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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 500-506

Correlation between epicardial fat volume as detected by echocrdiography and multidetector computed tomography with the extent and severity of coronary atherosclerosis

1 Department of Cardiology, Al-Azhar University (for Girls), Egypt
2 Department of Cardiology, Al-Azhar University (for Boys), Cairo, Egypt
3 Cardiology Department, Al-Azhar University, Cairo, Egypt

Date of Submission03-Aug-2020
Date of Decision14-Aug-2020
Date of Acceptance16-Aug-2020
Date of Web Publication2-Oct-2020

Correspondence Address:
MD Asmaa A Ali Hassan
Lecture of Cardiology, Department of Cardiology, Al-Azhar University (for Girls), Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjamf.sjamf_79_20

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Background Epicardial fat is a visceral deposition of fat. It causes local inflammation and affects coronary artery disease (CAD), so it has been considered a risk factor for cardiovascular disease.
Aim To study the relationship between epicedial fat, as measured by multidetector computed tomography and transthoracic echocardiography, and the severity of CAD using invasive coronary angiography (ICA).
Patients and methods This is an observational study that included 100 patients with suspected CAD presented to the Department of Cardiology in Kopry Elkoppa Hospital from September 2015 to December 2017. Epicardial fat thickness (EFT) was measured by transthoracic echocardiography, and epicardial fat volume (EFV) was measured by multidetector computed tomography, and ICA was done.
Results The studied population was divided into two groups: group A (86 patients) with significant CAD and group B (14 patients) without significant CAD. We divided group A according to the number of vessel affected by ICA into group I (single-vessel or two-vessel disease) and group II (multivessel disease). EFT and EFV were significantly increased in group II compared with group I. EFT and EFV were positively correlated with age, weight, family history of ischemic heart disease, and high Ca score more than or equal to 400. Cutoff value of EFV in predicting multivessel disease was more than or equal to 55 ml, and EFT was more than or equal to 6.5 mm. By multivariate analysis, the EFV is considered an independent risk factor for CAD.
Conclusion EFT and EFV are sig. higher in patients with multivessel disease. Epicardial fat is an indicator and also a predictor of CAD severity and multivessel disease occurrence.

Keywords: epicardial fat thickness, epicardial fat volume, multidetector computed tomography

How to cite this article:
Ali Hassan AA, Abdel-Aziz IS, Moselhy D, Fereig HM. Correlation between epicardial fat volume as detected by echocrdiography and multidetector computed tomography with the extent and severity of coronary atherosclerosis. Sci J Al-Azhar Med Fac Girls 2020;4:500-6

How to cite this URL:
Ali Hassan AA, Abdel-Aziz IS, Moselhy D, Fereig HM. Correlation between epicardial fat volume as detected by echocrdiography and multidetector computed tomography with the extent and severity of coronary atherosclerosis. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Oct 28];4:500-6. Available from: http://www.sjamf.eg.net/text.asp?2020/4/3/500/296965

  Introduction Top

Coronary artery diseases (CAD) are the leading cause of mortality worldwide [1]. The INTERHEART study showed that smoking, dyslipidemia, diabetes mellitus (DM), hypertension (HTN), obesity, physical inactivity, psychological factors, and a high-risk diet were accounted for more than 90% of myocardial infarction risk [2]. Primary prevention is an important cornerstone for people who are at risk for CAD.

Novel cardiovascular risk factors were identified in several researches. The epicardial fat (EF) around the heart can be classified into different parts [3].

The physiological roles of EF are immune barrier, coronary artery protection, and source of fatty acid in myocardium [4]. However, as the epicardial fat volume (EFV) increases, it becomes hypoxic and dysfunctional [5]. So, it has been reported to affect coronary atherosclerosis [6].

  Aim Top

The aim is to study the relationship between EF, measured by multidetector computed tomography (CT) and transthoracic echocardiography, and the extent and severity of CAD using invasive coronary angiography (ICA).

  Patients and methods Top

It is an observational study of 100 suspected case of CAD presented to the Department of Cardiology in Kopry Alkoppa Military Hospital, Cairo, during the period between September 2015 and December 2017. In adherence of the guideline of the ethical committee of Al-Azhar University, Cairo, Egypt.

A written consent was taken from all participants.

Inclusion criteria

Chest pain (atypical chest pain, chest tightness, burning sensation), new ECG changes, and/or equivocal stress test were the inclusion criteria.

Exclusion criteria

Contrast allergy and renal abnormalities (estimated GFR<30 ml), previous CABG, previous percutaneous coronary angiography, intracardiac devices, heart rate more than or equal to 80 bpm, or any type of arrhythmia were the exclusion criteria.

Careful medical history taking, clinical examination, BMI, and laboratory investigations, including CBC, RFT, and lipid profile, were done.

In the study, 12-lead surface resting ECG was done to assess presence of rate, rhythm, and ischemic changes such as Q-QS wave, horizontal or down-sloping ST depression less than 1 mm, and symmetrical T wave inversion in three consecutive leads Left Bundle Branch Block (LBBB).

Transthoracic echocardiography studies were done by a Vivid 5 cardiac ultrasound system (GE Medical Systems, Horten, Norway) using M-mode, 2-D echo, and Doppler with color flow imaging. We measured LV dimensions and systolic function from 2D echo-guided M-mode, and left atrial and aortic root diameter. Epicardial fat thickness (EFT) was measured in the parasternal long-axis and short axis views at mid ventricle in three cycles at end-systole, and the average value was calculated. By 2D echocardiography, wall motion abnormalities of the 17 segments were assessed semiquantitatively in all views. Wall motion score index was calculated by dividing the total of the wall motion scores of each segment by 17.
  1. CT scan using the 64-slice CT scanner Somatom Definition Flash (SEMINS Medical Solution VA44A, Erlangen, Germany). Scout image was taken at first, and then gated ECG-triggered noncontrast scan to measure coronary calcium score. The region of interest for imaging is defined, and tomogram is taken. Calculation of the time delay was done; this time delay results in increase in the concentration of contrast at the coronary arteries and the ascending aorta. A three-dimensional reconstruction of axial images at an optimal window was done at workstation ([Figure 1] and [Figure 2]).
    Figure 1 Epicardial fat thickness is echo-free space between the outer wall of the myocardium and the visceral layer of pericardium (the yellow arrow).

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    Figure 2 Measurement of epicardial fat volume by multidetector computed tomography.

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  2. We analyzed image data by multiplanar reformatted images. Two-dimensional reconstructions of the coronary arteries were performed on several planes to assess patency of vessels. EFV was obtained. In noncontrast cardiac CT, it was manually traced in each fourth slice from the level of aortic root till the apex using 5.0-mm-thick slices with slices taken 35–45 per heart. At the end, the software automatically traced the parietal pericardium in all slices for measurement of EFV. Then ICA was done. We classified the patients into two groups according to the results of the ICA into two groups (A) with sig. CAD and (B) without sig. CAD, and according to the number of vessel affected by ICA, we further divided group A into group I (single or two-vessel disease) and group II (multivessel disease).

Statistical analysis

We analyzed the data using independent samples t test for comparing between two means. A binomial logistic regression was used to predict the probability. Receiver operating characteristic curve also was used. P value of less than 0.05 is considered significant.

  Results Top

We studied 100 patients, with mean age of 57±9.1 years, and there was predominance of male sex (93%). We found the occurrence of risk factors such as diabetes, HTN, dyslipidemia, smoking, and family history of CAD among 46, 63, 54, 35, and 42%, respectively. Echocardiographic data showed that the mean ejection fraction was 62.0±7.5, the wall motion score index of the 17 segments was 1, and average EFT was 5.6±1.4 mm ([Figure 3]).
Figure 3 Showing % of risk factors of all patients.

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Overall, 14% of patients showed equivocal result by MSCT so they proceeded to ICA. They showed nonsignificant coronary angiography and were classified as group B. The remaining 86% had significant CAD and were categorized into group A. Patients in ‘group A’ have been further classified into group I (single or two-vessel disease) and group II (multivessel disease) ([Table 1]).
Table 1 Comparison between group A and group B regarding the demographic data

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The prevalence of either risk factor (sex and family history of CAD) was increased significantly in group A versus group B. There was no difference regarding BMI, height, HTN, DM, smoking, and dyslipidemia between both groups.

EFV and average EFT were significantly increased in group A in comparison with group B. These results have been depicted in [Table 2].
Table 2 Group I versus group II patients regarding the epicardial fat data (N=86)

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It was observed that older age and dyslipidemia (only triglycerides) were found to be significantly associated with group II. Multivariate regression analysis found that EFV was the only statistically significant predictor for multivessel disease, with P value less than 0.005. The results have been depicted in [Table 3].
Table 3 Multivariate regression analysis of predictors of multivessel disease (group II)

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The cutoff value of EFV in predicting multivessel disease was more than or equal to 55 ml, and the cutoff value of EFT in predicting multivessel disease was more than or equal to 6.5 mm, with sensitivity, specificity, and the P value shown in [Table 4].
Table 4 Epicardial fat volume and epicardial fat thickness in predicting multivessel disease using receiver operating characteristic curve analysis

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We correlated between EFV by multidetector computed tomography of the 100 patients and the different risk factors such as sex, age, HTN, DM, smoking, dyslipidemia, weight, family history of ischemic heart disease (IHD), and Ca score by CT. We found that EFV positively correlated with DM (P<0.001), family history of IHD (P<0.001), and high Ca score (P<0.001). Weak correlations were observed in HTN and dyslipidemia as in [Table 5].
Table 5 Comparing epicardial fat volume (ml) according to different risk factors

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We found that EFT was positively correlated with HTN, patients with family history of IHD, older age, BMI, and high Ca score, but there were insignificant correlation with DM, sex, or dyslipidemia.

We finally found that EFT positively correlates with EFV, as shown in [Table 6].
Table 6 Correlation between epicardial fat volume (ml) and average epicardial fat thickness (mm)

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  Discussion Top

EFV has been considered as a novel risk factor for predicting coronary atherosclerosis. So, its quantification improves CAD risk prediction and coronary calcium scoring. These parameters were studied by Mahabadi et al. [7]; Ding et al. [8]; and Mahabadi et al. [9] in USA.

Our study population was predominantly males (93%), with mean age of 57 years. We divided our patients according to the results of the coronary angiography into two groups: group A with sig. CAD and group B without sig. CAD. Group A compromised 86 patients, and group B compromised 14 patients. We further divided group A patients into two groups according to the number of vessels affected into single or two-vessel disease (group I, which had 68 patients) and multivessel disease (group II which had 18 patients). We found that the risk of developing CAD increases in males than in females. This difference in sex may be owing to the useful effect of feminine hormones especially estrogen as in Lennep et al. [10], who found the diagnosis for CAD and peripheral artery disease was more prevalent in males than females (P<0.0001). We also found that there was a significant difference between both groups regarding LV systolic function (but still within normal range in both groups) and wall motion score index. This coincides with a study by Squeri et al. [11], who found that severe CAD was observed in patients who had significantly lower LVEF, and reduced LVEF identifies high-risk patients.

EFT showed a considerable difference between two groups (group A 5.72±1.48 mm versus group B 4.89±0.56 mm), which agreed with a study by Eroglu et al. [12], who found that EFT was increased in patients with significant CAD compared with the other group.

Group A showed higher EFV than group B, which is in concordance with previous studies by Aslanabadi et al. [13], and Djaberi et al. [14].

The EFV showed correlation with DM, family history of IHD, and high Ca score group, but there was no correlation with other risk factors, including HTN, smoking, and dyslipidemia. The same results were seen by Alexopoulos et al. [15].

Group II showed significantly higher incidence among older patients, with P value less than 0.025, than group I. Dyslipidemia (only triglycerides) was higher in group II, which coincidence with the result of a study by Abd Alamir et al. [16].

EFT and EFV moreover were increased in group II. This result was the same as Kamal et al. [17], who found that EFT correlated significantly with the severity of CAD.

We found the cutoff value of EFT of 6.5 mm, at which we can predict the presence of multivessel disease. Eroglu et al. [12] found a cut-off value of 5.2 mm, which coincided with our results. We further found the cut-off value of EFV of 55 ml, at which we can predict the presence of multivessel disease. Spearman et al. [18] evaluated the prognostic value of EFV in 10 252 patients and showed the cutoffs of EFV of 125 ml appeared most appropriate for prognostic risk stratification.

We also found EFV to be an indicator for prediction of CAD. The same results were shown by studies conducted previously by Cheng et al. [19], and Harada et al. [20].

  Conclusion Top

EFT and EFV are significantly higher in patients with multivessel disease. EF is a good predictor of CAD severity and multivessel disease occurrence.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

The top 10 causes of death worldwide: WHO January 2017 update. Available at: www.who.int/mediacentre/factsheets/fs310/en/) [Accessed December 2017].  Back to cited text no. 1
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Bertaso AG, Bertol D, Duncan BB, Foppa M. Epicardial fat: definition, measurements and systematic review of main outcomes. Arq Bras Cardiol 2013; 101:e18–e28.  Back to cited text no. 3
Sacks HS, Fain JN, Cheema P, Bahouth SW, Garrett E, Wolf RY et al. Inflammatory genes in epicardial fat contiguous with coronary atherosclerosis in the metabolic syndrome and type2 diabetes: changes associated with pioglitazone. Diabetes Care 2011; 34:730–733.  Back to cited text no. 4
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Mahabadi AA, Massaro JM, Rosito GA, Levy D, Murabito JM, Wolf PA et al. Association of pericardial fat, intrathoracic fat, and visceral abdominal fat with cardiovascular disease. Eur Heart J 2009; 30:850–856.  Back to cited text no. 7
Ding J, Hsu F-C, Harris TB, Liu Y, Kritchevsky SB, Szklo M et al. The association of pericardial fat with incident coronary heart disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Am J Clin Nutr 2009; 90:499–504.  Back to cited text no. 8
Mahabadi AA, Berg MH, Lehmann N, Kälsch H, Bauer M, Kara K et al. Association of epicardial fat with cardiovascular risk factors and incident myocardial infarction in the general population. J Am Coll Cardiol 2013; 61:13.  Back to cited text no. 9
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Mohammed SF, Hussain I, Abou Ezzeddine OF, Takahama H, Kwon SH, Forfia P et al. Ejection fraction change and coronary artery disease severity: a vasodilator contrast stress-echocardiography study. Circulation 2014; 130:2310–2320.  Back to cited text no. 11
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 arterydisease. Nutr Metab Cardiovasc Dis 2009; 19:211–217.  Back to cited text no. 12
Aslanabadi N, Salehi R, Javadrashid A, Tarzamni M, Khodadad B, Enamzadeh E et al. Epicardial and pericardial fat volume correlate with the severity of coronary artery stenosis. J Cardiovasc Thorac Res 2014; 6:235–239.  Back to cited text no. 13
Djaberi R, Schuijf JD, van Werkhoven JM, Nucifora G, Wouter Jukema J, Bax JJ. Relation of epicardial adipose tissue to coronary atherosclerosis. Am J Cardiol 2008; 102:1602–1607.  Back to cited text no. 14
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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