Table 1.
Studies investigating the role of EAT in heart failure with preserved and mildly reduced ejection fraction.
| Manuscript | Study Design | Sample Size | Method | Major Findings |
|---|---|---|---|---|
| Obokata, 2017 [31] | Retrospective single center study | 99 obese HFpEF patients (mean age 65 ± 11 years, 38% male, BMI 40.8 ± 5.6 kg/m2), 96 non-obese HFpEF patients (mean age 70 ± 10 years, 38% male, BMI 26.0 ± 2.7 kg/m2), 71 non-obese control subjects free of HF (mean age 62 ± 10 years, 42% male, BMI 25.4 ± 2.8 kg/m2) | Echocardiography (EAT thickness) | Compared to non-obese HFpEF and controls, obese HFpEF patients had an increased EAT (10 ± 2 versus 7 ± 2 and 6 ± 2 mm; p < 0.0001), worse exercise capacity (peak oxygen consumption, 7.7 ± 2.3 versus 10.0 ± 3.4 and 12.9 ± 4.0 mL/min·kg; p < 0.0001), increased plasma volume, more concentric LV remodeling, and lower N-proBNP values. Pulmonary capillary wedge pressure was correlated with body mass and plasma volume in obese HFpEF (r = 0.22 and 0.27, both p < 0.05) but not in non-obese HFpEF. The increase in heart volumes in obese HFpEF was associated with greater pericardial restraint and heightened ventricular interdependence. |
| Van Woerden, 2018 [57] | Observational prospective single center study | 64 HFpEF patients (median age 70 ± 10.7 years, 63% male, BMI 29.6 ± 5.7 kg/m2) vs. 20 controls (median age 66 ± 5.5 years, 65% male, BMI 27.2 ± 4.6 kg/m2) | Cardiac magnetic resonance (EAT volume) | Total EAT volume higher in HFpEF compared to controls (107 mL/m2 vs. 77 mL/m2, p < 0.0001). HFpEF patients with atrial fibrillation and/or type 2 diabetes mellitus had more EAT 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). |
| Wu, 2020 [51] | National Taiwan University Hospital CMRI registry | 163 HFpEF patients (mean age 61 ± 15 years, 63% male, BMI 26 ± 4 kg/ m2), 34 HFrEF patients (mean age 55 ± 15 years, 82% male, BMI 25 ± 5 kg/ m2), 28 HFmrEF patients, 108 non-HF controls | Cardiac magnetic resonance (EAT volume and intramyocardial mass) | Intramyocardial fat higher in HFpEF than HFrEF patients or non-HF controls [intramyocardial fat content 1.56% (1.26, 1.89) vs. 0.75% (0.50, 0.87) and 1.0% (0.79, 1.15), p < 0.05]. Intramyocardial fat correlated with LV diastolic dysfunction parameters in HFpEF patients independently of age, co-morbidities, BMI, gender, and myocardial fibrosis (β = −0.34, p = 0.03; β = 0.29, p = 0.025; and β = 0.25, p = 0.02, respectively). |
| Gorter, 2020 [54] | Observational prospective single center study | 75 HFpEF patients (mean age 74 ± 9 years; 32% male, BMI 29 ± 6 kg/m2, 36% obese) | Echocardiography (EAT thickness) | Increased EAT associated with higher right ventricular end-diastolic pressure and with lower VO2-max independently from pulmonary venous resistance (OR 1.16 [1.02 to 1.34], p = 0.03, and OR 0.64 [0.49 to 0.84], p = 0.002, respectively), and obesity (OR 0.69 [0.53 to 0.92], p = 0.01). EAT thickness was not associated with left-sided filling pressures. |
| Koepp, 2020 [60] | Observational prospective single center study | 77 patients with HFpEF, obesity and increased EAT (mean age 67 ± 12 years, 32% male, BMI 39.9 ± 6.6 kg/m2) vs. 92 patients with HFpEF, obesity and reduced EAT (mean age 66 ± 10 years, 43% male, BMI 34.5 ± 4.2 kg/m2) | Echocardiography (EAT thickness) | Obese patients with HFpEF with increased EAT had higher right atrial, pulmonary artery, and pulmonary capillary wedge pressures at rest and during exercise and lower peak oxygen consumption (VO2) |
| Van Woerden, 2021 [55] | Observational prospective single center study | 102 HFpEF patients with LVEF > 40% (mean age 70 ± 10 years, male 51%, BMI 29.5 ± 5.8 kg/m2) | Cardiac magnetic resonance (EAT volume) | Right ventricular EAT was positively associated with RV mass after adjusting for total EAT, sex, NT-proBNP, renal function, and blood glucose. Atrial EAT was increased in patients with atrial fibrillation compared to those without atrial fibrillation (30 vs. 26 mL/m2, p = 0.04). |
| Pugliese, 2021 [56] | Observational prospective single center study | 205 HFrEF patients (median age 65 (IQR: 55–74) years, 65% male, BMI 27 (IQR: 21–33) kg/m2), 188 HFpEF patients (median age 73 (IQR: 64–80) years, 48% male, BMI 31.5 (IQR: 29–36) kg/m2), 44 healthy controls (median age 61 (IQR: 54–70) years, 59% male, BMI 23 (IQR: 22–24) kg/m2). | Echocardiography (EAT thickness) | HFpEF patients displayed the highest EAT. In HFpEF, EAT had a direct association with troponin T, C-reactive protein, and right ventriculo–arterial uncoupling, whereas an inverse correlation with peak VO2 and AVO2diff was observed. Increased EAT in HFpEF was related to a higher risk of adverse events. |
| Ying, 2021 [59] | Observational prospective single center study | 55 HFpEF patients (mean age 67 ± 11 years, 25% male), 33 controls (mean age 57 ± 10 years, 36% male) | Cardiac magnetic resonance (EAT thickness) | HFpEF patient had higher EAT (4.6 [IQR 2.0]) vs. controls (3.2 [IQR 1.4], p < 0.001). Increased EAT was associated with lower well-being scores. |
| Van Woerden, 2022 [58] | Observational prospective single center study | 105 HFpEF patients (mean age 72 ± 8 years, 50% male, and mean LVEF 53 ± 8%), median follow-up of 24 (17–25) months | Cardiac magnetic resonance (EAT volume) | EAT was associated with all-cause mortality (HR, 2.06 [1.26–3.37], p = 0.004) and HF hospitalizations (HR, 1.54 [1.04–2.30], p = 0.03). |
| Venkateshvaran, 2022 [45] | Prospective, multinational study (PROMIS-HFpEF) | 182 HFpEF patients: n = 54 patients with increased EAT ≥ 9 mm (mean age 73 (68–77) years, 57% male, and mean LVEF 62 (56–66)%), vs. n = 128 patients with reduced EAT < 9 mm (mean age 76 (70–82) years, 54% male, mean LVEF 58 (54–64)%). | Echocardiography (EAT thickness) | Patients with increased EAT had higher body mass index (32 (28–40) vs. 27 (23–30) kg/m2; p < 0.001), lower NT-proBNP (466 (193–1133) vs.1120 (494–1990) pg/mL; p < 0.001), smaller indexed LV end-diastolic and LA volumes. EAT was moderately and significantly correlated with BMI (r = 0.49, p < 0.001). When adjusted for BMI, EAT was associated with LV septal wall thickness (B = 1.02, [1–1.04], p = 0.018) and mitral E wave deceleration time (B01.03, [1.01–1.05], p = 0.005). Increased EAT was associated with proteomic markers of adipose biology and inflammation, insulin resistance, endothelial dysfunction, and dyslipidaemia. |
| Jin, 2022 [61] | Observational retrospective, 2 different cohorts | 99 HFpEF patients (mean age 65 ± 11 years, 63% male, BMI 29 ± 6.3 kg/m2); 366 HFrEF/HFmrEF patients (mean age 57 ± 11 years, 84% male, BMI 27 ± 5.6 kg/m2); 149 controls (mean age 58 ± 10.8 years, 46% male, BMI 25 ± 3.9 kg/m2). | Echocardiography (EAT thickness) | EAT thickness lower in HFrEF/HFmrEF (7.3 ± 2.5) vs. HFpEF (8.3 ± 2.6 mm, p < 0.05). Greater EAT thickness associated with higher LV and LA function in HFrEF but not in HFpEF. Increased EAT associated with LA dysfunction in HFpEF but not in HFrEF/HFmrEF. |