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Hemodynamic and Functional Impact of Epicardial Adipose Tissue in Heart Failure With Preserved Ejection Fraction
Open accessAbstract
Objectives This study determined the impact of excess epicardial adipose tissue (EAT) in patients with the obese phenotype of heart failure with preserved ejection fraction (HFpEF).Background Patients with HFpEF and an elevated body mass index differ from nonobese patients, but beyond generalized obesity, fat distribution may be more important. Increases in EAT are associated with excess visceral adiposity, inflammation, and cardiac fibrosis, and EAT has been speculated to play an important role in the pathophysiology of HFpEF, but no study has directly evaluated this question.Methods Patients with HFpEF and obesity (n = 169) underwent invasive hemodynamic exercise testing with expired gas analysis and echocardiography. Increased EAT was defined by echocardiography (EAT thickness ≥9 mm).Results Compared with obese patients without increased EAT (HFpEF EAT-, n = 92), obese patients with HFpEF with increased EAT (HFpEF EAT+; n = 77) displayed a higher left ventricular eccentricity index, indicating increased pericardial restraint, but similar resting biventricular structure and function. In contrast, hemodynamics were more abnormal in patients with HFpEF EAT+, with higher right atrial, pulmonary artery, and pulmonary capillary wedge pressures at rest and during exercise compared with those of patients with HFpEF EAT-. Peak oxygen consumption (VO 2) was reduced in both groups but was 20% lower in patients with HFpEF EAT+ (p < 0.01).Conclusions Among patients with the obese phenotype of HFpEF, the presence of increased EAT is associated with more profound hemodynamic derangements at rest and exercise, including greater elevation in cardiac filling pressures, more severe pulmonary hypertension, and greater pericardial restraint, culminating in poorer exercise capacity. Further study is needed to understand the biology and treatment of excessive EAT in patients with HFpEF.
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“As compared with nonobese HFpEF, patients with obesity-related HFpEF display distinct pathophysiologic features, including greater volume expansion5,17, more severe inflammation6,7, increases in visceral and paracardiac adipose tissue5,15,18,19 and more severe myocardial injury15.”
From Effects of tirzepatide on circulatory overload and end-organ damage in heart failure with preserved ejection fraction and obesity: a secondary analysis of the SUMMIT trial (2025) · cites this paper as [18]
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“Paracardiac adipose tissue (epicardial and pericardial adipose tissue) in patients with obesity may also impair LV relaxation20 and increase cardiac filling pressures, owing to increases in extrinsic restraint on the heart in obesity-related HFpEF.2,6,7”
From Tirzepatide Reduces LV Mass and Paracardiac Adipose Tissue in Obesity-Related Heart Failure (2025) · cites this paper as [7]
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“Occupying a fixed pericardial space, the EAT mass may drive an abnormal ventricular distensibility determining a constrictive pattern responsible of pressure equalization across ventricles in different physiologic states, particularly during exercise and in patients with obesity and with or without diabetes [85,86].”
From Dysregulated epicardial adipose tissue as a risk factor and potential therapeutic target of heart failure with preserved ejection fraction in diabetes (2022) · cites this paper as [86]
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Heart Failure With Preserved Ejection Fraction
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Metadata
- Authors
- Koepp, K. E., Obokata, M., Reddy, Y. N. V., Olson, T. P., & Borlaug, B. A.
- Affiliations
- Mayo Clinic (US)
- Corresponding author
- Borlaug, Barry A.
- Venue
- JACC Heart Failure
- Publisher
- Elsevier BV
- Published
- 2020-08
- Volume
- 8
- Issue
- 8
- Pages
- 657-666
- ISSN
- 2213-1779 (ISSN-L)
- PMC
- PMC7395878
- OpenAlex
- W3041438146
- Cited by
- 269
- References
- 41
- Citations by year
- 2026: 29 · 2025: 68 · 2024: 57 · 2023: 43 · 2022: 35 · 2021: 31 · 2020: 5
- FWCI
- 17.62
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- JACC Heart Failure (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Disease and Adiposity
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- epicardial adipose tissue, heart failure with preserved ejection fraction, obesity, hemodynamics, cardiac filling pressure, pulmonary hypertension, exercise capacity, visceral fat, myocardial fibrosis
- MeSH terms
- Adipose Tissue, Aged, Echocardiography, Female, Follow-Up Studies, Heart Atria, Heart Failure, Heart Ventricles, Humans, Male, Pericardium, Pulmonary Wedge Pressure, Retrospective Studies, Stroke Volume, Exercise Tolerance
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