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Crum Y, Hoendermis ES, van Veldhuisen DJ, van Woerden G, Lobeek M, Dickinson MG, Meems LMG, Voors AA, Rienstra M, Gorter TM. Epicardial adipose tissue and pericardial constraint in heart failure with preserved ejection fraction. ESC Heart Fail 2024. [PMID: 38438270 DOI: 10.1002/ehf2.14739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/08/2024] [Accepted: 02/11/2024] [Indexed: 03/06/2024] Open
Abstract
AIMS Obesity and epicardial adiposity play a role in the pathophysiology of heart failure with preserved ejection fraction (HFpEF), and both are associated with increased filling pressures and reduced exercise capacity. The haemodynamic basis for these observations remains inaccurately defined. We hypothesize that an abundance of epicardial adipose tissue (EAT) within the pericardial sac is associated with haemodynamic signs of pericardial constraint. METHODS AND RESULTS HFpEF patients who underwent invasive heart catheterization with simultaneous echocardiography were included. Right atrial pressure (RAP), right ventricular end-diastolic pressure, and pulmonary capillary wedge pressure (PCWP) were invasively measured. The presence of a square root sign on the right ventricular pressure waveform and the RAP/PCWP ratio (surrogate parameters for pericardial constraint) were investigated. EAT thickness alongside the right ventricle was measured on echocardiography. Sixty-four patients were studied, with a mean age of 73 ± 10 years, 64% women, and a mean body mass index (BMI) of 28.6 ± 5.4 kg/m2 . In total, 47 patients (73%) had a square root sign. The presence of a square root sign was associated with higher BMI (29.3 vs. 26.7 kg/m2 , P = 0.02), higher EAT (4.0 vs. 3.4 mm, P = 0.03), and higher RAP (9 vs. 6 mmHg, P = 0.04). Women had more EAT than men (4.1 vs. 3.5 mm, P = 0.04), despite a comparable BMI. Women with a square root sign had significantly higher EAT (4.3 vs. 3.3 mm, P = 0.02), a higher mean RAP (9 vs. 5 mmHg, P = 0.02), and a higher RAP/PCWP ratio (0.52 vs. 0.26, P = 0.002). In men, such associations were not seen, although there was no significant interaction between men and women (P > 0.05 for all analyses). CONCLUSIONS Obesity and epicardial adiposity are associated with haemodynamic signs of pericardial constraint in patients with HFpEF. The pathophysiological and therapeutic implications of this finding need further study.
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Affiliation(s)
- Yoran Crum
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Gijs van Woerden
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Michelle Lobeek
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Michael G Dickinson
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Laura M G Meems
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, Groningen, The Netherlands
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2
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Hoorntje ET, Burns C, Marsili L, Corden B, Parikh VN, Te Meerman GJ, Gray B, Adiyaman A, Bagnall RD, Barge-Schaapveld DQCM, van den Berg MP, Bootsma M, Bosman LP, Correnti G, Duflou J, Eppinga RN, Fatkin D, Fietz M, Haan E, Jongbloed JDH, Hauer AD, Lam L, van Lint FHM, Lota A, Marcelis C, McCarthy HJ, van Mil AM, Oldenburg RA, Pachter N, Planken RN, Reuter C, Semsarian C, van der Smagt JJ, Thompson T, Vohra J, Volders PGA, van Waning JI, Whiffin N, van den Wijngaard A, Amin AS, Wilde AAM, van Woerden G, Yeates L, Zentner D, Ashley EA, Wheeler MT, Ware JS, van Tintelen JP, Ingles J. Variant Location Is a Novel Risk Factor for Individuals With Arrhythmogenic Cardiomyopathy Due to a Desmoplakin ( DSP) Truncating Variant. Circ Genom Precis Med 2023; 16:e003672. [PMID: 36580316 PMCID: PMC9946166 DOI: 10.1161/circgen.121.003672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Truncating variants in desmoplakin (DSPtv) are an important cause of arrhythmogenic cardiomyopathy; however the genetic architecture and genotype-specific risk factors are incompletely understood. We evaluated phenotype, risk factors for ventricular arrhythmias, and underlying genetics of DSPtv cardiomyopathy. METHODS Individuals with DSPtv and any cardiac phenotype, and their gene-positive family members were included from multiple international centers. Clinical data and family history information were collected. Event-free survival from ventricular arrhythmia was assessed. Variant location was compared between cases and controls, and literature review of reported DSPtv performed. RESULTS There were 98 probands and 72 family members (mean age at diagnosis 43±8 years, 59% women) with a DSPtv, of which 146 were considered clinically affected. Ventricular arrhythmia (sudden cardiac arrest, sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator therapy) occurred in 56 (33%) individuals. DSPtv location and proband status were independent risk factors for ventricular arrhythmia. Further, gene region was important with variants in cases (cohort n=98; Clinvar n=167) more likely to occur in the regions resulting in nonsense mediated decay of both major DSP isoforms, compared with n=124 genome aggregation database control variants (148 [83.6%] versus 29 [16.4%]; P<0.0001). CONCLUSIONS In the largest series of individuals with DSPtv, we demonstrate that variant location is a novel risk factor for ventricular arrhythmia, can inform variant interpretation, and provide critical insights to allow for precision-based clinical management.
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Affiliation(s)
- Edgar T Hoorntje
- Department of Genetics, University Medical Centre Groningen, University of Groningen (E.T.H., G.J.t.M., J.D.H.J.).,Netherlands Heart Institute, Utrecht, the Netherlands (E.T.H., L.P.B., L.L., J.P.v.T.)
| | - Charlotte Burns
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.B., B.G., R.D.B., C.S.).,Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.B., B.G., C.S., L.Y., J.I.)
| | - Luisa Marsili
- Department of Clinical Genetics, Amsterdam University Medical Centre, location AMC, University of Amsterdam, the Netherlands (L.M., J.P.v.T.).,Clinique de Génétique, CHU Lille, Lille, France (L.M.)
| | - Ben Corden
- National Heart and Lung Institute and MRC London Institute of Medical Science, Imperial College London and Cardiovascular Research Centre, Royal Brompton and Harefield NHS Foundation Trust, London, UK (B.C., A.L., N.W., J.S.W.)
| | - Victoria N Parikh
- Stanford Centre for Inherited Cardiovascular Disease, Department of Medicine, Stanford University School of Medicine, CA (V.N.P., C.R., E.A.A., M.T.W.)
| | - Gerard J Te Meerman
- Department of Genetics, University Medical Centre Groningen, University of Groningen (E.T.H., G.J.t.M., J.D.H.J.)
| | - Belinda Gray
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.B., B.G., R.D.B., C.S.).,Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.B., B.G., C.S., L.Y., J.I.)
| | - Ahmet Adiyaman
- Department of Cardiology, Isala Heart Center, Zwolle (A.A.)
| | - Richard D Bagnall
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.B., B.G., R.D.B., C.S.).,Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.)
| | | | - Maarten P van den Berg
- Department of Cardiology, University of Groningen, University Medical Centre Groningen (M.P.v.d.B., G.v.W.)
| | - Marianne Bootsma
- Department of Cardiology, University of Leiden, Leiden University Medical Centre (M.B.)
| | - Laurens P Bosman
- Netherlands Heart Institute, Utrecht, the Netherlands (E.T.H., L.P.B., L.L., J.P.v.T.).,Department of Cardiology, University of Utrecht (L.P.B.)
| | - Gemma Correnti
- Adult Genetics Unit, Royal Adelaide Hospital and Faculty of Health and Medical Sciences, University of Adelaide (G.C.)
| | - Johan Duflou
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.B., B.G., R.D.B., C.S.)
| | | | - Diane Fatkin
- Victor Chang Cardiac Research Institute, Sydney (D.F.)
| | - Michael Fietz
- Department of Diagnostic Genomics, PathWest Laboratory, Medicine WA, Redlands, Australia (M.F.)
| | | | - Jan D H Jongbloed
- Department of Genetics, University Medical Centre Groningen, University of Groningen (E.T.H., G.J.t.M., J.D.H.J.)
| | - Arnaud D Hauer
- Department of Cardiology, Haga Teaching Hospital, the Hague (A.D.H.)
| | - Lien Lam
- Netherlands Heart Institute, Utrecht, the Netherlands (E.T.H., L.P.B., L.L., J.P.v.T.)
| | - Freyja H M van Lint
- Department of Genetics, University of Utrecht, University Medical Centre Utrecht, the Netherlands (F.H.M.v.L., J.P.v.T.)
| | - Amrit Lota
- National Heart and Lung Institute and MRC London Institute of Medical Science, Imperial College London and Cardiovascular Research Centre, Royal Brompton and Harefield NHS Foundation Trust, London, UK (B.C., A.L., N.W., J.S.W.)
| | - Carlo Marcelis
- Department of Clinical Genetics, Radboud University Medical Centre, Nijmegen, the Netherlands (C.M.)
| | - Hugh J McCarthy
- Department of Clinical Genetics, Children's Hospital Westmead, Sydney, Australia (H.J.M.)
| | - Anneke M van Mil
- Department of Clinical Genetics, Leiden University Medical Centre (D.Q.C.M.B.-S., A.M.v.M.)
| | - Rogier A Oldenburg
- Department of Clinical Genetics, Erasmus University Medical Centre, Rotterdam, the Netherlands (R.A.O.)
| | | | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centre, Amsterdam, the Netherlands (R.N.P.)
| | - Chloe Reuter
- Stanford Centre for Inherited Cardiovascular Disease, Department of Medicine, Stanford University School of Medicine, CA (V.N.P., C.R., E.A.A., M.T.W.)
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute (C.B., B.G., R.D.B., C.S.).,Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.B., B.G., C.S., L.Y., J.I.)
| | | | - Tina Thompson
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital (T.T., J.V., D.Z.)
| | - Jitendra Vohra
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital (T.T., J.V., D.Z.).,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Australia (J.V., D.Z.)
| | - Paul G A Volders
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM) (P.G.A.V.)
| | | | - Nicola Whiffin
- National Heart and Lung Institute and MRC London Institute of Medical Science, Imperial College London and Cardiovascular Research Centre, Royal Brompton and Harefield NHS Foundation Trust, London, UK (B.C., A.L., N.W., J.S.W.)
| | - Arthur van den Wijngaard
- Department of Clinical Genetics, Laboratory Clinical Genetics, Maastricht University Medical Centre (A.v.d.W.)
| | - Ahmad S Amin
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam University Medical Centre, location AMC, the Netherlands (A.S.A., A.A.M.W.)
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Heart Centre, Amsterdam University Medical Centre, location AMC, the Netherlands (A.S.A., A.A.M.W.)
| | - Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Centre Groningen (M.P.v.d.B., G.v.W.)
| | - Laura Yeates
- Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.B., B.G., C.S., L.Y., J.I.).,Cardio Genomics Program at Centenary Institute, The University of Sydney (L.Y., J.I.)
| | - Dominica Zentner
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital (T.T., J.V., D.Z.).,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Australia (J.V., D.Z.)
| | - Euan A Ashley
- Stanford Centre for Inherited Cardiovascular Disease, Department of Medicine, Stanford University School of Medicine, CA (V.N.P., C.R., E.A.A., M.T.W.)
| | - Matthew T Wheeler
- Stanford Centre for Inherited Cardiovascular Disease, Department of Medicine, Stanford University School of Medicine, CA (V.N.P., C.R., E.A.A., M.T.W.)
| | - James S Ware
- National Heart and Lung Institute and MRC London Institute of Medical Science, Imperial College London and Cardiovascular Research Centre, Royal Brompton and Harefield NHS Foundation Trust, London, UK (B.C., A.L., N.W., J.S.W.)
| | - J Peter van Tintelen
- Netherlands Heart Institute, Utrecht, the Netherlands (E.T.H., L.P.B., L.L., J.P.v.T.).,Department of Clinical Genetics, Amsterdam University Medical Centre, location AMC, University of Amsterdam, the Netherlands (L.M., J.P.v.T.).,Department of Genetics, University of Utrecht, University Medical Centre Utrecht, the Netherlands (F.H.M.v.L., J.P.v.T.)
| | - Jodie Ingles
- Faculty of Medicine and Health (C.B., B.G., R.D.B., J.D., C.S., L.Y., J.I.).,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia (C.B., B.G., C.S., L.Y., J.I.).,Cardio Genomics Program at Centenary Institute, The University of Sydney (L.Y., J.I.).,Centre for Population Genomics, Garvan Institute of Medical Research and UNSW Sydney (J.I.).,Centre for Population Genomics, Murdoch Children's Research Institute, Melbourne, Australia (J.I.)
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3
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van Woerden G, van Veldhuisen DJ, Westenbrink BD, de Boer RA, Rienstra M, Gorter TM. Connecting epicardial adipose tissue and heart failure with preserved ejection fraction: mechanisms, management and modern perspectives. Eur J Heart Fail 2022; 24:2238-2250. [PMID: 36394512 PMCID: PMC10100217 DOI: 10.1002/ejhf.2741] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/19/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Obesity is very common in patients with heart failure with preserved ejection fraction (HFpEF) and it has been suggested that obesity plays an important role in the pathophysiology of this disease. While body mass index defines the presence of obesity, this measure provides limited information on visceral adiposity, which is probably more relevant in the pathophysiology of HFpEF. Epicardial adipose tissue is the visceral fat situated directly adjacent to the heart and recent data demonstrate that accumulation of epicardial adipose tissue is associated with the onset, symptomatology and outcome of HFpEF. However, the mechanisms by which epicardial adipose tissue may be involved in HFpEF remain unclear. It is also questioned whether epicardial adipose tissue may be a specific target for therapy for this disease. In the present review, we describe the physiology of epicardial adipose tissue and the pathophysiological transformation of epicardial adipose tissue in response to chronic inflammatory diseases, and we postulate conceptual mechanisms on how epicardial adipose tissue may be involved in HFpEF pathophysiology. Lastly, we outline potential treatment strategies, knowledge gaps and directions for further research.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - B Daan Westenbrink
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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4
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van Meijeren AR, Ties D, de Koning MSLY, van Dijk R, van Blokland IV, Lizana Veloz P, van Woerden G, Vliegenthart R, Pundziute G, Westenbrink DB, van der Harst P. Association of epicardial adipose tissue with different stages of coronary artery disease: A cross-sectional UK Biobank cardiovascular magnetic resonance imaging substudy. Int J Cardiol Heart Vasc 2022; 40:101006. [PMID: 35372662 PMCID: PMC8971641 DOI: 10.1016/j.ijcha.2022.101006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 11/28/2022]
Abstract
Objective Increased epicardial adipose tissue (EAT) has been identified as a risk factor for the development of coronary artery disease (CAD). However, the exact role of EAT in the development of CAD is unclear. This study aims to compare EAT volumes between healthy controls and individuals with stable CAD and a history of myocardial infarction (MI). Furthermore, associations between clinical and biochemical parameters with EAT volumes are examined. Methods This retrospective cross-sectional study included 171 participants from the United Kingdom Biobank (56 healthy controls; 60 stable CAD; 55 post MI), whom were balanced for age, sex and body mass index (BMI). EAT volumes were quantified on end-diastolic cardiac magnetic resonance (CMR) imaging short-axis slices along the left and right ventricle and indexed for body surface area (iEAT) and iEAT volumes were compared between groups. Results iEAT volumes were comparable between control, CAD and MI cases (median [IQR]: 66.1[54.4-77.0] vs. 70.9[55.8-85.5] vs. 67.6[58.6-82.3] mL/m2, respectively (p > 0.005 for all). Increased HDL-cholesterol was associated with decreased iEAT volume (β = -14.8, CI = -24.6 to -4.97, p = 0.003) and suggestive associations (P-value < 0.05 and ≥ 0.005) were observed between iEAT and triglycerides (β = 3.26, CI = 0.42 to 6.09, p = 0.02), Apo-lipoprotein A (β = -16.3, CI = -30.3 to -2.24, p = 0.02) and LDL-cholesterol (β = 3.99, CI = -7.15 to -0.84, p = 0.01). Conclusions No significant differences in iEAT volumes were observed between patients with CAD, MI and healthy controls. Our results indicate the importance of correcting for confounding by CVD risk factors, including circulating lipid levels, when studying the relationship between EAT volume and CAD. Further mechanistic studies on causal pathways and the role of EAT composition are warranted.
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Affiliation(s)
- Anne Ruth van Meijeren
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Daan Ties
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Marie-Sophie L Y de Koning
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Randy van Dijk
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Irene V van Blokland
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | - Gijs van Woerden
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Rozemarijn Vliegenthart
- University of Groningen, University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands
| | - Gabija Pundziute
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Daan B Westenbrink
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands.,Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
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5
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van Woerden G, van Veldhuisen DJ, Gorter TM, Ophuis B, Saucedo-Orozco H, van Empel VPM, Willems TP, Geelhoed B, Rienstra M, Westenbrink BD. The value of echocardiographic measurement of epicardial adipose tissue in heart failure patients. ESC Heart Fail 2022; 9:953-957. [PMID: 35146949 PMCID: PMC8934911 DOI: 10.1002/ehf2.13828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/16/2021] [Accepted: 01/17/2022] [Indexed: 11/08/2022] Open
Abstract
Aims Epicardial adipose tissue (EAT) is increasingly recognized as an important factor in the pathophysiology of heart failure (HF). Cardiac magnetic resonance (CMR) imaging is the gold‐standard imaging modality to evaluate EAT size, but in contrast to echocardiography, CMR is costly and not widely available. We investigated EAT thickness on echocardiography in relation to EAT volume on CMR, and we assessed the agreement between observers for measuring echocardiographic EAT. Methods and results Patients with HF and left ventricular ejection fraction >40% were enrolled. All patients underwent CMR imaging and transthoracic‐echocardiography. EAT volume was quantified on CMR short‐axis cine‐stacks. Echocardiographic EAT thickness was measured on parasternal long‐axis and short‐axis views. Linear regression analyses were used to assess the association between EAT volume on CMR and EAT thickness on echocardiography. Intraclass correlation coefficient (ICC) was used to assess the interobserver agreement as well as the intraobserver agreement. EAT on CMR and echocardiography was evaluated in 117 patients (mean age 71 ± 10 years, 49% women and mean left ventricular ejection fraction 54 ± 7%). Mean EAT volume on CMR was 202 ± 64 mL and ranged from 80 to 373 mL. Mean EAT thickness on echocardiography was 3.8 ± 1.5 mm and ranged from 1.7 to 10.2 mm. EAT volume on CMR and EAT thickness on echocardiography were significantly correlated (junior‐observer: r = 0.62, P < 0.001, senior‐observer: r = 0.33, P < 0.001), and up to one‐third of the variance in EAT volume was explained by EAT thickness (R2 = 0.38, P < 0.001). The interobserver agreement between junior and senior observers for measuring echocardiographic EAT was modest [ICC, 0.65 (95% confidence interval (CI) 0.47–0.77], whereas the intraobserver agreement was good (ICC 0.98, 95% CI 0.84–0.99). Conclusions There was a modest correlation between EAT volume on CMR and EAT thickness on echocardiography. Limited agreement between junior and senior observers for measuring echocardiographic EAT was observed. EAT thickness on echocardiography is limited in estimating EAT volume.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bob Ophuis
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Huitzilihuitl Saucedo-Orozco
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, University of Maastricht, Medical University Centre Maastricht, Maastricht, The Netherlands
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bastiaan Geelhoed
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Berend Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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6
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van Veldhuisen SL, Gorter TM, van Woerden G, de Boer RA, Rienstra M, Hazebroek EJ, van Veldhuisen DJ. OUP accepted manuscript. Eur Heart J 2022; 43:1955-1969. [PMID: 35243488 PMCID: PMC9123239 DOI: 10.1093/eurheartj/ehac071] [Citation(s) in RCA: 77] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/12/2022] Open
Abstract
Aims Obesity is a global health problem, associated with significant morbidity and mortality, often due to cardiovascular (CV) diseases. While bariatric surgery is increasingly performed in patients with obesity and reduces CV risk factors, its effect on CV disease is not established. We conducted a systematic review and meta-analysis to evaluate the effect of bariatric surgery on CV outcomes, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Methods and results PubMed and Embase were searched for literature until August 2021 which compared bariatric surgery patients to non-surgical controls. Outcomes of interest were all-cause and CV mortality, atrial fibrillation (AF), heart failure (HF), myocardial infarction, and stroke. We included 39 studies, all prospective or retrospective cohort studies, but randomized outcome trials were not available. Bariatric surgery was associated with a beneficial effect on all-cause mortality [pooled hazard ratio (HR) of 0.55; 95% confidence interval (CI) 0.49–0.62, P < 0.001 vs. controls], and CV mortality (HR 0.59, 95% CI 0.47–0.73, P < 0.001). In addition, bariatric surgery was also associated with a reduced incidence of HF (HR 0.50, 95% CI 0.38–0.66, P < 0.001), myocardial infarction (HR 0.58, 95% CI 0.43–0.76, P < 0.001), and stroke (HR 0.64, 95% CI 0.53–0.77, P < 0.001), while its association with AF was not statistically significant (HR 0.82, 95% CI 0.64–1.06, P = 0.12). Conclusion The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.
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Affiliation(s)
- Sophie L van Veldhuisen
- Department of Surgery/Vitalys Clinic, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Eric J Hazebroek
- Department of Surgery/Vitalys Clinic, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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7
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van Woerden G, van Veldhuisen DJ, Manintveld OC, van Empel VPM, Willems TP, de Boer RA, Rienstra M, Westenbrink BD, Gorter TM. Epicardial Adipose Tissue and Outcome in Heart Failure With Mid-Range and Preserved Ejection Fraction. Circ Heart Fail 2021; 15:e009238. [PMID: 34935412 PMCID: PMC8920003 DOI: 10.1161/circheartfailure.121.009238] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Supplemental Digital Content is available in the text. Epicardial adipose tissue (EAT) accumulation is thought to play a role in the pathophysiology of heart failure (HF) with mid-range and preserved ejection fraction, but its effect on outcome is unknown. We evaluated the prognostic value of EAT volume measured with cardiac magnetic resonance in patients with HF with mid-range ejection fraction and HF with preserved ejection fraction.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
| | - Olivier C Manintveld
- Department of Cardiology, University of Rotterdam, Erasmus Medical Center Rotterdam, the Netherlands (O.C.M.)
| | - Vanessa P M van Empel
- Department of Cardiology, University of Maastricht, Medical University Center Maastricht, the Netherlands (V.P.M.v.E.)
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, the Netherlands. (T.P.W.)
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
| | - B Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands. (G.v.W., D.J.v.V., R.A.d.B., M.R., B.D.W., T.M.G.)
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8
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van Woerden G, van Veldhuisen DJ, Gorter TM, van Empel VPM, Hemels MEW, Hazebroek EJ, van Veldhuisen SL, Willems TP, Rienstra M, Westenbrink BD. Importance of epicardial adipose tissue localization using cardiac magnetic resonance imaging in patients with heart failure with mid-range and preserved ejection fraction. Clin Cardiol 2021; 44:987-993. [PMID: 34085724 PMCID: PMC8259147 DOI: 10.1002/clc.23644] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/23/2021] [Accepted: 05/05/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Epicardial adipose tissue (EAT) has been implicated in the pathophysiology of heart failure (HF) with left ventricular ejection fraction (LVEF) >40%, but whether this is due to a regional or global effect of EAT remains unclear. HYPOTHESIS Regional EAT is associated with alterations in local cardiac structure and function. METHODS Patients with HF and LVEF >40% were studied. Cardiac Magnetic Resonance imaging was used to localize EAT surrounding the right ventricle (RV) and LV separately, using anterior- and posterior interventricular grooves as boundaries. Atrial- and ventricular EAT were differentiated using the mitral-valve position. All EAT depots were related to the adjacent myocardial structure. RESULTS 102 consecutive HF patients were enrolled. The majority of EAT was present around the RV (42% of total EAT, p < .001). RV-EAT showed a strong association with increased RV mass (β = 0.60, p < .001) and remained associated with RV mass after adjusting for total EAT, sex, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), renal function and blood glucose. LV-EAT showed a similar association with LV mass in univariable analysis, albeit less pronounced (β = 0.24, p = .02). Atrial EAT was increased in patients with atrial fibrillation compared to those without atrial fibrillation (30 vs. 26 ml/m2 , p = .04), whereas ventricular EAT was similar (74 vs. 75 ml/m2 , p = .9). CONCLUSIONS Regional EAT is strongly associated with local cardiac structure and function in HF patients with LVEF >40%. These data support the hypothesis that regional EAT is involved in the pathophysiology of HF with LVEF >40%.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, University of Maastricht, Medical University Centre Maastricht, Maastricht, Netherlands
| | | | | | | | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Berend Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Tromp J, Bryant JA, Jin X, van Woerden G, Asali S, Yiying H, Liew OW, Ching JCP, Jaufeerally F, Loh SY, Sim D, Lee S, Soon D, Tay WT, Packer M, van Veldhuisen DJ, Chin C, Richards AM, Lam CSP. Epicardial fat in heart failure with reduced versus preserved ejection fraction. Eur J Heart Fail 2021; 23:835-838. [PMID: 33724596 DOI: 10.1002/ejhf.2156] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/14/2021] [Accepted: 03/10/2021] [Indexed: 02/03/2023] Open
Affiliation(s)
- Jasper Tromp
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Xuanyi Jin
- National Heart Centre Singapore, Singapore, Singapore.,Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Salma Asali
- National Heart Centre Singapore, Singapore, Singapore
| | - Han Yiying
- National Heart Centre Singapore, Singapore, Singapore
| | - Oi Wah Liew
- Cardiovascular Research Institute (CVRI), National University Heart Centre Singapore (NUHS), Singapore, Singapore
| | - Jenny Chong Pek Ching
- Cardiovascular Research Institute (CVRI), National University Heart Centre Singapore (NUHS), Singapore, Singapore
| | | | | | - David Sim
- National Heart Centre Singapore, Singapore, Singapore
| | - Sheldon Lee
- Changi General Hospital, Singapore, Singapore
| | - Dinna Soon
- Khoo Teck Puat Hospital, Singapore, Singapore
| | - Wan Ting Tay
- National Heart Centre Singapore, Singapore, Singapore
| | - Milton Packer
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Calvin Chin
- National Heart Centre Singapore, Singapore, Singapore
| | - A Mark Richards
- Cardiovascular Research Institute (CVRI), National University Heart Centre Singapore (NUHS), Singapore, Singapore.,Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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10
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van Veldhuisen DJ, van Woerden G, Gorter TM, van Empel VP, Manintveld OC, Tieleman RG, Maass AH, Vernooy K, Westenbrink BD, van Gelder IC, Rienstra M. Ventricular tachyarrhythmia detection by implantable loop recording in patients with heart failure and preserved ejection fraction: the VIP-HF study. Eur J Heart Fail 2020; 22:1923-1929. [PMID: 32683763 PMCID: PMC7693069 DOI: 10.1002/ejhf.1970] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS The primary aim of the VIP-HF study was to examine the incidence of sustained ventricular tachyarrhythmias (VTs) in heart failure (HF) with mid-range (HFmrEF) or preserved ejection fraction (HFpEF). Secondary aims were to examine the incidence of non-sustained VTs, bradyarrhythmias, HF hospitalizations and mortality. METHODS AND RESULTS This was an investigator-initiated, prospective, multicentre, observational study of patients with HF and left ventricular ejection fraction (LVEF) >40%. Patients underwent extensive phenotyping, after which an implantable loop recorder was implanted. We enrolled 113 of the planned 250 patients [mean age 73 ± 8 years, 51% women, New York Heart Association class II/III 54%/46%, median N-terminal pro B-type natriuretic peptide 1367 (710-2452) pg/mL and mean LVEF 54 ± 6%; 75% had LVEF >50%]. Eighteen percent had non-sustained VTs and 37% had atrial fibrillation on Holter monitoring. During a median follow-up of 657 (219-748) days, the primary endpoint of sustained VT was observed in one patient. The incidence of the primary endpoint was 0.6 (95% confidence interval 0.2-3.5) per 100 person-years. The incidence of the secondary endpoint of non-sustained VT was 11.5 (7.1-18.7) per 100 person-years. Five patients developed bradyarrhythmias [3.2 (1.4-7.5) per 100 person-years], three were implanted with a pacemaker. In total, 23 patients (20%) were hospitalized for HF [16.3 (10.9-24.4) per 100 person-years]. Fourteen patients (12%) died [8.7 (5.2-14.7) per 100 person-years]; 10 due to cardiovascular causes, and four sudden deaths, one with implantable loop recorder-confirmed bradyarrhythmias as terminal event, three others undetermined. CONCLUSION Despite the lower than expected number of included patients, the incidence of sustained VTs in HFmrEF/HFpEF was low. Clinically relevant bradyarrhythmias were more often observed than expected.
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Affiliation(s)
- Dirk J. van Veldhuisen
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Gijs van Woerden
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Thomas M. Gorter
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Vanessa P.M. van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM)Medical University Centre MaastrichtMaastrichtThe Netherlands
| | | | - Robert G. Tieleman
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
- Department of CardiologyMartini Hospital GroningenGroningenThe Netherlands
| | - Alexander H. Maass
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM)Medical University Centre MaastrichtMaastrichtThe Netherlands
| | - B. Daan Westenbrink
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Isabelle C. van Gelder
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Michiel Rienstra
- Department of CardiologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
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11
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
| | - Sophie L van Veldhuisen
- Department of Bariatric Surgery, Rijnstate Hospital, Postal number 1190, 6800 TA Arnhem, the Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30.001, 9700 RB, Groningen, the Netherlands
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12
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van Woerden G, van Veldhuisen DJ, Rienstra M, Westenbrink BD. Myocardial adiposity in heart failure with preserved ejection fraction: the plot thickens. Eur J Heart Fail 2019; 22:455-457. [PMID: 31769136 DOI: 10.1002/ejhf.1653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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13
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van Woerden G, Gorter TM, Westenbrink BD, Willems TP, van Veldhuisen DJ, Rienstra M. Epicardial fat in heart failure patients with mid-range and preserved ejection fraction. Eur J Heart Fail 2018; 20:1559-1566. [PMID: 30070041 PMCID: PMC6607508 DOI: 10.1002/ejhf.1283] [Citation(s) in RCA: 157] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 12/28/2022] Open
Abstract
Aims Adipose tissue and inflammation may play a role in the pathophysiology of patients with heart failure (HF) with mildly reduced or preserved ejection fraction. We therefore investigated epicardial fat in patients with HF with preserved (HFpEF) and mid‐range ejection fraction (HFmrEF), and related this to co‐morbidities, plasma biomarkers and cardiac structure. Methods and results A total of 64 HF patients with left ventricular ejection fraction >40% and 20 controls underwent routine cardiac magnetic resonance examination. Epicardial fat volume was quantified on short‐axis cine stacks covering the entire epicardium and was related to clinical correlates, biomarkers associated with inflammation and myocardial injury, and cardiac function and contractility on cardiac magnetic resonance. HF patients and controls were of comparable age, sex and body mass index. Total epicardial fat volume was significantly higher in HF patients compared to controls (107 mL/m2 vs. 77 mL/m2, P <0.0001). HF patients with atrial fibrillation and/or type 2 diabetes mellitus had more epicardial fat than HF patients without these co‐morbidities (116 vs. 100 mL/m2, P =0.03, and 120 vs. 97 mL/m2, P =0.001, respectively). Creatine kinase‐MB, troponin T and glycated haemoglobin in patients with HF were positively correlated with epicardial fat volume (R =0.37, P =0.006; R =0.35, P =0.01; and R =0.42, P =0.002, respectively). Conclusion Heart failure patients had more epicardial fat compared to controls, despite similar body mass index. Epicardial fat volume was associated with the presence of atrial fibrillation and type 2 diabetes mellitus and with biomarkers related to myocardial injury. The clinical implications of these findings are unclear, but warrant further investigation.
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Affiliation(s)
- Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - B Daan Westenbrink
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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