Epicardial adipose tissue volume and density are associated with heart failure with improved ejection fraction

Abstract

Background: Heart failure (HF) with improved ejection fraction (EF, HFimpEF) is a distinct HF subtype, characterized by left ventricular (LV) reverse remodeling and myocardial functional recovery. Multiple cardiometabolic factors are implicated in this process. Epicardial adipose tissue (EAT), emerging as an endocrine and paracrine organ, contributes to the onset and progression of HF. However, the relation between EAT and the incidence of HFimpEF is still unclear.

Methods: A total of 203 hospitalized HF patients with reduced EF (HFrEF, LVEF ≤ 40%) who underwent coronary CT angiography (CCTA) during index hospitalization were consecutively enrolled between November 2011 and December 2022. Routine follow-up and repeat echocardiograms were performed. The incidence of HFimpEF was defined as (1) an absolute LVEF improvement ≥ 10% and (2) a second LVEF > 40% (at least 3 months apart). EAT volume and density were semiautomatically quantified on non-enhanced series of CCTA scans.

Results: During a median follow-up of 8.6 (4.9 ~ 13.3) months, 104 (51.2%) patients developed HFimpEF. Compared with HFrEF patients, HFimpEF patients had lower EAT volume (115.36 [IQR 87.08 ~ 154.78] mL vs. 169.67 [IQR 137.22 ~ 218.89] mL, P < 0.001) and higher EAT density (-74.92 ± 6.84 HU vs. -78.76 ± 6.28 HU, P < 0.001). Multivariate analysis showed lower EAT volume (OR: 0.885 [95%CI 0.822 ~ 0.947]) and higher density (OR: 1.845 [95%CI 1.023 ~ 3.437]) were both independently associated with the incidence of HFimpEF. Subgroup analysis revealed that the association between EAT properties and HFimpEF was not modified by HF etiology.

Conclusions: This study reveals that lower EAT volume and higher EAT density are associated with development of HFimpEF. Therapies targeted at reducing EAT quantity and improving its quality might provide favorable effects on myocardial recovery in HF patients.

Keywords: Epicardial adipose tissue; Heart failure with improved ejection fraction; Heart failure with reduced ejection fraction; Myocardial recovery.

Fig. 1

Flowchart of patient enrollment. HFimpEF heart failure with improved ejection fraction, HFrEF heart failure with reduced ejection fraction, LVEF left ventricular ejection fraction

Fig. 2

EAT on non-enhanced series of CCTA in HFrEF and HFimpEF patients. Shown are representative axial, sagittal and coronal images of EAT in patients with persistent HFrEF and HFimpEF. EAT density was converted into pseudo-color according to CT attenuation ranging from − 190 to − 30 HU. 3D visualization of EAT was performed by reconstruction of EAT volumes. A color scale bar is shown aside. A EAT in HFrEF; B EAT in HFimpEF. CCTA coronary CT angiography, EAT epicardial adipose tissue, HFimpEF heart failure with improved ejection fraction, HFrEF heart failure with reduced ejection fraction, HU Hounsfield units

Fig. 3

HFimpEF patients had lower EAT volume but higher EAT density compared with persistent HFrEF patients. Shown are EAT volume (A) and EAT density (B) in patients with persistent HFrEF and HFimpEF. Horizontal lines in the box: upper, 75% percentile; middle, median; lower, 25% percentile. Upper whisker, 95% percentile; lower whisker, 5% percentile. EAT epicardial adipose tissue, HFimpEF heart failure with improved ejection fraction, HFrEF heart failure with reduced ejection fraction, HU Hounsfield units

Fig. 4

Correlation between changes in LVEF and EAT volume or density. The dashed line indicates the predictive changes in LVEF by EAT volume (A) or density (B) using linear regression.  EAT epicardial adipose tissue, HU Hounsfield units, LVEF left ventricular ejection fraction