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

Study Questions:

Is epicardial adipose volume predictive of progression in coronary artery calcification (CAC)?


Data from the present analysis were collected as part of the Heinz Nixdorf Recall study, a population-based, prospective cohort study design, which examined novel and traditional cardiovascular disease risk factors. Participants were ages 45-75 years at the time of enrollment and resided in three adjacent cities in Germany between 2000 and 2003. Participants were included in this analysis if they had no known coronary artery disease at baseline, and no revascularization procedures between baseline and follow-up. CAC was quantified from noncontrast cardiac electron beam computed tomography at baseline and after 5 years. Epicardial adipose tissue (EAT) was defined as fat volume inside the pericardial sac and was quantified from axial computed tomography images. Association of EAT volume with CAC progression (log[CAC(follow-up) +1] - log[CAC(baseline) + 1]) was depicted as percent progression of CAC + 1 per standard deviation (SD) of EAT.


A total of 3,367 subjects (mean age 59 ± 8 years; 47% male) were included. Median CAC score at baseline was 7.0 and 25.8 after a follow-up period of 5.1 ± 0.3 years. EAT was strongly correlated with both body mass index (BMI) and waist circumference. Subjects with progression of CAC above the median had higher EAT volume than subjects with less CAC change (101.1 ± 47.1 ml vs. 84.4 ± 43.4 ml; p < 0.0001). In regression analysis, 6.3% (95% confidence interval [CI], 2.3%-10.4%; p = 0.0019) of progression of CAC + 1 was attributable to 1 SD of EAT, which remained significant after adjustment for risk factors (6.1% [95% CI, 1.2%-11.2%]; p = 0.014). For subjects with a CAC score of >0 to ≤100, progression of CAC + 1 by 20% (95% CI, 11%-31%; p < 0.0001) was attributable to 1 SD of EAT. Effect sizes decreased with CAC at baseline, with no relevant link for subjects with a CAC score ≥400 (0.2% [95% CI, -03.5% to 4.2%]; p = 0.9). Likewise, subjects ages <55 years at baseline showed the strongest association of EAT with CAC progression (20.6% [95% CI, 9.7%-32.5%]; p < 0.0001). The effect of EAT on CAC progression was more pronounced in subjects with low BMI, and decreased with degree of adiposity (BMI ≤25 kg/m2, 19.8% [95% CI, 9.2%-31.4%]; p = 0.0001, BMI >40 kg/m2, 0.8% [95% CI, -26.7%-38.9%]; p = 0.96).


The investigators concluded that EAT is associated with the progression of CAC, especially in young subjects and subjects with low CAC score, suggesting that EAT may promote early atherosclerosis development.


These data support the use of EAT in risk stratification. In particular among those younger patients with normal BMI, EAT may identify individuals at increased risk for cardiovascular events. Further research, including data on non-white populations, is warranted.

Clinical Topics: Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Computed Tomography, Nuclear Imaging

Keywords: Waist Circumference, Coronary Artery Disease, Atherosclerosis, Body Mass Index, Tomography, X-Ray Computed, Adiposity, Calcinosis, Risk Factors, Germany, Regression Analysis, ESC Congress

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