Is echocardiographic epicardial fat thickness increased in patients with coronary artery disease? A systematic review and meta-analysis
Keywords:
Adipose tissue, Epicardial fat thickness, Echocardiography, Coronary artery disease, Meta-analysisAbstract
Background: The relation of epicardial fat thickness (EFT) to coronary artery disease (CAD) has recently been reported in multiple studies. Echocardiography is a safe and relatively inexpensive and accessible approach to assess regional EFT, which can be performed easily in many centers. Objective: To determine the association between echocardiographic EFT and the presence or the absence of CAD. Methods: This was a systematic review and meta-analysis conducted on literature available in electronic databases up to March 2018. The articles measuring EFT by echocardiography in the right ventricular (RV) free wall were included in the study. The quality of the enrolled items was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist. The analyses were performed using the Comprehensive Meta-Analysis version 2 software. Cochran's Q test and I2 index were used to evaluate heterogeneity. Results: This meta-analysis was performed on 13 studies involving 2,436 patients (1,622 with CAD, and 814 without CAD). The maximum EFT reported by echocardiography was 12.9±2.7 mm in the CAD group and 8.4±2.5 mm in the non-CAD group. The minimum EFT reported by echocardiography was 2.2±1.8 mm in the CAD group and 1.8±1.4 mm in the non-CAD group. The heterogeneity was found among the researched studies (I2=91.8%, p=0.000, Q-value=146.43, df [Q] =12) using the random effect model. The patients with CAD had a significantly higher echocardiographic EFT than those without CAD (SMD=1.03, 95% CI= 0.70-1.37, p=0.000). Conclusion: According to the findings of this meta-analysis, the echocardiographic EFT in the subjects with CAD was significantly higher than that of those without CAD. The measurement of echocardiographic EFT seems to be an acceptable strategy for risk stratification of heart diseases considering ease of use, cost-effectiveness and non-exposure characteristics, compared to other imaging interventions.
References
Gaborit B, Sengenes C, Ancel P, Jacquier A, Dutour A. Role of Epicardial Adipose Tissue in Health and
Disease: A Matter of Fat? Compr Physiol. 2017; 7(3): 1051-82. doi: 10.1002/cphy.c160034. PMID:
Chistiakov DA, Grechko AV, Myasoedova VA, Melnichenko AA, Orekhov AN. Impact of the
cardiovascular system-associated adipose tissue on atherosclerotic pathology. Atherosclerosis. 2017; 263:
-8. doi: 10.1016/j.atherosclerosis.2017.06.017. PMID: 28629772.
Talman AH, Psaltis PJ, Cameron JD, Meredith IT, Seneviratne SK, Wong DT. Epicardial adipose tissue:
far more than a fat depot. Cardiovasc Diagn Ther. 2014; 4(6): 416-29. PMID: 25610800, PMCID:
PMC4278038.
Ghaderi F, Eshraghi A, Shamloo AS, Mousavi S. Association of Epicardial and Pericardial Fat Thickness
with Coronary Artery Disease. Electron Physician. 2016; 8(9): 2982-9. doi: 10.19082/2982. PMID:
, PMCID: PMC5074760.
Chaowalit N, Somers VK, Pellikka PA, Rihal CS, Lopez-Jimenez F. Subepicardial adipose tissue and the
presence and severity of coronary artery disease. Atherosclerosis. 2006; 186(2): 354-9. doi:
1016/j.atherosclerosis.2005.08.004. PMID: 16183065.
Yun KH, Rhee SJ, Yoo NJ, Oh SK, Kim NH, Jeong JW, et al. Relationship between the Echocardiographic
Epicardial Adipose Tissue Thickness and Serum Adiponectin in Patients with Angina. J Cardiovasc
Ultrasound. 2009; 17(4): 121-6. doi: 10.4250/jcu.2009.17.4.121. PMID: 20661336, PMCID: PMC2889395.
Eroglu S, Sade LE, Yildirir A, Bal U, Ozbicer S, Ozgul AS, et al. Epicardial adipose tissue thickness by
echocardiography is a marker for the presence and severity of coronary artery disease. Nutr Metab
Cardiovasc Dis. 2009; 19(3): 211-7. doi: 10.1016/j.numecd.2008.05.002. PMID: 18718744.
Mustelier JV, Rego JOC, González AG, Sarmiento JCG, Riverón BV. Echocardiographic parameters of
epicardial fat deposition and its relation to coronary artery disease. Arquivos brasileiros de cardiologia.
; 97(2): 122-9. doi: 10.1590/S0066-782X2011005000068. PMID: 21655877.
Xu Y, Cheng X, Hong K, Huang C, Wan L. How to interpret epicardial adipose tissue as a cause of
coronary artery disease: a meta-analysis. Coron Artery Dis. 2012; 23(4): 227-33. doi:
1097/MCA.0b013e328351ab2c. PMID: 22361934.
Wu FZ, Chou KJ, Huang YL, Wu MT. The relation of location-specific epicardial adipose tissue thickness
and obstructive coronary artery disease: systemic review and meta-analysis of observational studies. BMC
Cardiovasc Disord. 2014; 14: 62. doi: 10.1186/1471-2261-14-62. PMID: 24884458, PMCID:
PMC4101835.
Mancio J, Azevedo D, Saraiva F, Azevedo AI, Pires-Morais G, Leite-Moreira A, et al. Epicardial adipose
tissue volume assessed by computed tomography and coronary artery disease: a systematic review and
meta-analysis. Eur Heart J Cardiovasc Imaging. 2018; 19(5): 490-7. PMID: 29236951.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews. 2015; 4:
doi: 10.1186/2046-4053-4-1. PMID: 25554246, PMCID: PMC4320440.
Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for nonrandomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003; 73(9):
-6. doi: 10.1046/j.1445-2197.2003.02748.x. PMID: 12956787.
Wu FZ, Wu CC, Kuo PL, Wu MT. Differential impacts of cardiac and abdominal ectopic fat deposits on
cardiometabolic risk stratification. BMC Cardiovasc Disord. 2016; 16: 20. doi: 10.1186/s12872-016-0195- 5. PMID: 26800881, PMCID: PMC4724070.
Maimaituxun G, Shimabukuro M, Fukuda D, Yagi S, Hirata Y, Iwase T, et al. Local Thickness of
Epicardial Adipose Tissue Surrounding the Left Anterior Descending Artery Is a Simple Predictor of
Coronary Artery Disease- New Prediction Model in Combination With Framingham Risk Score. Circ J.
; 82(5): 1369-78. doi: 10.1253/circj.CJ-17-1289. PMID: 29563352.
Austys D, Bulotaitė E, Valevičienė NR, Stukas R. Epikardinio riebalinio audinio tūrio bei storio skirtumai
tarp patyrusių miokardo infarktą ir širdies bei kraujagyslių ligomis nesiskundžiančių asmenų. Sveikatos
mokslai. 2015; 25(3): 41-7. doi: 10.5200/sm-hs.2015.048.
Wu FZ, Huang YL, Wang YC, Lin HS, Chen CS, Ju YJ, et al. Impact of location of epicardial adipose
tissue, measured by coronary artery calcium-scoring computed tomography on obstructive coronary artery
disease. American Journal of Cardiology. 2013; 112(7): 943-9. doi: 10.1016/j.amjcard.2013.05.022. PMID:
Kim HM, Kim KJ, Lee HJ, Yu HT, Moon JH, Kang ES, et al. Epicardial adipose tissue thickness is an
indicator for coronary artery stenosis in asymptomatic type 2 diabetic patients: its assessment by cardiac
magnetic resonance. Cardiovascular diabetology. 2012; 11(1): 83. doi: 10.1186/1475-2840-11-83. PMID:
, PMCID: PMC3461492.
Bastarrika G, Broncano J, Schoepf UJ, Schwarz F, Lee YS, Abro JA, et al. Relationship between coronary
artery disease and epicardial adipose tissue quantification at cardiac CT: comparison between automatic
volumetric measurement and manual bidimensional estimation. Academic radiology. 2010; 17(6): 727-34.
doi: 10.1016/j.acra.2010.01.015. PMID: 20363161.
Wang TD, Lee WJ, Shih FY, Huang CH, Chen WJ, Lee YT, et al. Association of epicardial adipose tissue
with coronary atherosclerosis is region-specific and independent of conventional risk factors and intra- abdominal adiposity. Atherosclerosis. 2010; 213(1): 279-87. doi: 10.1016/j.atherosclerosis.2010.07.055.
PMID: 20801451.
Hwang IC, Park HE, Choi SY. Epicardial adipose tissue contributes to the development of non-calcified
coronary plaque: a 5-year computed tomography follow-up study. J Atheroscler Thromb. 2017; 24(3): 262- 74. doi: 10.5551/jat.36467. PMID: 27506880, PMCID: PMC5383543.
Picard FA, Gueret P, Laissy JP, Champagne S, Leclercq F, Carrie D, et al. Epicardial adipose tissue
thickness correlates with the presence and severity of angiographic coronary artery disease in stable
patients with chest pain. PloS One. 2014; 9(10): e110005. doi: 10.1371/journal.pone.0110005. PMID:
, PMCID: PMC4204866.
Bachar GN, Dicker D, Kornowski R, Atar E. Epicardial adipose tissue as a predictor of coronary artery
disease in asymptomatic subjects. American Journal of Cardiology. 2012; 110(4): 534-8. doi:
1016/j.amjcard.2012.04.024. PMID: 22579086.
Yüce G, Türkvatan A, Yener Ö. Can aortic atherosclerosis or epicardial adipose tissue volume be used as a
marker for predicting coronary artery disease? Journal of cardiology. 2015; 65(2): 143-9. doi:
1016/j.jjcc.2014.03.017. PMID: 24954286.
Kim SH, Chung JH, Kwon BJ, Song SW, Choi WS. The associations of epicardial adipose tissue with
coronary artery disease and coronary atherosclerosis. Int Heart J. 2014; 55(3): 197-203. doi:
1536/ihj.13-303. PMID: 24806380.
Zehir R, Güner A, Hayiroglu MI, Oz TK, Osken A, Aksu H, et al. The clinical usefulness of epicardial
adipose tissue in patients with high-intermediate pre-test probability for coronary artery disease. Kardiol
Pol. 2018. doi: 10.5603/KP.a2018.0054. PMID: 29399757.
Reddy RP, Shetty RK, Raman VG, Nayar S, Shetty K. Correlation of echocardiographic epicardial fat
thickness with severity of coronary artery disease: An observational study. Heart Rhythm. 2014; 66: S59.
doi: 10.1016/j.ihj.2014.10.164.
Ahn SG, Lim HS, Joe DY, Kang SJ, Choi BJ, Choi SY, et al. Relationship of epicardial adipose tissue by
echocardiography to coronary artery disease. Heart. 2008; 94(3): e7. doi: 10.1136/hrt.2007.118471. PMID:
Sen F, Yilmaz S, Sen Ö, Balc KG, Duman İ, Topaloglu S, et al. Epicardial adipose tissue is related to
coronary collateral vessel formation in patients with acute coronary syndrome. Scandinavian
Cardiovascular Journal. 2015; 49(3): 130-5. doi: 10.3109/14017431.2015.1023345. PMID: 25752649.
Tachibana M, Miyoshi T, Osawa K, Toh N, Oe H, Nakamura K, et al. Measurement of epicardial fat
thickness by transthoracic echocardiography for predicting high-risk coronary artery plaques. Heart and
vessels. 2016; 31(11): 1758-66. doi: 10.1007/s00380-016-0802-5. PMID: 26833041.
Tran T, Small G, Cocker M, Yam Y, Chow BJ. A single slice measure of epicardial adipose tissue can
serve as an indirect measure of total epicardial adipose tissue burden and is associated with obstructive
coronary artery disease. European Heart Journal–Cardiovascular Imaging. 2013; 15(4): 423-30. doi:
1093/ehjci/jet175. PMID: 24107904.
Bhuiyan G, Roy G, Siddique M, Rahman M, Ahmed K, Nahar F. Relationship between Echocardiographic
Epicardial Adipose Tissue (EAT) Thickness and Angiographically Detected Coronary Artery Disease.
Mymensingh Med J. 2017; 26(3): 498-504. PMID: 28919601.
Nabati M, Saffar N, Yazdani J, Parsaee MS. Relationship between epicardial fat measured by
echocardiography and coronary atherosclerosis: a single-blind historical cohort study. Echocardiography.
; 30(5): 505-11. doi: 10.1111/echo.12083. PMID: 23305488.
Jeong JW, Jeong MH, Yun KH, Oh SK, Park EM, Kim YK, et al. Echocardiographic Epicardial Fat
Thickness and Coronary Artery Disease. Circulation Journal. 2007; 71(4): 536-9. doi: 10.1253/circj.71.536.
Nishio S, Kusunose K, Yamada H, Hirata Y, Ise T, Yamaguchi K, et al. Echocardiographic epicardial
adipose tissue thickness is associated with symptomatic coronary vasospasm during provocative testing.
Journal of the American Society of Echocardiography. 2017; 30(10): 1021-7.
Ulucan S, Kaya Z, Efe D, Keser A, Katlandur H, Aygun F, et al. Epicardial fat tissue predicts increased
long-term major adverse cardiac event in patients with moderate cardiovascular risk. Angiology. 2015;
(7): 619-24. doi: 10.1177/0003319714548211. PMID: 25163773.
Lu MT, Park J, Ghemigian K, Mayrhofer T, Puchner SB, Liu T, et al. Epicardial and paracardial adipose
tissue volume and attenuation–Association with high-risk coronary plaque on computed tomographic
angiography in the ROMICAT II trial. Atherosclerosis. 2016; 251: 47-54. doi:
1016/j.atherosclerosis.2016.05.033. PMID: 27266821, PMCID: PMC4983201.
Ng AC, Goo SY, Roche N, van der Geest RJ, Wang WY. Epicardial Adipose Tissue Volume and Left
Ventricular Myocardial Function Using 3-Dimensional Speckle Tracking Echocardiography. Can J Cardiol.
; 32(12): 1485-92. doi: 10.1016/j.cjca.2016.06.009. PMID: 27720272.
Romijn MA, Danad I, Bakkum MJ, Stuijfzand WJ, Tulevski, II, Somsen GA, et al. Incremental diagnostic
value of epicardial adipose tissue for the detection of functionally relevant coronary artery disease.
Atherosclerosis. 2015; 242(1): 161-6. doi: 10.1016/j.atherosclerosis.2015.07.005. PMID: 26188540.
Mahabadi AA, Lehmann N, Kälsch H, Robens T, Bauer M, Dykun I, et al. Association of epicardial
adipose tissue with progression of coronary artery calcification is more pronounced in the early phase of
atherosclerosis: results from the Heinz Nixdorf recall study. Cardiovascular Imaging. 2014; 7(9): 909-16.
doi: 10.1016/j.jcmg.2014.07.002.
Yang C, Li L, Zha Y, Peng Z. Correlation between epicardial adipose tissue and severity of coronary artery
stenosis evaluated by 64-MDCT. Clinical imaging. 2016; 40(3): 477-80. doi:
1016/j.clinimag.2015.12.003. PMID: 27133690
Uygur B, Celik O, Ozturk D, Erturk M, Otcu H, Ustabasıoglu FE, et al. The relationship between location- specific epicardial adipose tissue volume and coronary atherosclerotic plaque burden in type 2 diabetic
patients. Kardiologia Polska. 2017; 75(3): 204-12. doi: 10.5603/KP.a2016.0167. PMID: 27958614.
Sinha SK, Thakur R, Jha MJ, Goel A, Kumar V, Kumar A, et al. Epicardial Adipose Tissue Thickness and
Its Association With the Presence and Severity of Coronary Artery Disease in Clinical Setting: A Cross- Sectional Observational Study. J Clin Med Res. 2016; 8(5): 410-9. doi: 10.14740/jocmr2468w. PMID:
, PMCID: PMC4817582.
Greulich S, Maxhera B, de Wiza DH, Smiris K, Mueller H, Heinrichs J, et al. Secretory products from
epicardial adipose tissue of patients with type 2 diabetes induce cardiomyocyte dysfunction. Circulation.
; 126(19): 2324-34. doi: 10.1161/CIRCULATIONAHA.111.039586. PMID: 23065384.
Kaya H, Ertas F, Oylumlu M, Bilik MZ, Yildiz A, Yuksel M, et al. Relation of epicardial fat thickness and
brachial flow-mediated vasodilation with coronary artery disease. J Cardiol. 2013; 62(6): 343-7. doi:
1016/j.jjcc.2013.05.009. PMID: 23810068.
Yañez-Rivera TG, Baños-Gonzalez MA, Ble-Castillo JL, Torres-Hernandez ME, Torres-Lopez JE,
Borrayo-Sanchez G. Relationship between epicardial adipose tissue, coronary artery disease and
adiponectin in a Mexican population. Cardiovascular ultrasound. 2014; 12(1): 35. doi: 10.1186/1476-7120- 12-35. PMID: 25200587, PMCID: PMC4163040.
Hirata Y, Yamada H, Kusunose K, Iwase T, Nishio S, Hayashi S, et al. Clinical Utility of Measuring
Epicardial Adipose Tissue Thickness with Echocardiography Using a High-Frequency Linear Probe in
Patients with Coronary Artery Disease. J Am Soc Echocardiogr. 2015; 28(10): 1240-6.
Shemirani H, Khoshavi M. Correlation of echocardiographic epicardial fat thickness with severity of
coronary artery disease-an observational study. Anadolu Kardiyol Derg. 2012; 12(3): 200-5. doi:
5152/akd.2012.061.
Iacobellis G, Lonn E, Lamy A, Singh N, Sharma AM. Epicardial fat thickness and coronary artery disease
correlate independently of obesity. Int J Cardiol. 2011; 146(3): 452-4. doi: 10.1016/j.ijcard.2010.10.117.
PMID: 21094545.
Meenakshi K, Rajendran M, Srikumar S, Chidambaram S. Epicardial fat thickness: A surrogate marker of
coronary artery disease - Assessment by echocardiography. Indian Heart J. 2016; 68(3): 336-41. doi:
1016/j.ihj.2015.08.005. PMID: 27316487, PMCID: PMC4911429.
Erkan AF, Tanindi A, Kocaman SA, Ugurlu M, Tore HF. Epicardial Adipose Tissue Thickness Is an
Independent Predictor of Critical and Complex Coronary Artery Disease by Gensini and Syntax Scores.
Tex Heart Inst J. 2016; 43(1): 29-37. doi: 10.14503/THIJ-14-4850. PMID: 27047282, PMCID:
PMC4810581.
Gholoobi A, Sajjadi SM, Shabestari MM, Eshraghi A, Shamloo AS. The impact of remote ischemic pre- conditioning on contrast-induced nephropathy in patients undergoing coronary angiography and
angioplasty: a double-blind randomized clinical trial. Electronic physician. 2015; 7(8): 1557. doi:
19082/1557. PMID: 26816582, PMCID: PMC4725407.
Schroeder S, Achenbach S, Bengel F, Burgstahler C, Cademartiri F, de Feyter P, et al. Cardiac computed
tomography: indications, applications, limitations, and training requirements: report of a Writing Group
deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of
Cardiology and the European Council of Nuclear Cardiology. Eur Heart J. 2007; 29(4): 531-56. doi:
1093/eurheartj/ehm544. PMID: 18084017.
Pierdomenico SD, Pierdomenico AM, Cuccurullo F, Iacobellis G. Meta-analysis of the relation of
echocardiographic epicardial adipose tissue thickness and the metabolic syndrome. American Journal of
Cardiology. 2013; 111(1): 73-8. doi: 10.1016/j.amjcard.2012.08.044. PMID: 23040591.
Iacobellis G, Pistilli D, Gucciardo M, Leonetti F, Miraldi F, Brancaccio G, et al. Adiponectin expression in
human epicardial adipose tissue in vivo is lower in patients with coronary artery disease. Cytokine. 2005;
(6): 251-5. doi: 10.1016/j.cyto.2004.11.002.
Karastergiou K, Evans I, Ogston N, Miheisi N, Nair D, Kaski JC, et al. Epicardial adipokines in obesity and
coronary artery disease induce atherogenic changes in monocytes and endothelial cells. Arteriosclerosis,
thrombosis, and vascular biology. 2010; 30(7): 1340-6. doi: 10.1161/ATVBAHA.110.204719. PMID:
Langheim S, Dreas L, Veschini L, Maisano F, Foglieni C, Ferrarello S, et al. Increased expression and
secretion of resistin in epicardial adipose tissue of patients with acute coronary syndrome. Am J Physiol
Heart Circ Physiol. 2010; 298(3): H746-53. doi: 10.1152/ajpheart.00617.2009. PMID: 20061546.
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