‘Letter to the editor: Epicardial, visceral and subcutaneous adipose tissue in heart failure with preserved ejection fraction’

Dear Editor,

We read with great interest the article by Lobeek et al., ¹ which offers valuable insights into the distribution of adipose tissue depot in heart failure with preserved ejection fraction (HFpEF) and highlights important sex‐specific differences in epicardial, visceral, and subcutaneous fat. The authors are to be commended for addressing this clinically relevant and underexplored area, as understanding adipose distribution in HFpEF has the potential to improve risk stratification and guide personalized management. Their use of multimodality imaging represents a noteworthy methodological strength and adds depth to the field. We sincerely appreciate their contribution in advancing this important topic; however, the study has the following limitations that merit further discussion.

First, the study used cardiac magnetic resonance (CMR) for epicardial adipose tissue (EAT) and computed tomography (CT) for visceral adipose tissue (VAT)/subcutaneous adipose tissue (SAT), which introduces measurement bias since different imaging modalities have variable reproducibility and sensitivity for adipose tissue quantification. This could partly explain the only ‘modest’ association found between VAT and EAT. For instance, Shuster et al. ² highlighted that CT and Magnetic Resonance imaging (MRI) provide differing estimates of visceral and subcutaneous adiposity, which may affect cross‐modality comparability. Second, the study focused only on volumetric quantification (EAT, VAT and SAT), ignoring functional aspects like adipose tissue inflammation, fibrosis, or metabolic activity, which are increasingly recognized as critical determinants of cardiovascular risk in HFpEF. This omission may underestimate the pathophysiological impact of adipose depots. For instance, Dronkers et al. ³ reviewed how molecular mechanisms (inflammation and adipokine secretion) in adipose depots influence HFpEF beyond fat volume. Third, the study provides a snapshot of fat distribution but cannot establish causality or predict clinical outcomes such as hospitalization, arrhythmias, or mortality. This weakens the translational impact of findings for clinical practice. For instance, van Woerden et al. ⁴ showed that longitudinal changes in EAT are associated with outcomes in HFpEF, underlining the need for follow‐up data. Fourth, the study enrolled patients from the Netherlands only, which limits external validity to diverse ethnic populations where adipose distribution and HFpEF phenotypes differ. For instance, South Asian patients have more VAT at lower body mass index (BMI), altering risk. Pandey et al. ⁵ demonstrated race‐specific associations between adipose distribution and Heart failure (HF) risk.

Thus, the future studies should aim to harmonize imaging, preferably using a single modality for all adipose depots or cross‐calibrated approaches, while integrating volumetric assessment with biomarker profiling and advanced techniques such as positron emission tomography (PET) or CT to capture metabolic activity. Additionally, prospective designs with long‐term clinical endpoints (e.g., mortality and HF hospitalization) are essential to establish prognostic value, and replication in multi‐ethnic, multicentre cohorts will ensure broader generalizability across diverse populations.

In conclusion, while the study by Lobeek et al. provides important insights into adipose tissue distribution in HFpEF, addressing the highlighted methodological and design limitations will be crucial for strengthening future research. By refining imaging strategies, incorporating functional assessments, extending follow‐up, and ensuring diverse patient representation, subsequent studies can better clarify the role of adipose depots in HFpEF and enhance their relevance for clinical practice.

Guarantor statement

All authors have read and approved the final version of the manuscript. They took complete responsibility for the data's integrity and the data analysis's accuracy.

Conflict of interest statement

Ahmed Raza and Ahmad Furqan declare that they have no conflict of interest.

Transparency statement

The authors affirm that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned (and if relevant, registered) have been explained.

Raza, A. , and Anjum, A. F. (2025) ‘Letter to the editor: Epicardial, visceral and subcutaneous adipose tissue in heart failure with preserved ejection fraction’. ESC Heart Failure, 12: 4529–4530. 10.1002/ehf2.15433.

Data availability statement

Data sharing does not apply to this article as no datasets were generated during the current study; all data were sourced from published literature.