated models. The performance of different models was compared in terms of area under the curve (AUC), calibration, clinical utility, and sensitivity.

Results

In both training and validation cohorts, the integrated model (AUC = 0.87, 0.74) demonstrated superior discriminatory ability compared to the FAI model (AUC = 0.68, 0.51), clinical feature model (AUC = 0.84, 0.67), and radiomic model (AUC = 0.85, 0.73). The nomogram derived from the combined radiomic and clinical features exhibited excellent performance in diagnosing and predicting unstable angina. Calibration curves showed good fit for all four machine learning models. Decision curve analysis indicated that the integrated model provided better clinical benefit than the other three models.

Conclusions

CCTA-based radiomics signature of PCAT is better than the FAI model in identifying unstable angina and stable angina. The integrated model constructed by combining radiomics and clinical features could further improve the diagnosis and differentiation ability of unstable angina.

Association of Epicardial Adipose Tissue and Ventricular Arrhythmias in Patients With Nonischemic Cardiomyopathy

Background

Risk stratification for sudden cardiac death (SCD) in patients with nonischemic cardiomyopathy (NICM) remains challenging.

Objectives

This study aimed to investigate the impact of epicardial adipose tissue (EAT) on SCD in NICM patients.

Methods

Our study cohort included 173 consecutive patients (age 53 ± 14 years, 73% men) scheduled for primary prevention implantable cardioverter-defibrillators (ICDs) implantation who underwent preimplant cardiovascular magnetic resonance. EAT volume surrounding both ventricles was manually quantified from cine left ventricular short-axis images by summation of the EAT volume of each slice using the modified Simpson rule. The primary endpoint was appropriate ICD therapy.

Results

During the mean follow-up of 3.6 years, 24 patients (14%) experienced an endpoint. An inverse and proportional relationship was evident between EAT and subsequent ICD therapies (P = 0.004). Even after adjusting for left ventricular mass and ejection fraction, EAT was significantly lower in patients with ICD therapy than those without. Low EAT was independently associated with an increased risk of ICD therapy in NICM patients (HRad per 10 mL/m2 decrease, 1.65; 95% CI: 1.17-2.42; P = 0.007). EAT ≤50 mL/m2 demonstrated a 3-fold increase in SCD event risk, with an estimated likelihood of 57% at 5 years. When considered with other potential risk factors, EAT provided incremental prognostic value in predicting ICD therapy.

Conclusions

Low ventricular EAT was associated with increased SCD risk in NICM patients receiving primary prevention ICD implantation, even in the presence of other risk markers. These data suggest a potential clinical role of EAT in selecting NICM patients who would benefit most from ICD implantation.

Production of the Key Immunoregulatory Cytokines and the Content of FoxP3+ T-Regulatory Lymphocytes in the Epicardial and Thymus Adipose Tissue in Patients with Coronary Heart Disease

FoxP3+ T-regulatory (Treg) lymphocytes and cytokine production by cells from the stromal vascular fraction (SVF) of epicardial (EAT) and thymus (TAT) adipose tissue of 42 patients with chronic coronary heart disease (CHD) were studied. In the SVF of TAT in patients with Gensini Score (GS)≥74 (the most severe atherosclerosis), the production of IL-1β, TNF, IL-4, and IFNγ was higher, while FoxP3 translocation into the nucleus was lower than in patients with GS<74. The GS index directly correlated with the production of IL-4, IL-1β, and TNF by cells of the SVF of TAT, and inversely - with the production of TNF, IL-17, and IL-10 by cells of the SVF of EAT. The proportion of CD25hiFoxP3+Treg with FoxP3 nuclear translocation in TAT inversely correlated with IFNγ production in TAT and directly correlated with IL-4 production in EAT. The results obtained suggest that the severity of coronary atherosclerosis is interrelated with the ability of SVF cells of EAT and TAT to produce cytokines and the properties of FoxP3+Treg lymphocytes.

Long-term prognostic value of CT-based high-risk coronary lesion attributes and radiomic features of pericoronary adipose tissue in diabetic patients

AIMS

To investigate the long-term prognostic value of coronary computed tomography angiography (CCTA)-derived high-risk attributes and radiomic features of pericoronary adipose tissue (PCAT) in diabetic patients for predicting major adverse cardiac event (MACE).

METHODS AND RESULTS

Diabetic patients with intermediate pre-test probability of coronary artery disease were prospectively enrolled and referred for CCTA. Three models (model-1 with clinical parameters; model-2 with clinical factors + CCTA imaging parameters; model-3 with the above parameters and PCAT radiomic features) were developed in the training cohort (835 patients) and tested in the independent validation cohort (557 patients). 1392 patients were included and MACEs occurred in 108 patients (7.8%). Multivariable Cox regression analysis revealed that HbA1c, coronary calcium Agatston score, significant stenosis and high-risk plaque were independent predictors for MACE whereas none of PCAT radiomic features showed predictive value. In the training cohort, model-2 demonstrated higher predictive performance over model-1 (C-index = 0.79 vs. 0.68, p < 0.001) whereas model-3 did not show incremental value over model-2(C-index = 0.79 vs. 0.80, p = 0.408). Similar findings were found in the validation cohort.

CONCLUSIONS

The combined model (clinical and CCTA high-risk anatomical features) demonstrated high efficacy in predicting MACE in diabetes. PCAT radiomic features failed to show incremental value for risk stratification.

Ethnic disparities and its association between epicardial adipose tissue thickness and cardiometabolic parameters

Excessive deposit of epicardial adipose tissue (EAT) were recently shown to be positively correlated with cardiovascular disease (CVD). This study aims to investigate the thickness of EAT and its association with the components of metabolic syndrome among multi-ethnic Malaysians with and without acute coronary syndrome (ACS). A total of 213 patients were recruited, with the thickness of EAT were quantified non-invasively using standard two-dimensional echocardiography. EAT thickness among the Malaysian population was prompted by several demographic factors and medical comorbidities, particularly T2DM and dyslipidaemia. ACS patients have significantly thicker EAT compared to those without ACS (4.1 mm vs 3.7 mm, p = 0.035). Interestingly, among all the races, Chinese had the thickest EAT distribution (4.6 mm vs 3.8 mm), with age (p = 0.04 vs p < 0.001), and overall diastolic blood pressure (p = 0.028) was also found to be associated with EAT thickness. Further study is warranted to investigate its role as a cardiovascular risk marker among Malaysians with ACS.

Epicardial adipose tissue volume highly correlates with left ventricular diastolic dysfunction in endogenous Cushing's syndrome

BACKGROUND

Cushing's syndrome (CS) is associated with increased risk for heart failure, which often initially manifests as left ventricular diastolic dysfunction (LVDD). In this study, we aimed to explore the potential risk factors of LVDD in CS by incorporating body composition parameters.

METHODS

A retrospective study was conducted on patients diagnosed with endogenous CS no less than 18 years old. The control group consisted of healthy individuals who were matched to CS patients in terms of gender, age, and BMI. LIFEx software (version 7.3) was applied to measure epicardial adipose tissue volume (EATV) on non-contrast chest CT, as well as abdominal adipose tissue and skeletal muscle mass at the first lumbar vertebral level. Echocardiography was used to evaluate left ventricular (LV) diastolic function. Body compositions and clinical data were examined in relation to early LVDD.

RESULTS

A total of 86 CS patients and 86 healthy controls were enrolled. EATV was significantly higher in CS patients compared to control subjects (150.33 cm3 [125.67, 189.41] vs 90.55 cm3 [66.80, 119.84], p < 0.001). CS patients had noticeably increased visceral fat but decreased skeletal muscle in comparison to their healthy counterparts. Higher prevalence of LVDD was found in CS patients based on LV diastolic function evaluated by E/A ratio (p < 0.001). EATV was proved to be an independent risk factor for LVDD in CS patients (OR = 1.015, 95%CI 1.003-1.026, p = 0.011). If the cut-point of EATV was set as 139.252 cm3 in CS patients, the diagnostic sensitivity and specificity of LVDD were 84.00% and 55.60%, respectively.

CONCLUSION

CS was associated with marked accumulation of EAT and visceral fat, reduced skeletal muscle mass, and increased prevalence of LVDD. EATV was an independent risk factor for LVDD, suggesting the potential role of EAT in the development of LVDD in CS.

Circulating RBP4 and FABP4 concentrations in patients with chronic schizophrenia are associated with increased epicardial adipose tissue volume and metabolic syndrome

Schizophrenia has been linked to an elevated cardiovascular risk profile and premature onset of cardiovascular disease. Quantifying epicardial adipose tissue (EAT) volume provides insight into its correlation with coronary artery disease (CAD) severity and associated risk factors. Previous research indicates higher pericardial adipose tissue in individuals with schizophrenia compared to non-schizophrenic counterparts. RBP4, FABP3, and FABP4 have been implicated in CAD pathogenesis. In this study, we examined the potential increase in EAT volume in individuals with chronic schizophrenia and aimed to elucidate the relationship between circulating levels of RBP4, FABP3, and FABP4 with EAT volume and coronary artery calcium score within this cohort. We recruited 186 consecutive patients with chronic schizophrenia and utilized enzyme-linked immunosorbent assay to assess plasma concentrations of RBP4, FABP3, and FABP4. Cardiac multislice computed tomography measured EAT volume and coronary artery calcium scores. Significantly higher EAT volume in patients with chronic schizophrenia compared to controls. RBP4 associated positively with metabolic factors and EAT volumes, while FABP3 associated positively with creatinine and coronary atherosclerosis markers. FABP4 showed positive associations with metabolic factors, hypertension, and EAT volumes, but negative associations with HDL-C and eGFR. Logistic regression identified RBP4 and FABP4 as independent factors associated with increased EAT volumes, even after adjusting for known biomarkers. Both RBP4 and FABP4 were significantly associated with metabolic syndrome components and EAT volume. This study elucidates the association between chronic schizophrenia and augmented EAT volume, suggesting plausible correlations with CAD-related health complications through RBP4 and FABP4 pathways.

Relationship Between Clinical Parameters and Histological Features of Epicardial Adipose Tissue and Aortic Valve Calcification Assessed on Computed Tomography

BACKGROUND

The relationships of the clinical and biological attributes of epicardial adipose tissue (EAT) with aortic valve calcification (AVC) have not been characterized. We evaluated the relationships of the clinical and histological features of EAT with AVC assessed using computed tomography (CT).

METHODS AND RESULTS

We enrolled 43 patients undergoing cardiac CT examination prior to elective cardiac surgery in whom AVC was identified on CT. EAT volume and density, coronary calcium score (CCS), AVC score (AVCS), and coronary atherosclerosis on CT angiography were evaluated in each patient. During cardiac surgery, 2 EAT samples were obtained for immunohistochemistry. The number of CD68- and CD11c-positive macrophages and osteocalcin-positive cells was counted in 6 random high-power fields of EAT sections. EAT density, but not EAT volume normalized to body surface area, was positively correlated with the number of macrophages and osteocalcin-positive cells in EAT. There was a positive correlation between ln(AVCS), but not ln(CCS+1), and the number of macrophages and osteocalcin-positive cells in EAT. Multivariate analysis revealed significant positive correlations for ln(AVCS) with EAT density (β=0.42; P=0.0072) and the number of CD68-positive macrophages (β=0.57; P=0.0022), CD11c-positive macrophages (β=0.62; P=0.0003), and osteocalcin-positive cells (β=0.52; P=0.0021) in EAT.

CONCLUSIONS

Inflammation and osteogenesis in EAT, reflected by high CT density, are associated with the severity of AVC representing aortic valve degeneration.

Remodeling of the Intracardiac Ganglia During the Development of Cardiovascular Autonomic Dysfunction in Type 2 Diabetes: Molecular Mechanisms and Therapeutics

Type 2 diabetes mellitus (T2DM) is one of the most significant health issues worldwide, with associated healthcare costs estimated to surpass USD 1054 billion by 2045. The leading cause of death in T2DM patients is the development of cardiovascular disease (CVD). In the early stages of T2DM, patients develop cardiovascular autonomic dysfunction due to the withdrawal of cardiac parasympathetic activity. Diminished cardiac parasympathetic tone can lead to cardiac arrhythmia-related sudden cardiac death, which accounts for 50% of CVD-related deaths in T2DM patients. Regulation of cardiovascular parasympathetic activity is integrated by neural circuitry at multiple levels including afferent, central, and efferent components. Efferent control of cardiac parasympathetic autonomic tone is mediated through the activity of preganglionic parasympathetic neurons located in the cardiac extensions of the vagus nerve that signals to postganglionic parasympathetic neurons located in the intracardiac ganglia (ICG) on the heart. Postganglionic parasympathetic neurons exert local control on the heart, independent of higher brain centers, through the release of neurotransmitters, such as acetylcholine. Structural and functional alterations in cardiac parasympathetic postganglionic neurons contribute to the withdrawal of cardiac parasympathetic tone, resulting in arrhythmogenesis and sudden cardiac death. This review provides an overview of the remodeling of parasympathetic postganglionic neurons in the ICG, and potential mechanisms contributing to the withdrawal of cardiac parasympathetic tone, ventricular arrhythmogenesis, and sudden cardiac death in T2DM. Improving cardiac parasympathetic tone could be a therapeutic avenue to reduce malignant ventricular arrhythmia and sudden cardiac death, increasing both the lifespan and improving quality of life of T2DM patients.

Large-scale single-nuclei profiling identifies role for ATRNL1 in atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia in humans, yet the molecular basis of AF remains incompletely understood. To determine the cell type-specific transcriptional changes underlying AF, we perform single-nucleus RNA-seq (snRNA-seq) on left atrial (LA) samples from patients with AF and controls. From more than 175,000 nuclei we find that only cardiomyocytes (CMs) and macrophages (MΦs) have a significant number of differentially expressed genes in patients with AF. Attractin Like 1 (ATRNL1) was overexpressed in CMs among patients with AF and localized to the intercalated disks. Further, in both knockdown and overexpression experiments we identify a potent role for ATRNL1 in cell stress response, and in the modulation of the cardiac action potential. Finally, we detect an unexpected expression pattern for a leading AF candidate gene, KCNN3. In sum, we uncover a role for ATRNL1 which may serve as potential therapeutic target for this common arrhythmia.

Cardio-Lipotoxicity of Epicardial Adipose Tissue

Epicardial adipose tissue is a unique visceral adipose tissue depot that plays a crucial role in myocardial metabolism. Epicardial adipose tissue is a major source of energy and free fatty acids for the adjacent myocardium. However, under pathological conditions, epicardial fat can affect the heart through the excessive and abnormal influx of lipids. The cardio-lipotoxicity of the epicardial adipose tissue is complex and involves different pathways, such as increased inflammation, the infiltration of lipid intermediates such as diacylglycerol and ceramides, mitochondrial dysfunction, and oxidative stress, ultimately leading to cardiomyocyte dysfunction and coronary artery ischemia. These changes can contribute to the pathogenesis of various cardio-metabolic diseases including atrial fibrillation, coronary artery disease, heart failure, and obstructive sleep apnea. Hence, the role of the cardio-lipotoxicity of epicardial fat and its clinical implications are discussed in this review.

Heart regeneration from the whole-organism perspective to single-cell resolution

Cardiac regenerative potential in the animal kingdom displays striking divergence across ontogeny and phylogeny. Here we discuss several fundamental questions in heart regeneration and provide both a holistic view of heart regeneration in the organism as a whole, as well as a single-cell perspective on intercellular communication among diverse cardiac cell populations. We hope to provide valuable insights that advance our understanding of organ regeneration and future therapeutic strategies.

Chest-CT-based radiomics feature of epicardial adipose tissue for screening coronary atherosclerosis

BACKGROUND AND AIMS

This study aims to investigate the diagnostic value of chest-CT epicardial adipose tissue (EAT) radiomics feature in coronary atherosclerotic stenosis.

METHODS

Clinical data from 215 individuals who underwent coronary angiography and chest-CT scan from January to July 2022 at our institution were retrospectively analyzed. Based on the coronary angiography results, the total population, men, and women were divided into the CAD group and non-CAD group. radiomics feature of EAT at the level of the bifurcation of the left-main coronary artery on the transverse level of chest CT were measured. The features contain both first-order feature and shape-order feature.The differences between groups were analyzed using the t test or Chi-square test. The diagnostic efficacy of each parameter in diagnosing atherosclerotic stenosis of coronary arteries was assessed by plotting the receiver operating characteristic (ROC) curve.

RESULTS

First-order features: Mean, IntDen, Median, and RawIntDen; shape-order features: Area, Perim, Round, and BSA index; and clinical index: HbA1c showed statistical significance between the CAD group and the non-CAD group. The ROC curve analysis demonstrated high diagnostic efficacy, with the best for diagnostic efficacy being Median for the first-order feature parameter (AUC, 0.753; 95% confidence interval [CI], 0.689-0.817; t = 4.785, p < 0.001), Round for the shape-order feature (AUC, 0.775; 95% CI, 0.714-0.836; t = 7.842, p < 0.001), and HbA1c for the clinical index (AUC, 0.797; 95% CI, 0.783-0.856; t = 6.406, p < 0.001). After dividing the participants into male and female subgroups, the best diagnostic efficacy was observed with the BSA index for men (AUC, 0.743; 95% CI, 0.656-0.829; t = 5.128, p < 0.001) and Round for women (AUC, 0.871; 95% CI, 0.793-0.949; t = 7.247, p < 0.001).

CONCLUSIONS

Median, Round in radiomics feature of EAT on chest CT may play a role in the assessment of coronary atherosclerotic stenosis.

Tirzepatide Reduces LV Mass and Paracardiac Adipose Tissue in Obesity-Related Heart Failure: SUMMIT CMR Substudy

BACKGROUND

Obesity is a known risk factor for heart failure with preserved ejection fraction (HFpEF) and is considered a distinct phenotype with more concentric remodeling. Epicardial adipose tissue (EAT) is also increased in obesity-related HFpEF and is associated with adverse events.

OBJECTIVE

The Cardiac Magnetic Resonance (CMR) Substudy of the SUMMIT trial was aimed to examine the effects of tirzepatide on cardiac structure and function with the underlying hypothesis that it would reduce left ventricular (LV) mass and EAT in obesity-related HFpEF.

METHODS

One hundred seventy-five patients with obesity-related HFpEF from the parent study of tirzepatide (2.5mg SQ weekly, increasing to a maximum of 15mg weekly) or matching placebo underwent CMR at baseline, which consisted of multiplanar cine imaging. One hundred six patients completed the CMR and had adequate image quality for analysis of LV and LA structure and function and paracardiac (epicardial plus pericardial) adipose tissue at both baseline and 52 weeks. The prespecified primary endpoint of this substudy was between-group changes in LV mass.

RESULTS

LV mass decreased by 11 g (95% C.I. -19 to -4) in the treated group (n = 50) when corrected for placebo (n =56) (p=0.004). Paracardiac adipose tissue decreased in the treated group by 45 ml (95% C.I. -69 to -22) when corrected for placebo (p<0.001). The change in LV mass in the treated group correlated with changes in body weight (p<0.02) and, tended to correlate with changes in waist circumference and blood pressure (p=0.06 for both). The LV mass change also correlated with changes in LV end diastolic volume and LA end diastolic and end systolic volumes (p<0.03 for all).

CONCLUSION

The CMR substudy of the SUMMIT trial demonstrated that tirzepatide therapy in obesity-related HFpEF led to reduced LV mass and paracardiac adipose tissue as compared to placebo and the change in LV mass paralleled weight loss. These physiologic changes may contribute to the reduction in heart failure events seen in the main SUMMIT trial.

Extrarenal Benefits of SGLT2 Inhibitors in the Treatment of Cardiomyopathies

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have emerged as pivotal medications for heart failure, demonstrating remarkable cardiovascular benefits extending beyond their glucose-lowering effects. The unexpected cardiovascular advantages have intrigued and prompted the scientific community to delve into the mechanistic underpinnings of these novel actions. Preclinical studies have generated many mechanistic theories, ranging from their renal and extrarenal effects to potential direct actions on cardiac muscle cells, to elucidate the mechanisms linking these drugs to clinical cardiovascular outcomes. Despite the strengths and limitations of each theory, many await validation in human studies. Furthermore, whether SGLT2 inhibitors confer therapeutic benefits in specific subsets of cardiomyopathies akin to their efficacy in other heart failure populations remains unclear. By examining the shared pathological features between heart failure resulting from vascular diseases and other causes of cardiomyopathy, certain specific molecular actions of SGLT2 inhibitors (particularly those targeting cardiomyocytes) would support the concept that these medications will yield therapeutic benefits across a broad range of cardiomyopathies. This article aims to discuss the important mechanisms of SGLT2 inhibitors and their implications in hypertrophic and dilated cardiomyopathies. Furthermore, we offer insights into future research directions for SGLT2 inhibitor studies, which hold the potential to further elucidate the proposed biological mechanisms in greater detail.

Echocardiographic assessment of epicardial adipose tissue thickness as independent predictor in coronary artery disease

This study aimed to assess the utility of echocardiography-measured epicardial adipose tissue (EAT) thickness (EATT) as an independent predictor for coronary artery disease (CAD), examining its correlation with oxidative stress levels in epicardial tissue and the complexity of the disease in patients undergoing open-heart surgery. This study included a total of 25 patients referred for cardiac surgery with 14 in the CAD group and 11 in the non-CAD group. Epicardial fat was sampled from patients subjected to open-heart surgery. EATT was higher in the CAD group compared to the non-CAD group (8.15 ± 2.09 mm vs. 5.12 ± 1.8 mm, p = 0.001). The epicardial reactive oxygen species level was higher in the CAD group compared to the non-CAD group (21.4 ± 2.47 nmol H2O2/g tisssue/h vs. 15.7 ± 1.55 nmol H2O2/g tisssue/h, p < 0.001). EATT greater than 6.05 mm was associated with CAD, with a sensitivity of 86% and specificity of 73%. Echocardiographically measured EATT is a significant, independent predictor of CAD. Its relationship with increased EAT oxidative stress levels suggests a potential mechanistic link between EATT and CAD pathogenesis. These findings highlight the importance of EATT as a diagnostic tool in assessing the complexity of CAD in patients undergoing cardiac surgery.

Gut Hormones in Heart Failure

Heart failure (HF) is a syndrome affecting all organ systems. While some organ interactions have been studied intensively in HF (such as the cardiorenal interaction), the endocrine gut has to some degree been overlooked. However, there is growing evidence of direct cardiac effects of several hormones secreted from the gastrointestinal tract. For instance, GLP-1 (glucagon-like peptide-1), an incretin hormone secreted from the distal intestine following food intake, has notable effects on the heart, impacting heart rate and contractility. GLP-1 may even possess cardioprotective abilities, such as inhibition of myocardial ischemia and cardiac remodeling. While other gut hormones have been less studied, there is evidence suggesting cardiostimulatory properties of several hormones. Moreover, it has been reported that patients with HF have altered bioavailability of numerous gastrointestinal hormones, which may have prognostic implications. This might indicate an important role of gut hormones in cardiac physiology and pathology, which may be of particular importance in the failing heart. We present an overview of the current knowledge on gut hormones in HF, focusing on HF with reduced ejection fraction, and discuss how these hormones may be regulators of cardiac function and central hemodynamics. Potential therapeutic perspectives are discussed, and knowledge gaps are highlighted herein.

Role of epicardial adipose tissue in cardiac remodeling

Epicardial adipose tissue, or epicardial fat, is a type of visceral fat located between the heart and the pericardium. Due to its anatomical proximity to the heart, EAT plays a significant role in both cardiac physiology and pathologies, including cardiac remodeling and cardiovascular diseases (CVD). However, our understanding of how EAT pathology is influenced by risk factors such as obesity and type 2 diabetes mellitus and how altered EAT can drive cardiac remodeling and CVD, remains limited. Herein, we aimed to summarize and discuss the latest findings on EAT and its role in cardiac remodeling, highlighting the outcomes of clinical and observational studies, provide mechanistic insights, and finally introduce emerging therapeutic agents and nutritional guidelines aimed at preventing these conditions.

An immunology model for accelerated coronary atherosclerosis and unexplained sudden death in the COVID-19 era

The immunological basis for cardiac deaths remote from potential triggering viral infection, including SARS-CoV-2 infection, remains enigmatic. Cardiac surface inflammation, including the pericardium, epicardium and superficial myocardium with associated coronary artery vasculitis in infant Kawasaki Disease (KD) and multisystem inflammatory syndrome in children (MIS-C) is well recognised. In this perspective, we review the evidence pointing towards prominent post-viral infection related epicardial inflammation in older subjects, resulting in atherosclerotic plaque destabilisation with seemingly unrelated myocardial infarction that may be temporally distant from the actual infectious triggers. Cardiac surface inflammation in the relatively immune cell rich tissues in the territory though where the coronary arteries traverse is common in the adult post-COVD pneumonic phase and is also well described after vaccination including pre-COVID era vaccinations. Immunologically, the pericardium/epicardium tissue was known to be critical for coronary artery territory atherosclerotic disease prior to the COVID-19 era and may be linked to the involvement of the coronary artery vasa vasorum that physiologically oxygenates the coronary artery walls. We highlight how viral infection or vaccination-associated diffuse epicardial tissue inflammation adjacent to the coronary artery vasa vasorum territory represents a critical unifying concept for seemingly unrelated fatal coronary artery atherosclerotic disease, that could occur soon after or remote from infection or vaccination in adults. Mechanistically, such epicardial inflammation impacting coronary artery vasa vasorum immunity acts as gateways towards the slow destabilisation of pre-existing atherosclerotic plaques, with resultant myocardial infarction and other cardiac pathology. This model offers immunologists and academic cardiologists an immunopathological roadmap between innocuous viral infections or vaccinations and seemingly temporally remote "unrelated" atherosclerotic disease with excess cardiac deaths.

The aging heart in focus: The advanced understanding of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for 50 % of heart failure (HF) cases, making it the most common type of HF, and its prevalence continues to increase in the aging society. HFpEF is a systemic syndrome resulting from many risk factors, such as aging, metabolic syndrome, and hypertension, and its clinical features are highly heterogeneous in different populations. HFpEF syndrome involves the dysfunction of multiple organs, including the heart, lung, muscle, and vascular system. The heart shows dysfunction of various cells, including cardiomyocytes, endothelial cells, fibroblasts, adipocytes, and immune cells. The complex etiology and pathobiology limit experimental research on HFpEF in animal models, delaying a comprehensive understanding of the mechanisms and making treatment difficult. Recently, many scientists and cardiologists have attempted to improve the clinical outcomes of HFpEF. Recent advances in clinically related animal models and systemic pathology studies have improved our understanding of HFpEF, and clinical trials involving sodium-glucose cotransporter 2 inhibitors have significantly enhanced our confidence in treating HFpEF. This review provides an updated comprehensive discussion of the etiology and pathobiology, molecular and cellular mechanisms, preclinical animal models, and therapeutic trials in animals and patients to enhance our understanding of HFpEF and improve clinical outcomes.

Epicardial fat density obtained with computed tomography imaging - more important than volume?

Epicardial adipose tissue (EAT) is a unique fat depot located between the myocardium and the visceral layer of pericardium. It can be further subdivided into pericoronary (PCAT), periatrial (PAAT) and periventricular adipose tissue (PVentAT), each of them exhibiting specific characteristics and association with the underlying tissue. Since no physical barrier separates EAT from the myocardium, this fat tissue can easily interact with the underlying cardiac structure. EAT can be visualized using various imaging modalities. Computed tomography provides not only information on EAT volume, but also on its density. Indeed, EAT density reflected by the recently developed fat attenuation index (FAI) is emerging as a useful index of PCAT inflammation, PAAT inflammation and fibrosis, while the relevance of density of PVentAT is much less known. The emerging data indicates that FAI can be an important diagnostic and prognostic tool in both coronary artery disease and atrial fibrillation. Future studies will demonstrate if it also could be used as a marker of efficacy of therapies and whether FAI PVentAT could indicate ventricular pathologies, such as heart failure. The aim of the review is to present computed tomography derived FAI as an important tool both to study and better understand the epicardial fat and as a potential predictive marker in cardiovascular disorders.

An enhanced deep learning method for the quantification of epicardial adipose tissue

Epicardial adipose tissue (EAT) significantly contributes to the progression of cardiovascular diseases (CVDs). However, manually quantifying EAT volume is labor-intensive and susceptible to human error. Although there have been some deep learning-based methods for automatic quantification of EAT, they are mostly uninterpretable and fail to harness the complete anatomical characteristics. In this study, we proposed an enhanced deep learning method designed for EAT quantification on coronary computed tomography angiography (CCTA) scan, which integrated both data-driven method and specific morphological information. A total of 108 patients who underwent routine CCTA examinations were included in this study. They were randomly assigned to training set (n = 60), validation set (n = 8), and test set (n = 40). We quantified and calculated the EAT volume based on the CT attenuation values within the predicted pericardium. The automatic method demonstrated strong agreement with expert manual quantification, yielding a median Dice score coefficients (DSC) of 0.916 (Interquartile Range (IQR): 0.846-0.948) for 2D slices. Meanwhile, the median DSC for the 3D volume was 0.896 (IQR: 0.874-0.908) between these two measures, with an excellent correlation of 0.980 (p < 0.001) for EAT volumes. Additionally, our model's Bland-Altman analysis revealed a low bias of -2.39 cm³. The incorporation of pericardial anatomical structures into deep learning methods can effectively enhance the automatic quantification of EAT. The promising results demonstrate its potential for clinical application.

The Effect of Semaglutide on Mortality and COVID-19-Related Deaths: An Analysis From the SELECT Trial

BACKGROUND

Patients with overweight and obesity are at increased risk of death from multiple causes, including cardiovascular (CV) death, with few therapies proven to reduce the risk.

OBJECTIVES

This study sought to assess the effect of semaglutide 2.4 mg on all-cause death, CV death, and non-CV death, including subcategories of death and death from coronavirus disease-2019 (COVID-19).

METHODS

The SELECT (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity) trial randomized 17,604 participants ≥45 years of age with a body mass index ≥27 kg/m2 with established CV disease but without diabetes to once-weekly subcutaneous semaglutide 2.4 mg or placebo; the mean trial duration was 3.3 years. Adjudicated causes of all deaths, COVID-19 cases, and associated deaths were captured prospectively.

RESULTS

Of 833 deaths, 485 (58%) were CV deaths, and 348 (42%) were non-CV deaths. Participants assigned to semaglutide vs placebo had lower rates of all-cause death (HR: 0.81; 95% CI: 0.71-0.93), CV death (HR: 0.85; 95% CI: 0.71-1.01), and non-CV death (HR: 0.77; 95% CI: 0.62-0.95). The most common causes of CV death with semaglutide vs placebo were sudden cardiac death (98 vs 109; HR: 0.89; 95% CI: 0.68-1.17) and undetermined death (77 vs 90; HR: 0.85; 95% CI: 0.63-1.15). Infection was the most common cause of non-CV death and occurred at a lower rate in the semaglutide vs the placebo group (62 vs 87; HR: 0.71; 95% CI: 0.51-0.98). Semaglutide did not reduce incident COVID-19; however, among participants who developed COVID-19, fewer participants treated with semaglutide had COVID-19-related serious adverse events (232 vs 277; P = 0.04) or died of COVID-19 (43 vs 65; HR: 0.66; 95% CI: 0.44-0.96). High rates of infectious deaths occurred during the COVID-19 pandemic, with less infectious death in the semaglutide arm, and resulted in fewer participants in the placebo group being at risk for CV death.

CONCLUSIONS

Compared to placebo, patients treated with semaglutide 2.4 mg had lower rates of all-cause death, driven similarly by CV and non-CV death. The lower rate of non-CV death with semaglutide was predominantly because of fewer infectious deaths. These findings highlight the effect of semaglutide on mortality across a broad population of patients with CV disease and obesity. (Semaglutide Effects on Cardiovascular Outcomes in Patients With Overweight or Obesity [SELECT]; NCT03574597).

Association of Cardiovascular Risk Factors and Coronary Calcium Burden with Epicardial Adipose Tissue Volume Obtained from PET-CT Imaging in Oncological Patients

Whole-body positron emission tomography (PET)-computed tomography (CT) imaging performed for oncological purposes may provide additional parameters such as the coronary artery calcium (CAC) and epicardial adipose tissue (EAT) volume with cost-effective prognostic information in asymptomatic people beyond traditional cardiovascular risk factors. We evaluated the feasibility of measuring the CAC score and EAT volume in cancer patients without known coronary artery disease (CAD) referred to whole-body 18F-FDG PET-CT imaging, regardless of the main clinical problem. We also investigated the potential relationships between traditional cardiovascular risk factors and CAC with EAT volume. A total of 109 oncological patients without overt CAD underwent whole-body PET-CT imaging with 18F-fluorodeoxyglucose (FDG). Unenhanced CT images were retrospectively viewed for CAC and EAT measurements on a dedicated platform. Overall, the mean EAT volume was 99 ± 49 cm3. Patients with a CAC score ≥ 1 were older than those with a CAC = 0 (p < 0.001) and the prevalence of hypertension was higher in patients with detectable CAC as compared to those without (p < 0.005). The EAT volume was higher in patients with CAC than in those without (p < 0.001). For univariable age, body mass index (BMI), hypertension, and CAC were associated with increasing EAT values (all p < 0.005). However, the correlation between the CAC score and EAT volume was weak, and in multivariable analysis only age and BMI were independently associated with increased EAT (both p < 0.001), suggesting that potential prognostic information on CAC and EAT is not redundant. This study demonstrates the feasibility of a cost-effective assessment of CAC scores and EAT volumes in oncological patients undergoing whole-body 18F-FDG PET-CT imaging, enabling staging cancer disease and atherosclerotic burden by a single test already included in the diagnostic work program, with optimization of the radiation dose and without additional costs.

Obesity and cardiovascular disease: an ESC clinical consensus statement

The global prevalence of obesity has more than doubled over the past four decades, currently affecting more than a billion individuals. Beyond its recognition as a high-risk condition that is causally linked to many chronic illnesses, obesity has been declared a disease per se that results in impaired quality of life and reduced life expectancy. Notably, two-thirds of obesity-related excess mortality is attributable to cardiovascular disease. Despite the increasingly appreciated link between obesity and a broad range of cardiovascular disease manifestations including atherosclerotic disease, heart failure, thromboembolic disease, arrhythmias, and sudden cardiac death, obesity has been underrecognized and sub-optimally addressed compared with other modifiable cardiovascular risk factors. In the view of major repercussions of the obesity epidemic on public health, attention has focused on population-based and personalized approaches to prevent excess weight gain and maintain a healthy body weight from early childhood and throughout adult life, as well as on comprehensive weight loss interventions for persons with established obesity. This clinical consensus statement by the European Society of Cardiology discusses current evidence on the epidemiology and aetiology of obesity; the interplay between obesity, cardiovascular risk factors and cardiac conditions; the clinical management of patients with cardiac disease and obesity; and weight loss strategies including lifestyle changes, interventional procedures, and anti-obesity medications with particular focus on their impact on cardiometabolic risk and cardiac outcomes. The document aims to raise awareness on obesity as a major risk factor and provide guidance for implementing evidence-based practices for its prevention and optimal management within the context of primary and secondary cardiovascular disease prevention.

Metabolic remodelling in atrial fibrillation: manifestations, mechanisms and clinical implications

Atrial fibrillation (AF) is a continually growing health-care burden that often presents together with metabolic disorders, including diabetes mellitus and obesity. Current treatments often fall short of preventing AF and its adverse outcomes. Accumulating evidence suggests that metabolic disturbances can promote the development of AF through structural and electrophysiological remodelling, but the underlying mechanisms that predispose an individual to AF are aetiology-dependent, thus emphasizing the need for tailored therapeutic strategies to treat AF that target an individual's metabolic profile. AF itself can induce changes in glucose, lipid and ketone metabolism, mitochondrial function and myofibrillar energetics (as part of a process referred to as 'metabolic remodelling'), which can all contribute to atrial dysfunction. In this Review, we discuss our current understanding of AF in the setting of metabolic disorders, as well as changes in atrial metabolism that are relevant to the development of AF. We also describe the potential of available and emerging treatment strategies to target metabolic remodelling in the setting of AF and highlight key questions and challenges that need to be addressed to improve outcomes in these patients.

DEep LearnIng-based QuaNtification of epicardial adipose tissue predicts MACE in patients undergoing stress CMR

BACKGROUND AND AIMS

This study investigated the additional prognostic value of epicardial adipose tissue (EAT) volume for major adverse cardiovascular events (MACE) in patients undergoing stress cardiac magnetic resonance (CMR) imaging.

METHODS

730 consecutive patients [mean age: 63 ± 10 years; 616 men] who underwent stress CMR for known or suspected coronary artery disease were randomly divided into derivation (n = 365) and validation (n = 365) cohorts. MACE was defined as non-fatal myocardial infarction and cardiac deaths. A deep learning algorithm was developed and trained to quantify EAT volume from CMR. EAT volume was adjusted for height (EAT volume index). A composite CMR-based risk score by Cox analysis of the risk of MACE was created.

RESULTS

In the derivation cohort, 32 patients (8.7 %) developed MACE during a follow-up of 2103 days. Left ventricular ejection fraction (LVEF) < 35 % (HR 4.407 [95 % CI 1.903-10.202]; p<0.001), stress perfusion defect (HR 3.550 [95 % CI 1.765-7.138]; p<0.001), late gadolinium enhancement (LGE) (HR 4.428 [95%CI 1.822-10.759]; p = 0.001) and EAT volume index (HR 1.082 [95 % CI 1.045-1.120]; p<0.001) were independent predictors of MACE. In a multivariate Cox regression analysis, adding EAT volume index to a composite risk score including LVEF, stress perfusion defect and LGE provided additional value in MACE prediction, with a net reclassification improvement of 0.683 (95%CI, 0.336-1.03; p<0.001). The combined evaluation of risk score and EAT volume index showed a higher Harrel C statistic as compared to risk score (0.85 vs. 0.76; p<0.001) and EAT volume index alone (0.85 vs.0.74; p<0.001). These findings were confirmed in the validation cohort.

CONCLUSIONS

In patients with clinically indicated stress CMR, fully automated EAT volume measured by deep learning can provide additional prognostic information on top of standard clinical and imaging parameters.

Association of epicardial fat with cardiac structure and function and exercise capacity in heart failure with preserved ejection fraction: A systematic review and meta-analysis

Background

Studies have reported the association of epicardial adipose tissue (EAT) with cardiac structure and function as well as exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF), yielding inconsistent results. We aimed to conduct a meta-analysis of studies on the association of EAT with cardiac structure and function and exercise capacity in HFpEF patients.

Methods and Results

We searched studies examining the association of EAT quantified by echocardiography, computed tomography, or magnetic resonance imaging (MRI) with cardiac structure and function or exercise capacity in HFpEF patients through PubMed, Web of Science, and Scopus. In cases of significant heterogeneity (I2 > 50 %), data were pooled using a random-effects model; otherwise, a fixed-effects model was used. We identified five echocardiography studies (n = 825) and six MRI studies (n = 562), but found no computed tomography studies. In the echocardiography studies, EAT thickness correlated positively with left ventricular (LV) mass (P random  < 0.01) and negatively with LV global longitudinal strain (P random  < 0.01) and peak exercise oxygen uptake (P fix  < 0.001). In the MRI studies, EAT volume correlated positively with LV mass (P fix  < 0.01), left atrial volume (P fix  < 0.001), and the ratio of LV early diastolic mitral inflow to early diastolic mitral annular velocity (E/e'; P random  < 0.01) and negatively with LV ejection fraction (P fix  < 0.01) and LV global longitudinal strain (P fix  < 0.001).

Conclusion

Our meta-analysis indicates a potential association of increased EAT with altered cardiac structure and function and exercise intolerance in HFpEF patients. However, our meta-analysis included only two or three studies for each outcome and thus further studies are necessary to confirm our findings.