Epicardial adipose tissue volume and myocardial ischemia in asymptomatic people living with diabetes: a cross-sectional study

Fully automated epicardial adipose tissue volume quantification with deep learning and relationship with CAC score and micro/macrovascular complications in people living with type 2 diabetes: the multicenter EPIDIAB study

BACKGROUND

The aim of this study (EPIDIAB) was to assess the relationship between epicardial adipose tissue (EAT) and the micro and macrovascular complications (MVC) of type 2 diabetes (T2D).

METHODS

EPIDIAB is a post hoc analysis from the AngioSafe T2D study, which is a multicentric study aimed at determining the safety of antihyperglycemic drugs on retina and including patients with T2D screened for diabetic retinopathy (DR) (n = 7200) and deeply phenotyped for MVC. Patients included who had undergone cardiac CT for CAC (Coronary Artery Calcium) scoring after inclusion (n = 1253) were tested with a validated deep learning segmentation pipeline for EAT volume quantification.

RESULTS

Median age of the study population was 61 [54;67], with a majority of men (57%) a median duration of the disease 11 years [5;18] and a mean HbA1c of7.8 ± 1.4%. EAT was significantly associated with all traditional CV risk factors. EAT volume significantly increased with chronic kidney disease (CKD vs no CKD: 87.8 [63.5;118.6] vs 82.7 mL [58.8;110.8], p = 0.008), coronary artery disease (CAD vs no CAD: 112.2 [82.7;133.3] vs 83.8 mL [59.4;112.1], p = 0.0004, peripheral arterial disease (PAD vs no PAD: 107 [76.2;141] vs 84.6 mL[59.2; 114], p = 0.0005 and elevated CAC score (> 100 vs  < 100 AU: 96.8 mL [69.1;130] vs 77.9 mL [53.8;107.7], p < 0.0001). By contrast, EAT volume was neither associated with DR, nor with peripheral neuropathy. We further evidenced a subgroup of patients with high EAT volume and a null CAC score. Interestingly, this group were more likely to be composed of young women with a high BMI, a lower duration of T2D, a lower prevalence of microvascular complications, and a higher inflammatory profile.

CONCLUSIONS

Fully-automated EAT volume quantification could provide useful information about the risk of both renal and macrovascular complications in T2D patients.

Excessive accumulation of epicardial adipose tissue promotes microvascular obstruction formation after myocardial ischemia/reperfusion through modulating macrophages polarization

BACKGROUND

Owing to its unique location and multifaceted metabolic functions, epicardial adipose tissue (EAT) is gradually emerging as a new metabolic target for coronary artery disease risk stratification. Microvascular obstruction (MVO) has been recognized as an independent risk factor for unfavorable prognosis in acute myocardial infarction patients. However, the concrete role of EAT in the pathogenesis of MVO formation in individuals with ST-segment elevation myocardial infarction (STEMI) remains unclear. The objective of the study is to evaluate the correlation between EAT accumulation and MVO formation measured by cardiac magnetic resonance (CMR) in STEMI patients and clarify the underlying mechanisms involved in this relationship.

METHODS

Firstly, we utilized CMR technique to explore the association of EAT distribution and quantity with MVO formation in patients with STEMI. Then we utilized a mouse model with EAT depletion to explore how EAT affected MVO formation under the circumstances of myocardial ischemia/reperfusion (I/R) injury. We further investigated the immunomodulatory effect of EAT on macrophages through co-culture experiments. Finally, we searched for new therapeutic strategies targeting EAT to prevent MVO formation.

RESULTS

The increase of left atrioventricular EAT mass index was independently associated with MVO formation. We also found that increased circulating levels of DPP4 and high DPP4 activity seemed to be associated with EAT increase. EAT accumulation acted as a pro-inflammatory mediator boosting the transition of macrophages towards inflammatory phenotype in myocardial I/R injury through secreting inflammatory EVs. Furthermore, our study declared the potential therapeutic effects of GLP-1 receptor agonist and GLP-1/GLP-2 receptor dual agonist for MVO prevention were at least partially ascribed to its impact on EAT modulation.

CONCLUSIONS

Our work for the first time demonstrated that excessive accumulation of EAT promoted MVO formation by promoting the polarization state of cardiac macrophages towards an inflammatory phenotype. Furthermore, this study identified a very promising therapeutic strategy, GLP-1/GLP-2 receptor dual agonist, targeting EAT for MVO prevention following myocardial I/R injury.

Changes in Epicardial Adipose Tissue Assessed by Chest CT in Breast Cancer Patients Receiving Adjuvant Chemotherapy with Anthracyclines and Trastuzumab

Background

Cardiotoxicity (CTX) induced by adjuvant chemotherapy is a significant factor that impacts the prognosis and quality of life in breast cancer (BC) patients. In this study, we aimed to investigate the changes in epicardial adipose tissue (EAT) before and after treatment in BC patients who received anthracyclines adjuvant chemotherapy protocol (AC-T) and anthracyclines combined with trastuzumabadjuvant chemotherapy protocol (AC-TH). Additionally, we assessed whether there were any differences in the changes in EAT between the two groups of patients. Our objective was to examine the effects of anthracyclines and trastuzumab on EAT and determine the potential role of EAT changes on CTX.

Methods

We reviewed female BC patients who were treated with adjuvant chemotherapy protocols of AC-T and AC-TH, all of whom underwent baseline (T0) and follow-up (T1) chest computed tomography (CT) and echocardiography. A cohort of healthy women, matched in age, underwent two chest CTs. EAT was quantified on chest CT using semi-automated software. CTX was defined as a > 10% reduction in left ventricular ejection fraction (LVEF) from baseline, with an absolute value of < 53%.

Results

A total of 41 BC patients were included in the study, with 23 patients in the AC-T group and 18 patients in the AC-TH group. Additionally, 22 healthy females were included as the normal group. None of the BC patients developed CTX after chemotherapy. The age did not differ significantly between the normal group and the AC-T group (p = 0.341) or the AC-TH group (p = 0.853). Similarly, the body mass index (BMI) of the normal group was comparable to that of the AC-T group (p = 0.377, 0.346) and the AC-TH group (p = 0.148, 0.119) before and after chemotherapy. The EAT volume index (mL/kg/ m 2 ) was significantly higher in both the AC-T group (5.11 ± 1.85 vs. 4.34 ± 1.55, p < 0.001) and the AC-TH group (4.53 ± 1.61 vs. 3.48 ± 1.62, p < 0.001) at T1 compared with T0. In addition, both the AC-T group (-72.95 ± 5.01 vs. -71.22 ± 3.91, p = 0.005) and the AC-TH group (-72.55 ± 5.27 vs. -68.20 ± 5.98, p < 0.001) exhibited a significant decrease in EAT radiodensity (HU) at T1 compared to T0. However, there was no significant difference observed in the normal group. At T0, no difference was seen in EAT volume index (4.34 ± 1.55 vs. 3.48 ± 1.62, p = 0.090) and radiodensity (-71.22 ± 3.91 vs. -68.20 ± 5.98, p = 0.059) between the AC-T and AC-TH groups. Similarly, at T1, there was still no significant difference observed in the EAT volume index (-5.11 ± 1.85 vs. 4.53 ± 1.61, p = 0.308) and radiodensity (-72.95 ± 5.00 vs. -72.54 ± 5.27, p = 0.802) between the two groups.

Conclusions

BC patients who underwent AC-T and AC-TH adjuvant chemotherapy protocols demonstrated a significant rise in the volume index of EAT, along with a substantial reduction in its radiodensity post-chemotherapy. These findings indicate that alterations in EAT could potentially aid in identifying cardiac complications caused by chemotherapeutic agents and remind clinicians to focus on changes in EAT after adjuvant chemotherapy in BC patients to prevent the practical occurrence of CTX.

The Role of Epicardial Adipose Tissue in Acute Coronary Syndromes, Post-Infarct Remodeling and Cardiac Regeneration

Epicardial adipose tissue (EAT) is a fat deposit surrounding the heart and located under the visceral layer of the pericardium. Due to its unique features, the contribution of EAT to the pathogenesis of cardiovascular and metabolic disorders is extensively studied. Especially, EAT can be associated with the onset and development of coronary artery disease, myocardial infarction and post-infarct heart failure which all are significant problems for public health. In this article, we focus on the mechanisms of how EAT impacts acute coronary syndromes. Particular emphasis was placed on the role of inflammation and adipokines secreted by EAT. Moreover, we present how EAT affects the remodeling of the heart following myocardial infarction. We further review the role of EAT as a source of stem cells for cardiac regeneration. In addition, we describe the imaging assessment of EAT, its prognostic value, and its correlation with the clinical characteristics of patients.

The relationship between epicardial adipose tissue volume on coronary computed tomography angiography and idiopathic ventricular tachycardia: a propensity score matching case-control study in Chinese population

Background

Large epicardial adipose tissue (EAT) volume is associated with the incidence of premature ventricular beats. The relationship between EAT volume and idiopathic ventricular tachycardia (IVT) is not yet clear. We aimed to investigate the effect of EAT volume on the risk of IVT.

Methods

This is a retrospective consecutive case-control study from January 2020 to September 2022. IVT patients (n=81) and control patients (n=162) undergoing coronary computed tomography angiography (CCTA) were retrospectively recruited. The patients in the control group were all hospitalized patients for different reasons, such as chest tightness, shortness of breath, chest pain, and so on. Demographic parameters and clinical characteristics of each individual were collected from the patient's medical records. We selected evaluation criteria for the conduct of a 1:1 propensity score (PS)-adjusted analysis. Multivariable logistic analysis was used to investigate risk factors for IVT. Furthermore, the impact of EAT volume on cardiac repolarization indices was assessed in IVT patients.

Results

Patients with IVT had a larger EAT volume than control group patients in the unadjusted cohort. Variables with P<0.10 in the univariable analysis and important factors were included in the multivariable analysis model, including body mass index (BMI), left ventricular ejection fraction (LVEF), early peak/artial peak (E/A) ratios <1, EAT attenuation, and EAT volume (per increase 10 mL). The multivariable logistic analysis found that EAT volume [per increase 10 mL, odds ratio (OR): 1.29, 95% confidence interval (CI): 1.17-1.41, P<0.001] was an independent risk factor for IVT. EAT volume (per increase 10 mL, OR: 1.43, 95% CI: 1.25-1.64, P<0.001) independent effect was demonstrated in the PS adjusted cohort (n=57 in both groups). The area under the curve of EAT volume to predict the risk of IVT patients in the PS adjusted cohort was 0.859. The sensitivity and specificity were 86.0%, and 75.4%, respectively. Furthermore, A large EAT volume of IVT patients had a longer time in Tp-e, and Tp-e/QTc, compared with low EAT volume.

Conclusions

Patients with IVT had increased EAT volume compared to control subjects. Our study revealed that large EAT volume is associated with an extended repolarization process in IVT patients. These insights are essential for understanding the mechanisms linking EAT with IVT.

Epicardial adipose tissue volume, plaque vulnerability and myocardial ischemia in non-obstructive coronary artery disease

Background

Epicardial adipose tissue (EAT) accumulation has been associated with inflammation, atherosclerosis and microvascular dysfunction. Whether increased EAT volume is associated with coronary plaque vulnerability and demand myocardial ischemia in patients with non-obstructive coronary artery disease (CAD) is less explored.

Methods

In 125 patients (median age 63[58, 69] years and 58% women) with chest pain and non-obstructive CAD, EAT volume was quantified on non-contrast cardiac CT images. EAT volume in the highest tertile (>125 ml) was defined as high EAT volume. Total coronary plaque volume and plaque vulnerability were quantified by coronary CT angiography (CCTA). Demand myocardial ischemia was detected by contrast dobutamine stress echocardiography.

Results

High EAT volume was more common in men and associated with higher BMI, hypertension, increased left ventricular mass index (LVMi), C-reactive protein (CRP) and positive remodelling (all p < 0.05). There was no difference in age, coronary calcium score, total and non-calcified plaque volume or presence of demand myocardial ischemia between groups (all p ≥ 0.34). In a multivariable model, obesity (p = 0.006), hypertension (p = 0.007) and LVMi (p = 0.016) were independently associated with high EAT volume. Including plaque vulnerability in an alternative model, positive remodelling (p = 0.038) was independently associated with high EAT volume.

Conclusion

In non-obstructive CAD, high EAT volume was associated with cardiometabolic risk factors, inflammation and plaque vulnerability, while there was no association with demand myocardial ischemia or coronary plaque volume. Following our results, the role of EAT volume as a biomarker in non-obstructive CAD remains unclear.

Epicardial adipose tissue, pulmonary veins anatomy, and the P-wave/PR interval ratio in young patients with atrial fibrillation

Background

Atrial fibrillation (AF) is uncommon in the youngest population. Epicardial adipose tissue (EAT) volume has been proposed as an independent AF risk factor.

Objective

The aim of this retrospective study was to evaluate the impact of the EAT, the anatomy of the pulmonary veins (PVs), and electrocardiogram (ECG) features in these young patients with AF.

Methods

Sixty-two patients divided in 2 groups, one with history of paroxysmal AF treated with ablation and the other, a control group, all younger than 30 years of age, were included. Computed tomography scans were performed in both groups to estimate the PVs anatomy and EAT volume. Twelve-lead ECGs were performed in all patients. Patients underwent follow-up in our outpatient clinic (35.9 ± 18.3 months).

Results

In the AF group, the EAT volume around the left atrium was 22.25 ± 9.3 cm3 compared with 12.61 ± 3.37 cm3, showing a statistically significance difference (P = .003). Family history resulted to be another significant risk factor (P = .009). During follow-up, 67.7% of the patients treated were still free of events. The anatomy and morphology of the right-sided PVs seemed to play a more consistent role in the patients with AF recurrences (P = .04). The P/PR ratio, a new ECG index, seemed predict AF recurrences after ablation (P = .03).

Conclusion

The abundance of EAT seems related to the risk of developing AF in young patients. The recurrence of AF is about 33% and does not seem related to the EAT volume, but rather to the anatomy of the PVs. A higher P/PR ratio might suggest recurrences.

Towards an adiposity-related disease framework for the diagnosis and management of obesities

Obesity is a complex disease that relapses frequently and associates with multiple complications that comprise a worldwide health priority because of its rising prevalence and association with numerous complications, including metabolic disorders, mechanic pathologies, and cancer, among others. Noteworthy, excess adiposity is accompanied by chronic inflammation, oxidative stress, insulin resistance, and subsequent organ dysfunction. This dysfunctional adipose tissue is initially stored in the visceral depot, overflowing subsequently to produce lipotoxicity in ectopic depots like liver, heart, muscle, and pancreas, among others. People living with obesity need a diagnostic approach that considers an exhaustive pathophysiology and complications assessment. Thus, it is essential to warrant a holistic diagnosis and management that guarantees an adequate health status, and quality of life. The present review summarizes the different complications associated with obesity, at the same time, we aim to fostering a novel framework that enhances a patient-centered approach to obesity management in the precision medicine era.

The relationship between frequent premature ventricular complexes and epicardial adipose tissue volume

Background

Epicardial adipose tissue (EAT) is related to atrial fibrillation. The association between EAT volume and premature ventricular complexes (PVCs) remains unclear. Our study aimed to investigate the effect of EAT volume on the risk of frequent PVCs and burden levels of PVCs.

Methods

This observational study retrospectively recruited consecutive patients who had consultation between 2019 and 2021 at the First Affiliated Hospital of Zhengzhou University. Frequent PVC patients (n = 402) and control patients (n = 402) undergoing non-contrast computed tomography (CT) were enrolled. We selected evaluation criteria for the conduct of a 1:1 propensity score matching (PSM) analysis. Multivariable logistic analysis was used to investigate factors related to frequent PVCs. Furthermore, the determinants of EAT volume and the burden levels of PVCs were evaluated.

Results

Patients with PVCs had a significantly larger EAT volume than control patients. EAT volume was significantly larger in male PVC patients with BMI ≥24 kg/m2, diabetes mellitus, and E/A ratio <1. EAT volume was independently associated with PVCs. Moreover, the larger EAT volume was an independent predictor for the high burden level of PVCs. We revealed that the risk of high PVC burden level was increased with the rising of EAT volume by restricted cubic splines.

Conclusions

EAT volume was larger in frequent PVC patients than in control patients, regardless of other confounding factors. A large EAT volume was independently associated with high burden levels of PVCs. EAT volume may be a new mechanism to explain the pathogenesis of PVCs.

Association between epicardial adipose tissue and incident heart failure mediating by alteration of natriuretic peptide and myocardial strain

BACKGROUND

Epicardial adipose tissue (EAT) has been suggested to exert deleterious effects on myocardium and cardiovascular disease (CVD) consequence. We evaluated the associations of EAT thickness with adverse outcomes and its potential mediators in the community.

METHODS

Participants without heart failure (HF) who had undergone cardiac magnetic resonance (CMR) to measure EAT thickness over the right ventricular free wall from the Framingham Heart Study were included. The correlation of EAT thickness with 85 circulating biomarkers and cardiometric parameters was assessed in linear regression models. The occurrence of HF, atrial fibrillation, coronary heart disease (CHD), and other adverse events was tracked since CMR was implemented. Their associations with EAT thickness and the mediators were evaluated using Cox regression and causal mediation analysis.

RESULTS

Of 1554 participants, 53.0% were females. Mean age, body mass index, and EAT thickness were 63.3 years, 28.1 kg/m², and 9.8 mm, respectively. After fully adjusting, EAT thickness positively correlated with CRP, LEP, GDF15, MMP8, MMP9, ORM1, ANGPTL3, and SERPINE1 and negatively correlated with N-terminal pro-B-type natriuretic peptide (NT-proBNP), IGFBP1, IGFBP2, AGER, CNTN1, and MCAM. Increasing EAT thickness was associated with smaller left ventricular end-diastolic dimension, thicker left ventricular wall thickness, and worse global longitudinal strain (GLS). During a median follow-up of 12.7 years, 101 incident HF occurred. Per 1-standard deviation increment of EAT thickness was associated with a higher risk of HF (adjusted hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.19-1.72, P < 0.001) and the composite outcome consisting of myocardial infarction, ischemic stroke, HF, and death from CVD (adjusted HR [95% CI], 1.23 [1.07-1.40], P = 0.003). Mediation effect in the association between thicker EAT and higher risk of HF was observed with NT-proBNP (HR [95% CI], 0.95 [0.92-0.98], P = 0.011) and GLS (HR [95% CI], 1.04 [1.01-1.07], P = 0.032).

CONCLUSIONS

EAT thickness was correlated with inflammation and fibrosis-related circulating biomarkers, cardiac concentric change, myocardial strain impairment, incident HF risk, and overall CVD risk. NT-proBNP and GLS might partially mediate the effect of thickened EAT on the risk of HF. EAT could refine the assessment of CVD risk and become a new therapeutic target of cardiometabolic diseases.

TRIAL REGISTRATION

URL: https://clinicaltrials.gov . Identifier: NCT00005121.

Diagnosis of coronary artery disease in patients with type 2 diabetes mellitus based on computed tomography and pericoronary adipose tissue radiomics: a retrospective cross-sectional study

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) are highly susceptible to cardiovascular disease, and coronary artery disease (CAD) is their leading cause of death. We aimed to assess whether computed tomography (CT) based imaging parameters and radiomic features of pericoronary adipose tissue (PCAT) can improve the diagnostic efficacy of whether patients with T2DM have developed CAD.

METHODS

We retrospectively recruited 229 patients with T2DM but no CAD history (146 were diagnosed with CAD at this visit and 83 were not). We collected clinical information and extracted imaging manifestations from CT images and 93 radiomic features of PCAT from all patients. All patients were randomly divided into training and test groups at a ratio of 7:3. Four models were constructed, encapsulating clinical factors (Model 1), clinical factors and imaging indices (Model 2), clinical factors and Radscore (Model 3), and all together (Model 4), to identify patients with CAD. Receiver operating characteristic curves and decision curve analysis were plotted to evaluate the model performance and pairwise model comparisons were performed via the DeLong test to demonstrate the additive value of different factors.

RESULTS

In the test set, the areas under the curve (AUCs) of Model 2 and Model 4 were 0.930 and 0.929, respectively, with higher recognition effectiveness compared to the other two models (each p < 0.001). Of these models, Model 2 had higher diagnostic efficacy for CAD than Model 1 (p < 0.001, 95% CI [0.129-0.350]). However, Model 4 did not improve the effectiveness of the identification of CAD compared to Model 2 (p = 0.776); similarly, the AUC did not significantly differ between Model 3 (AUC = 0.693) and Model 1 (AUC = 0.691, p = 0.382). Overall, Model 2 was rated better for the diagnosis of CAD in patients with T2DM.

CONCLUSIONS

A comprehensive diagnostic model combining patient clinical risk factors with CT-based imaging parameters has superior efficacy in diagnosing the occurrence of CAD in patients with T2DM.

Clinical relevance of coronary risk classification and reclassification with coronary artery calcium score in asymptomatic people living with diabetes. An observational study

AIMS

To explore (i) in what proportion and direction coronary artery calcium (CAC) score reclassifies coronary risk in asymptomatic diabetic patients at high a priori coronary risk, and (ii) whether screening for asymptomatic myocardial ischemia / coronary stenosis only in patients at very high coronary risk - whether a priori or combined with those reclassified at very high risk according to their CAC score - has good sensitivity to detect these conditions.

METHODS

We retrospectively selected 377 asymptomatic primary prevention diabetic patients at high or very high a priori coronary risk according to national guidelines. All had their CAC score measured and underwent stress myocardial scintigraphy to detect myocardial ischemia. Those identified with ischemia then had a coronary angiography to identify coronary stenoses.

RESULTS

Of the selected patients, 242 and 135 patients had a high and very high a priori coronary risk, respectively. After taking into account their CAC score, the former were reclassified into three risk categories: moderate (n = 159, 66%), high (n = 38) and very high (45 patients) risk. Myocardial ischemia was identified in 35 patients and coronary stenoses in 14 of the latter. Had a stress scintigraphy been performed only in the 135 patients at very high risk a priori, 18 patients would have been detected with ischemia (sensitivity 51%), and 9 with coronary stenoses (sensitivity 64%). Had a scintigraphy also been performed on the 45 patients at very high risk after CAC-reclassification, an additional 7 and 5 patients with ischemia and coronary stenoses, respectively, would have been identified.

CONCLUSION

Following national guidelines, 66% of our population of asymptomatic diabetic persons at high a priori coronary risk were reclassified into the moderate risk category, translating into less stringent goals for risk factor control. Eighteen percent were reclassified into the very high-risk category, leading to 100% detection sensitivity for patients with ischemia and coronary stenoses.

Quantification of Cardiac Adipose Tissue in Failing and Nonfailing Human Myocardium

Background

Because body mass index (BMI) is generally used clinically to define obesity and to estimate body adiposity, BMI likely is positively correlated with epicardial adipose tissue (EAT) level. Based on echocardiography, previous outcomes on this matter have varied from almost absent to rather strong correlations between BMI and EAT. The purpose of our study was to unambiguously examine EAT content and determine if correlations exist between EAT content and BMI, cause of heart failure, or contractile force.

Methods and Results

We qualitatively scored 150 human hearts ex vivo on EAT distribution. From each heart, multiple photographs of the heart were taken, and both atrial and ventricular adipose tissue levels were semiquantitatively scored. Main findings include a generally higher EAT content on nonfailing hearts compared with end‐stage failing hearts (atrial adipose tissue level 5.70±0.13 vs. 5.00±0.12, P<0.001; ventricular adipose tissue level 5.14±0.16 vs. 4.57±0.12, P=0.0048). The results also suggest that EAT quantity is not strongly correlated with BMI in nonfailing (atrial adipose tissue level r=0.069, ventricular adipose tissue level r=0.14) or failing (atrial adipose tissue level r=−0.022, ventricular adipose tissue level r=0.051) hearts. Atrial EAT is closely correlated with ventricular EAT in both nonfailing (r=0.92, P<0.001) and failing (r=0.87, P<0.001) hearts.

Conclusions

EAT volume appears to be inversely proportional to severity of or length of time with heart failure based on our findings. Based on a lack of correlation with BMI, it is incorrect to assume high EAT volume given high body fat percentage.