Cardiac visceral fat and cardiometabolic risk in the elderly
Aging is characterized by several changes in body mass composition with loss of muscle mass and increase in
fat mass, particularly visceral fat. Visceral fat is represented mainly by abdominal and cardiac depots and it is
directly related to chronic low-grade inflammation, insulin-resistance and metabolic syndrome. Unfavourable
outcomes as cardiovascular death are also associated with the amount of visceral fat depots. In this scenario,
the cardiac visceral fat seems to play an important role in increasing the cardiometabolic risk. This review aims
to provide a literature revision about the role of cardiac visceral fat on cardiometabolic risk in elderly.
The relationship between body fat and the risk of morbidity and mortality changes with changing age. Indeed, overweight or obese middle-aged adults present with an increased risk of morbidity and mortality, while a body mass index (BMI) included between 25 and 30 kg/m2 shows a potential protective effect in aged people 1. Body fat redistribution associated with age may be the underlying factor of the “obesity paradox”, according to which overweight is associated with an increased risk – but decreased mortality – for cardiovascular disease (CD) 2. Several mechanisms have been proposed to explain the protective role of increased body fat and BMI in older people, such as a greater metabolic reserve, a different cytokine profile secerned by fat, a lower activation of the sympathetic nervous system, and a reduced concentration of plasmatic natriuretic peptides 2. Aging is associated with progressive changes in body composition characterized by a loss of fat free mass and an increase in fat mass, particularly referred as visceral fat (VF) 3. The increase in VF, a key factor for the development of insulin-resistance, is a hallmark of metabolic syndrome (MetS) 4-6. MetS is a clinical condition characterized by several abnormalities in lipid and glucose metabolism 7. In aged subjects, MetS associates with a higher risk for acute coronary events, myocardial infarction, heart failure, and cardiovascular mortality 8. MetS includes several cardiovascular risk factors such as increased fasting glucose, low HDL cholesterol, hypertriglyceridemia and hypertension 9. In sight of this, body fat distribution rather than BMI is suggested to be a better predictor factor of morbidity and mortality in older people 1.
For many years, intra-abdominal fat has been considered the main representative of visceral fat. However, in recent times cardiac visceral fat (CVF) has been shown to play an important role in cardiometabolic risk 10.
Cardiac visceral fat is closely associated with the body mass index (BMI), since it increases during weight gain, and it decreases after weight loss 11.
This review aims to present the current evidence related to the clinical importance of cardiac visceral fat as marker of metabolic dysfunction and cardiovascular disease risk in old people. Since most studies were not specifically performed on aged patients (and other investigations excluded old subjects, focusing on adults), we will try to summarize the available data in the geriatric population.
THE DIFFERENT DEPOTS OF ADIPOSE TISSUE IN THE HEART
The nomenclature used to differentiate cardiac visceral fat depots is often misleading, with several discrepancies and ambiguities among different Authors 12. Cardiac visceral fat includes both intra- and extra-pericardial fat. Intra-pericardial fat is represented by depots situated between the myocardium and the visceral pericardium, in direct contact with the surface of myocardium and coronary vessels. This fat layer has been referred as epicardial fat (EF) 13 (Fig. 1). Fat depots localized between the visceral and the parietal pericardium, or just external but attached to the parietal pericardium, are named pericardial fat (PF) 13. The fat layer surrounding arteries and arterioles is defined as perivascular fat (PVF). Extra-pericardial fat (EPF) (or intrathoracic or paracardial fat) is referred to thoracic adipose tissue external to the parietal pericardium 13-15. In this review we will refer to this nomenclature.
Another classification of cardiac visceral fat identifies three types of depot: the EF, located within the pericardial sac; the PF, located between the external surface of the parietal pericardium and medial face of mediastinum; the pericoronary fat (PCF), represented by the adipose tissue surrounding the coronary arteries within the visceral epicardium 16.
EF and PF can be assessed by cardiac CT, MRI and echocardiography. Ultrasonography is a very safe and reliable technique to identify EF and PF. EF is visualized as echo-free space between the myocardium surface and the visceral layer of pericardium, whereas PF appear as a hypoechoic space anterior to the EF and the parietal pericardium 17.
Particularly, several recent studies have been currently focusing on EF 18. Nevertheless, in many studies EF and PF are used indifferently 16. For instance, reports from the Framingham Heart Study did not differentiate between EF and PF, since the biomolecular properties of these two fat depots were supposed to be similar 19 20. Nevertheless, the inappropriate use of EF and PF is misleading and is incorrect according to the main literature 21.
On the contrary, studies on the association between extra-pericardial fat and cardiovascular risk are lacking. Chen et al. found an association between EPF and MetS, even though this study is characterized by a reduced number of the sample and a short follow-up time 22.
EPICARDIAL FAT AND CARDIOMETABOLIC RISK
EF origins from the splanchnic-pleural mesoderm associated with the gut, similarly to the mesenteric and omental fat 14. EF is mainly localized on the right ventricle surface and anterior wall of the left ventricle as well as on atrioventricular grooves and great coronary vessels, reaching the main thickness at the anterior and lateral walls of the right atrium. Normally, about 80% of the heart surface is covered by the epicardial adipose tissue, EF contributing for the 20% to the whole heart mass 15.
Two-dimensional echocardiography can be used to visualize and measure EF. Parasternal long-axis and short-axis views allow the most accurate measurement of EF thickness overlying the right ventricle. EF thickness ranges from 1 to 23 mm 23.
EF and myocardium are not divided by muscle fascia, sharing the same microcirculation 24. Taking into account that fat accumulation in the epicardial space is limited - especially in obese individuals - the largest ectopic depots as body weight increases are located in the visceral abdominal area and in the extra-pericardial area 10.
EF is characterized by a wide individual variability which is dependent on the instrumental methodology but also on different clinical and demographic features such as age, obesity, gender, and ethnicity 25. Indeed, EF tends to increase with age 25 26. No consensus exists about the impact of gender on the EF thickness. The amount of EF increases with the increase of total body fat 27 and seems to be related to male gender and high body mass index (BMI) 26. On the other hand, a recent study showed that in old age EF thickness was greater in women than in men 28.
Based on data from the Framingham study, some Authors described a higher association between EF and female gender, but this observation was not confirmed by other studies 20 25 29 30. Postmenopausal women with MetS showed a greater amount of EF with respect to those without MetS 31. Concerning ethnicity, African-American men present with less EF depots than non-Hispanic white men, but these data may be also related to the high frequency of central obesity reported in the first group 25 32.
Patients with Mets present with higher EF thickness compared to patients without Mets, and the presence of MetS is an independent predictor of increased EF 33. Iacobellis et al. described that values of EF of 9.5 mm in men and 7.5 mm in women may predict accurately the presence of Mets 34. However, this study enrolled subjects aged 40.8 ± 11.5 years old.
Another study showed how in old patients EF, but not intra-abdominal fat, was associated with MetS, while both were closely related with hepatic steatosis 35.
Normally, epicardial adipocytes exert several physiological function for the myocardium at metabolic, thermogenic, mechanic and textural level 36. However, this positive role is lost in particular conditions associated with an augmented amount of EF, such as obesity 37.
EF presents with the most intensive metabolic activity as compared to pericardial and other visceral fat 14 24. In fact, EF produces higher levels of free fatty acids (FFA), with increased release of FFA after catecholamine stimulation; moreover, high lipolysis activity in EF could be associated with lower insulin sensitivity and a larger number of β3-adrenoreceptors 38.
EF is also associated to the pro-inflammatory state, and it is characterized by unique physiological and metabolic profile. Indeed, with respect to visceral fat in other body sites, EF presents with small adipocyte size, characterized by low reduction during weight loss, and several metabolic features such as different fatty acid composition, high protein content and fatty acid synthesis, reduced glucose utilization, and high level of adipokine secretion 26. Moreover, compared to the sub-cutaneous, the epicardial adipose tissue is able to produce higher level of chemokines and inflammatory cytokines such as interleukin 1β (IL-1β), interleukin 6 (IL-6), and tumor necrosis factor (TNF-α), interacting with numerous cardiovascular pathways via vasocrine and paracrine signalling 39 40. Increased EF deposits are associated with higher serum level of C-reactive protein (PCR) and low-grade systemic inflammation 33. These proinflammatory properties are independent of clinical conditions such as the presence of diabetes or obesity 39. Nevertheless, EF may produce anti-inflammatory and antiatherogenic adipokines, but the regulation of this balance is still unknown 23. Adiponectin and adrenomedullin represent the most important adipokines secerned by EF, particularly in the coronary circulation. Adiponectin plays a role in the modulation of insulin sensitivity, and it exerts anti-inflammatory and antiatherogenic effects, whereas adrenomedullin acts as vasodilator, anti-inflammatory and anti-vasogenic 23. Moreover, EF presents with the highest percentage of lipogenesis and free fatty acid metabolism as compared to other visceral fat depots 41.
As previously cited, EF is closely related to MetS as well as its main several components such as endothelial dysfunction, blood pressure, insulin-resistance, high fasting glucose, presence of diabetes or hypertension, high serum levels of LDL-cholesterol and triglycerides, and increased risk of cardiovascular disease 23 42 43. The study by Yorgun et al. demonstrated that EF and pericoronary fat thickness are associated with the presence of MetS 5. Particularly, the Authors found that subjects presenting with MetS were older than those without, highlighting a progressive relationship between the growing number of MetS components and EF thickness 5. Of note, in this study age was reported as an independent risk factor associated with mean EF thickness 5.
With respect to visceral abdominal fat (VAT), EF is also associated with coronary atherosclerosis, probably mediated by paracrine pathways which induce the progression of coronary vessel inflammation and atherosclerosis 5 16. In this context, EF measurement may be useful to evaluate coronary artery disease (CAD) risk and to predict the extent and activity of CAD 7 44.
Another evidence from the Framingham Heart Study identified how fat deposits around the heart are an independent predictor of CVD risk 29. Mahabadi et al. demonstrated the role of EF as an independent predictive factor of future major adverse cardiac events (MACE) beyond traditional cardiovascular risk factors in the general population 45 46. Of note, the statistical models used in this study were all adjusted for age.
Even though cardiac visceral fat has been recently proposed as a new marker of cardiometabolic risk 10, in a recent observational study on 113 subjects, some Authors did not find any independent association between EF and metabolic components such as blood pressure, plasma triglycerides, and insulin resistance 10. The evidence of this study suggests how the isolated increase of EF is not necessarily associated with higher metabolic or CV risk 10. Nevertheless, people enrolled in this investigation were from 18 to 74 years old, but data were not stratified for age classes.
In the last years, several pieces of evidence have been highlighted about the association between EF and hypertension. Cardiac fat has been found expanded in patients with hypertension compared to healthy controls 47. Dicker et al. found a higher EF thickness in hypertensive patients rather than patient without hypertension, as well as in hypertensive patients with non-dipper profile 48-50. Of note, in this study hypertensive patients were older than controls, and EF thickness was associated with age 48. A positive correlation was also found between EF thickness and blood pressure among prehypertensive patients (even though no older subjects were enrolled) 51-53. In untreated adult patients, high values of EF thickness may be independently associated with diastolic dysfunction and atrial dilatation; EF thickness results as a stronger predictive factor than abdominal obesity 54.
Data about the relationship between EF and serum triglyceride levels are discordant through studies, showing a large degree of variability. Some studies did not show any association between serum triglycerides and EF thickness, while other Authors highlighted a low degree of correlation 5 55-58. This heterogeneity could be linked to the difference in age, weight and morbidity of the different study populations.
Recently, Calabuig et al. have shown how EF thickness was independently associated with high-density lipoprotein cholesterol and high level of serum triglycerides 59. This study also demonstrated that EF thickness increases with age even in subjects without MetS 59.
Both EF and extra-pericardial fat are associated with insulin resistance. Particularly, a positive association was found between EF and insulin-resistance or glucose tolerance in patients without diabetes and normal cardiac function 11 60. Insulin resistance, age and blood glucose level after 2 hours of oral tolerance test were found independent predictor factors of high EF thickness in non-diabetic patients 61. Similarly, Narumi et al. highlighted that increased values of EF thickness were independently associated with IR in non-obese and non-diabetic patients 62. Furthermore, patients with morbid obesity showed higher EF thickness values associated with insulin resistance, inappropriate high left ventricular mass, and left ventricular dysfunction 63. In addition, Iacobellis et al. found a significant association between EF thickness and obesity-related insulin resistance 64.
Despite the associative results, the exact pathogenesis between EF and insulin resistance is not yet clear 65.
Diabetes is an important perturbing factor in the normal homeostasis of glucose metabolism in the heart. In fact, diabetic patients show that peripheral insulin resistance and low insulin stimulated myocardial glucose uptake with a range of reduction up to 40% 11. In a study performed on a geriatric population, diabetic patients showed higher EF thickness compared to non-diabetic subjects 66. Recently, Yagi et al. have confirmed that the amount of EF is greater in patients with diabetes, regardless of type 1 or 2 diabetes mellitus and of EF measured method used, suggesting that an augmented EF could be an independent predictor of newly-diagnosed diabetes mellitus 67. A strong correlation between fasting plasma glucose and EF measured with echocardiography and CT has also been lately highlighted 68.
Recent investigations suggest that EF may represent a more reliable measure of visceral adiposity. In fact, although visceral fat correlates with the waist circumference, this can be modified by numerous factors such as the amount of subcutaneous fat, especially in older people 7 18 69.
EF measured by ultrasonography is associated with anthropometric and clinical parameters of MetS (as body mass index, BMI) so that EF may be a useful index of MetS 5. Echocardiographic measure of EF is more and more often considered as a new parameter to evaluate cardiac and visceral obesity 7.
PERICARDIAL FAT AND CARDIOMETABOLIC RISK
Pericardial fat originates from the division of primitive thoracic mesenchyme, which gives rise to the parietal pericardium and the external thoracic wall 23.
Data from the Framingham Heart Study Offspring and Third Generation showed that, as compared with other ectopic fat depots (including abdominal subcutaneous adipose tissue, abdominal visceral adipose tissue, intramuscular fat, intrathoracic fat, thoracic periaortic fat, intrahepatic fat, and renal sinus fat), pericardial fat presented with the great magnitude of correlation with intrathoracic and abdominal visceral fat 26 70. However, the metabolic activity of EF and PF is different 21. Unlike EF, PF has not yet shown an association with metabolic syndrome, visceral adiposity, heart morphology, insulin resistance, and other features 21. Moreover, the term “pericardial” used in several studies is referred to fat in the pericardium without any distinction between EF and PF 20 71 72. Recent pieces of evidence – even though on adult subjects – indicate that PF appears strongly associated with obesity and hypertension 17 47. Sicari et al. studied EF and PF separately and found how PF – rather than EF – is related to parameters of metabolic syndrome, such as serum triglyceride and glucose concentrations, blood pressure, insulin sensitivity, and BMI 73. Notably, in this study the PF thickness detected by echocardiography, but not that detected by MRI, was correlated with age 73. Another correlation between PF and cardiovascular risk was found considering the 10-year CHD Framingham risk score 73. Dabbah et al. investigated the association between EF and PF, and diastolic filling, finding a low correlation among PF and diastolic indices 74. Definitely, despite several studies suggesting that PF could play an active role as a cardiovascular risk factor, its role still needs to be studied 75.
Among the cardiac visceral fat depots, the EF presents with peculiar metabolic features. Indeed, the EF is characterized by differences in fatty acid composition, higher protein content and dissimilar metabolic profile, such as higher production of FFA, high levels of lipolysis activity, and reduced glucose utilization. Moreover, the EF shows active endocrinal properties as compared to the PF, and a close association with a low-grade pro-inflammatory state favoured by sharing the microcirculation with the myocardium. While a few studies on the association between the PF and cardiometabolic risk are available, there is strong evidence supporting the close association between the EF and cardiometabolic risk. Beyond the CV risk factors, EF is also an independent predictor factor of MACE. However, the available literature on cardiac visceral fat and cardiovascular risk includes only a small number of studies specifically targeting the old population. Future investigations are needed to address many questions in the geriatric field of research.
Figures and tables
- Chang S-H, Beason TS, Hunleth JM. A systematic review of body fat distribution and mortality in older people. Maturitas. 2012; 72:175-91.
- Chapman IM. Obesity paradox during aging. In: Body composition and aging. Basel: KARGER. 2010; 37:20-36.
- Lo Buglio A, Bellanti F, Capurso C. Adherence to Mediterranean diet, malnutrition, length of stay and mortality in elderly patients hospitalized in internal medicine wards. Nutrients. 2019; 11:790.
- Mottillo S, Filion KB, Genest J. The metabolic syndrome and cardiovascular risk. J Am Coll Cardiol. 2010; 56:1113-32.
- Yorgun H, Canpolat U, Hazırolan T. Increased epicardial fat tissue is a marker of metabolic syndrome in adult patients. Int J Cardiol. 2013; 165:308-13.
- Phillips CM, Tierney AC, Perez-Martinez P. Obesity and body fat classification in the metabolic syndrome: Impact on cardiometabolic risk metabotype. Obesity. 2013; 21:e154-61.
- Veronica G, Esther R-RM. Aging, metabolic syndrome and the heart. Aging Dis. 2012; 3:269-79.
- Butler J, Rodondi N, Zhu Y. Metabolic syndrome and the risk of cardiovascular disease in older adults. J Am Coll Cardiol. 2006; 47:1595-602.
- Saad MAN, Cardoso GP, Martins W de A. Prevalence of metabolic syndrome in elderly and agreement among four diagnostic criteria. Arq Bras Cardiol. 2014; 102:263-9.
- Sironi AM, Petz R, De Marchi D. Impact of increased visceral and cardiac fat on cardiometabolic risk and disease. Diabet Med. 2012; 29:622-7.
- Gastaldelli A, Morales MA, Marraccini P. The role of cardiac fat in insulin resistance. Curr Opin Clin Nutr Metab Care. 2012; 15:523-8.
- Guglielmi V, Sbraccia P.. Epicardial adipose tissue: at the heart of the obesity complications. Acta Diabetol. 2017; 54:805-12.
- Iozzo P. Myocardial, perivascular, and epicardial fat. Diabetes Care. 2011; 34:S371-9.
- Sacks HS, Fain JN. Human epicardial adipose tissue: a review. Am Heart J. 2007; 153:907-17.
- Ansaldo AM, Montecucco F, Sahebkar A. Epicardial adipose tissue and cardiovascular diseases. Int J Cardiol. 2019; 278:254-60.
- Lim S, Meigs JB. Ectopic fat and cardiometabolic and vascular risk. Int J Cardiol. 2013; 169:166-76.
- Iacobellis G, Assael F, Ribaudo MC. Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res. 2003; 11:304-10.
- CENGEL A. Epicardial adipose tissue, metabolic syndrome, inflammation, and cardiovascular risk. Turk Kardiyol Dern Arsivi-Archives Turkish Soc Cardiol. 2012; 40:696-8.
- Fox CS, Gona P, Hoffmann U. Pericardial fat, intrathoracic fat, and measures of left ventricular structure and function: the Framingham heart study. Circulation. 2009; 119:1586-91.
- Rosito GA, Massaro JM, Hoffmann U. Pericardial fat, visceral abdominal fat, cardiovascular disease risk factors, and vascular calcification in a community-based sample. Circulation. 2008; 117:605-13.
- Iacobellis G. Epicardial and pericardial fat: close, but very different. Obesity. 2009; 17:625.
- Chen O, Sharma A, Ahmad I. Correlation between pericardial, mediastinal, and intrathoracic fat volumes with the presence and severity of coronary artery disease, metabolic syndrome, and cardiac risk factors. Eur Heart J Cardiovasc Imaging. 2015; 16:37-46.
- Iacobellis G, Willens HJ. Echocardiographic epicardial fat: a review of research and clinical applications. J Am Soc Echocardiogr. 2009; 22:1311-9.
- Iacobellis G, Corradi D, Sharma AM. Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med. 2005; 2:536-43.
- Bertaso AG, Bertol D, Duncan BB. Epicardial fat: definition, measurements and systematic review of main outcomes. Arq Bras Cardiol. 2013; 101:e18-28.
- Mazzoccoli G, Dagostino MP, Greco A.. Age-related changes of epicardial fat thickness. Biomed Prev Nutr. 2012; 2:38-41.
- Womack HC. The relationship between human body weight, subcutaneous fat, heart weight, and epicardial fat. Hum Biol. 1983; 55:667-76.
- Kim S-A, Kim M-N, Shim W-J. Epicardial adipose tissue is related to cardiac function in elderly women, but not in men. Nutr Metab Cardiovasc Dis. 2017; 27:41-7.
- Mahabadi AA, Massaro JM. Association of pericardial fat, intrathoracic fat, and visceral abdominal fat with cardiovascular disease burden: the Framingham heart study. Eur Heart J. 2008; 30:850-6.
- Shmilovich H, Dey D, Cheng VY. Threshold for the upper normal limit of indexed epicardial fat volume: derivation in a healthy population and validation in an outcome-based study. Am J Cardiol. 2011; 108:1680-5.
- Fernández Muñoz MJ, Basurto Acevedo L, Córdova Pérez N. Epicardial adipose tissue is associated with visceral fat, metabolic syndrome, and insulin resistance in menopausal women. Rev Española Cardiol (English Ed). 2014; 67:436-41.
- Willens HJ, Gómez-Marín O, Chirinos JA. Comparison of epicardial and pericardial fat thickness assessed by echocardiography in African American and non-Hispanic white men: a pilot study. Ethn Dis. 2008; 18:311-6.
- Tok D, Kadife I, Turak O. Increased epicardial fat thickness is associated with low grade systemic inflammation in metabolic syndrome. Turk Kardiyol Dern Ars. 2012; 40:690-5.
- Iacobellis G, Willens HJ, Barbaro G. Threshold values of high-risk echocardiographic epicardial fat thickness. Obesity. 2008; 16:887-92.
- Stramaglia G, Greco A, Guglielmi G. Echocardiography and dual-energy x-ray absorptiometry in the elderly patients with metabolic syndrome: a comparison of two different tecniques to evaluate visceral fat distribution. J Nutr Health Aging. 2010; 14:6-10.
- Fitzmaurice DA, Accetta G, Haas S. Comparison of international normalized ratio audit parameters in patients enrolled in GARFIELD-AF and treated with vitamin K antagonists. Br J Haematol. 2016; 174:610-23.
- Yamaguchi Y, Cavallero S, Patterson M. Adipogenesis and epicardial adipose tissue: a novel fate of the epicardium induced by mesenchymal transformation and PPARγ activation. Proc Natl Acad Sci. 2015; 112:2070-5.
- Gruzdeva O, Borodkina D, Uchasova E. Localization of fat depots and cardiovascular risk. Lipids Health Dis. 2018; 17:218.
- Mazurek T, Zhang L, Zalewski A. Human epicardial adipose tissue is a source of inflammatory mediators. Circulation. 2003; 108:2460-6.
- Xourgia E, Papazafiropoulou A. Effects of antidiabetic drugs on epicardial fat. World J Diabetes. 2018; 9:141-8.
- Marchington JM, Pond CM. Site-specific properties of pericardial and epicardial adipose tissue: the effects of insulin and high-fat feeding on lipogenesis and the incorporation of fatty acids in vitro. Int J Obes. 1990; 14:1013-22.
- Nelson MR, Mookadam F, Thota V. Epicardial fat: an additional measurement for subclinical atherosclerosis and cardiovascular risk stratification?. J Am Soc Echocardiogr. 2011; 24:339-45.
- Roever L, Resende ES, Diniz ALD. Epicardial adipose tissue and metabolic syndrome: an update protocol for systematic review and meta-analysis. Medicine (Baltimore). 2018; 97:e0387.
- Bronas UG, Dengel DR. Influence of vascular oxidative stress and inflammation on the development and progression of atherosclerosis. Am J Lifestyle Med. 2010; 4:521-34.
- Mahabadi AA, Berg MH, Lehmann N. Association of epicardial fat with cardiovascular risk factors and incident myocardial infarction in the general population. J Am Coll Cardiol. 2013; 61:1388-95.
- Possner M, Liga R, Gaisl T. Quantification of epicardial and intrathoracic fat volume does not provide an added prognostic value as an adjunct to coronary artery calcium score and myocardial perfusion single-photon emission computed tomography. Eur Hear J Cardiovasc Imaging. 2016; 17:885-91.
- Sironi AM, Gastaldelli A, Mari A. Visceral fat in hypertension. Hypertension. 2004; 44:127-33.
- Dicker D, Atar E, Kornowski R. Increased epicardial adipose tissue thickness as a predictor for hypertension: a cross-sectional observational study. J Clin Hypertens. 2013; 15:893-8.
- Sengul C, Cevik C, Ozveren O. Epicardial fat thickness is associated with non-dipper blood pressure pattern in patients with essential hypertension. Clin Exp Hypertens. 2012; 34:165-70.
- Ertas F, Kaya H, Acet H. Increased echocardiographic epicardial fat thickness is related to impaired diurnal blood pressure profiles. Blood Press. 2012; 21:202-8.
- Sironi AM, Pingitore A, Ghione S. Early hypertension is associated with reduced regional cardiac function, insulin resistance, epicardial, and visceral fat. Hypertens (Dallas, Tex. 1979). 2008; 51:282-8.
- Eroğlu S, Sade LE, Yıldırır A. Association of epicardial adipose tissue thickness by echocardiography and hypertension. Turk Kardiyol Dern Arsivi-Archives Turkish Soc Cardiol. 2013; 41:115-22.
- Turak O. Relation between epicardial adipose tissue thickness and blood pressure levels in prehypertension. Turk Kardiyol Dern Arsivi-Archives Turkish Soc Cardiol. 2014; 42:358-64.
- Çetin M, Kocaman SA, Durakoğlugil ME. Effect of epicardial adipose tissue on diastolic functions and left atrial dimension in untreated hypertensive patients with normal systolic function. J Cardiol. 2013; 61:359-64.
- Cha S-A, Park Y-M, Yun J-S. A comparison of effects of DPP-4 inhibitor and SGLT2 inhibitor on lipid profile in patients with type 2 diabetes. Lipids Health Dis. 2017; 16:58.
- Konishi M, Sugiyama S, Sugamura K. Association of pericardial fat accumulation rather than abdominal obesity with coronary atherosclerotic plaque formation in patients with suspected coronary artery disease. Atherosclerosis. 2010; 209:573-8.
- Jang H-C, Lee H-K, Lee H. Analyzing correlation between epicardial fat area and metabolic syndrome risk factor by using low-dose Lung CT. Pakistan J Med Sci. 2015; 31:1207-12.
- Goel R, Alharthi M, Jiamsripong P. Epicardial fat and its association with cardiovascular risk: a cross-sectional observational study. Hear Views. 2010; 11:103.
- Calabuig Á, Barba J, Guembe MJ. Epicardial adipose tissue in the general middle-aged population and its association with metabolic syndrome. Rev Española Cardiol. 2017; 70:254-60.
- Tan-Ramos KC, Allyn-Sy R, Choa V.. Echocardiographic epicardial adipose tissue thickness as a marker of insulin resistance. J. ASEAN Fed Endocr Soc. 2014; 29:129-34.
- Altin C, Sade LE, Gezmis E. Assessment of epicardial adipose tissue and carotid/femoral intima media thickness in insulin resistance. J Cardiol. 2017; 69:843-50.
- Narumi T, Watanabe T, Iwayama T. Increased epicardial adipose tissue volume predicts insulin resistance and coronary artery disease in non-obese subjects without metabolic syndrome. IJC Metab Endocr. 2014; 3:14-9.
- Pucci G, Battista F, de Vuono S. Pericardial fat, insulin resistance, and left ventricular structure and function in morbid obesity. Nutr Metab Cardiovasc Dis. 2014; 24:440-6.
- Iacobellis G, Leonetti F.. Epicardial adipose tissue and insulin resistance in obese subjects. J Clin Endocrinol Metab. 2005; 90:6300-2.
- Canpolat U, Bahadir N, Coteli C.. Chicken or egg causality paradox between insulin resistance and epicardial fat. Angiology. 2016; 67:970-1.
- Baldasseroni S, Pratesi A, Orso F. Epicardial adipose tissue and insulin resistance in patients with coronary artery disease with or without left ventricular dysfunction. Monaldi Arch Chest Dis. 2013; 80:170-6.
- Li Y, Liu B, Li Y. Epicardial fat tissue in patients with diabetes mellitus: a systematic review and meta-analysis. Cardiovasc Diabetol. 2019; 18:3.
- Wang T-D, Lee W-J, Shih F-Y. Relations of epicardial adipose tissue measured by multidetector computed tomography to components of the metabolic syndrome are region-specific and independent of anthropometric indexes and intraabdominal visceral fat. J Clin Endocrinol Metab. 2009; 94:662-9.
- Snijder M, Visser M, Dekker J. The prediction of visceral fat by dual-energy X-ray absorptiometry in the elderly: a comparison with computed tomography and anthropometry. Int J Obes. 2002; 26:984-93.
- Lee JJ, Pedley A, Hoffmann U. Visceral and intrahepatic fat are associated with cardiometabolic risk factors above other ectopic fat depots: the Framingham heart study. Am J Med. 2018; 131:684-92.e12.
- Yamada H, Sata M.. Role of pericardial fat: the good, the bad and the ugly. J Cardiol. 2015; 65:2-4.
- Okura K, Maeno K, Okura S. Pericardial fat volume is an independent risk factor for the severity of coronary artery disease in patients with preserved ejection fraction. J Cardiol. 2015; 65:37-41.
- Sicari R, Sironi AM, Petz R. Pericardial rather than epicardial fat is a cardiometabolic risk marker: an MRI vs echo study. J Am Soc Echocardiogr. 2011; 24:1156-62.
- Dabbah S, Komarov H, Marmor A. Epicardial fat, rather than pericardial fat, is independently associated with diastolic filling in subjects without apparent heart disease. Nutr Metab Cardiovasc Dis. 2014; 24:877-82.
- Hirata Y, Yamada H, Sata M.. Epicardial fat and pericardial fat surrounding the heart have different characteristics. Circ J. 2018; 82:2475-6.
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