Epicardial fat thickness and serum transaminase values in myocardial infarction with concomitant metabolic-associated fatty liver disease

Aim. To assess the relationship between epicardial fat thickness (EFT) and metabolic-associated fatty liver disease (MAFLD), including hepatic steatosis (HS) and steatohepatitis, in myocardial infarction (MI), as well as to analyze the changes of transaminase levels in patients with a combination of ST-elevation MI (STEMI) and MAFLD to accurately identify liver disease. Material and methods. A total of 163 patients with ST-elevation myocardial infarction (STEMI) (n=144) and non-ST-elevation myocardial infarction (NSTEMI) (n=19) with metabolic syndrome (MetS) were admitted for primary coronary angiography and percutaneous intervention (PCI). Eighty-two patients had concomitant MAFLD (55 with steatosis and 27 with steatosis). Liver elastometry, EFT measurement, cardiac troponin I levels, alanine and aspartate aminotransferase (ALT and AST) levels, and cytokeratin-18 fragment concentrations were measured. Results. MAFLD in patients with MI compared to patients without liver pathology is associated with higher EFT (p<0,01). According to two-way analysis of variance, a stable increase in blood AST and ALT levels was established for the combination of MI and MAFLD (p<0,05, generalized η² effect size ≥0,11 for both aminotransferases). In STEMI combined with steatohepatitis, compared to HS and STEMI without MAFLD (control), a significantly higher EFT (p<0,01), AST (p<0,05) and ALT (p<0,001) levels were noted. Conclusion. MAFLD in patients with MI is associated with an increase in EFT. For the combination of STEMI-steatohepatitis, compared to STEMI-HS and STEMI without MAFLD, a higher EFT was observed. This may indicate not only the role of EFT in acute coronary pathology but also the relationship of this indicator with MAFLD severity. In uncomplicated STEMI, analysis and interpretation of transaminase activity in assessing MAFLD are recommended no earlier than 10 days.

Epicardial adipose tissues reflecting visceral fat accumulations of the heart are associated with metabolic syndrome (MetS) and can be a predictor of other cardiometabolic diseases. It can adversely influence autonomic nervous system (ANS) of heart. Heart rate recovery (HRR) is an easy method for measuring ANS dysfunction. The purpose of this study was to determine whether epicardial fat thickness (EFT) and nonalcoholic fatty liver disease (NAFLD) are related to HRR in patients with MetS. We enrolled 772 consecutive patients from a health-screening center who underwent abdominal ultrasonography, treadmill test, and cardiac echocardiography. EFT using echocardiography and HRR by symptom-limited exercise testing was assessed. According to the presence of MetS and NAFLD, patients were classified into the four groups. In NAFLD patients, EFT was higher and HRR was lower, especially in patients with MetS and NAFLD, compared to non-MetS participants without NAFLD (MetS with NAFLD, EFT 7.5 ± 4.4 mm, HRR 31.9 ± 12.7; MetS without NAFLD, EFT 4.9 ± 3.0 mm, HRR 39.5 ± 11.1; non-MetS with NAFLD, EFT 5.9 ± 3.6 mm, HRR 36.6 ± 12.7; and non-MetS without NAFLD, EFT 4.4 ± 3.5 mm, HRR 43.4 ± 14.5, p < 0.001). Patients with severe liver steatosis (LS) showed significantly higher EFT than those with moderate LS (14.2 ± 2.0 vs. 7.5 ± 3.1 mm, P < 0.001), and EFT was positively correlated with severity of LS (r = 0.431, P < 0.001). HRR was significantly correlated with EFT (r = -0.386, P < 0.001) and severity of LS (r = -0.324, P < 0.001). EFT and NAFLD were significantly correlated with HRR in patients with MetS and they may be highly related to increased cardiovascular risk. These results suggest a cross-link among EFT, NAFLD, and cardiac autonomic dysfunction in patients with MetS.

Nonalcoholic Fatty Liver Disease in Children: Where Are We?

Relationship of epicardial fat thickness and nonalcoholic fatty liver disease to coronary artery calcification: From the CAESAR study

Objective: Liver fat and visceral adiposity are involved in the development of the metabolic syndrome (MetS), and epicardial adipose tissue reflects visceral fat deposit which affects the cardiac autonomic system. The aim of this study was to determine if, and to what extent, epicardial fat thickness (EFT) and non-alcoholic fatty liver disease (NAFLD) are related to heart rate recovery (HRR) as a simple cardiac autonomic indicator in patients with MetS. Design and Method: A total of 772 consecutive patients in health screening center who underwent abdominal ultrasonography, echocardiography and a treadmill test were enrolled. Echocardiographic EFT and HRR, defined as peak heart rate minus heart rate after a 1-minute recovery time, were measured. Patients were classified according to the presence of metabolic syndrome and NAFLD. Results: EFT was significantly higher and HRR was significantly lower in NAFLD patients, especially in the MetS with NAFLD, compared to the non-MetS without NAFLD (MetS with NAFLD, EFT 7.5 ± 4.4 mm and HRR 31.9 ± 12.7; MetS without NAFLD, EFT 4.9 ± 3.0 mm and HRR 39.5 ± 11.1; non-MetS with NAFLD, EFT 5.9 ± 3.6 mm and HRR 36.6 ± 12.7; non-MetS without NAFLD, EFT 4.4 ± 3.5 mm and HRR 43.4 ± 14.5; p < 0.001). Patients with severe (n = 24, ultrasound score 3) showed significantly higher EFT than those with moderate liver steatosis (n = 123, score 2) (p's < 0.001), and EFT was positively correlated with the severity of liver steatosis (r = 0.431, p < 0.001). Moreover, HRR was significantly correlated with EFT (r = −0.386, p < 0.001) and the severity of liver steatosis (r = −0.324, p < 0.001). Conclusions: EFT and NLFLD were significantly correlated with HRR in patients with MetS, and therefore may be best related to cardiovascular increased risk. Our result suggests a cross-link between epicardial fat, NLFLD and autonomic dysregulation in MetS.

We read the article“Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients” by Ozcan et al. [1] with great interest. The authors aimed to investigate the association between TIMI risk score and epicardial fat thickness (EFT) in patients with non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (USAP). They concluded that EFT is independently associated with TIMI risk score and may be an emerging risk factor for adverse events in NSTEMI/USAP patients. We thank the authors for their contribution of the present study, which is successfully designed and documented. EFT measurement with echocardiography has several advantages, including its low cost, easy accessibility, rapid applicability, and good reproducibility. EFT has a three-dimensional distribution, and two-dimensional echocardiography cannot give an adequate window of all cardiac segments, especially in obese subjects, and is highly dependent on acoustic windows [2]. It is widely recognized that an accumulation of EFT is strongly related to coronary artery disease (CAD). EFT amount may contribute to systemic inflammation beyond traditional cardiovascular risks and body fat composition. EFT measured by echocardiography has been known to be associated with metabolic syndrome [3]. Additionally, echocardiography-based EFT measurement was related to several metabolic abnormalities and independently associated with fatty liver disease [4]. Also, the duration of hormone therapy (HT) may be different in these patients. We think that the results of the study would be more robust if the authors had mentioned these factors including the duration of HT and liver function tests. EFT can also be affected by atherosclerotic risk factors such as alcohol consumption, hypothyroidism [5], and higher inflammatory status [3], for example, an inflammatory disease, cardiac syndrome X, and infection [6]. In the present study, the authors did not mention these possibly contributing factors. It would have been better if the authors had given information about these factors. Furthermore, the severity of CAD was evaluated by calculation of Gensini scores in the present study. However, the SYNTAX score (SS) may also be used for grading of coronary complexity based on angiographic visual assessment. The addition of clinical risk factors to the SS has been shown to potentially further augment its utility in the objective evaluation of the severity of CAD. The Logistic Clinical SXscore consisting of four continuous variables including SXscore, age, creatinine clearance, and left ventricular ejection fraction substantially enhances the risk stratification of CAD patients for the outcome of long-term all-cause death compared with the SXscore in isolation. The Logistic Clinical SXscore was able to accurately distinguish patients with or without a clinical outcome and could accurately predict individual patient risk without underor over-estimating risk [7]. Second, we strongly believe that it would be better to give interobserver and intraobserver variability for CAD severity in the current study. Finally, EFT itself without other inflammatory markers may not provide information to clinicians about systemic inflammation. Therefore, we think that it should be evaluated together with other serum inflammatory markers. We believe that these findings will help evaluate the results of further studies on EFT and TIMI risk score in acute coronary syndrome patients.

We read with great interest the article “Epicardial Fat Thickness as a Marker of Coronary Artery Disease in Diabetics: A Single Center Study” by Abdul Nadeem Akhter et al, in which the investigators examined the association of epicardial fat thickness (EFT) with coronary artery disease (CAD) among patients with diabetes [1]. A critical clinical question is addressed: Does echocardiographic EFT reliably stratify cardiometabolic risk in this population, and can it serve as a clinically actionable marker of CAD severity? The authors analyzed a large cohort (n = 2340) using uniform echocardiographic methodology and multivariable regression, reporting that higher EFT was significantly associated with increased CAD burden. Their findings provide important insights into the pathophysiological role of EFT in diabetic cardiovascular risk. The authors' selection of a large sample size, consistent imaging protocol, and robust regression models is commendable. Their clear reporting of baseline characteristics and analytic approach makes the main point evident: EFT may represent a novel echocardiographic marker of cardiovascular risk in diabetes. The immediate application of these findings to routine practice, however, is limited by several challenges. First, external validity requires greater emphasis. Recent studies demonstrate that population-specific variations in EFT significantly influence cardiometabolic risk, thereby limiting the generalizability of findings across diverse ethnic and demographic groups [2]. Second, the dichotomous cut-off (≥5 mm) offers analytical simplicity but risks misrepresenting a continuous biological variable such as EFT. This approach reduces statistical power and may obscure clinically relevant thresholds; modeling EFT as a continuous measure or with ROC-derived cut points would provide a more nuanced understanding [3]. Third, the study does not assess whether EFT provides incremental prognostic value beyond established tools such as coronary artery calcium (CAC) scoring. Prior evidence shows that increased EFT is associated with higher CAC burden and greater mortality, raising the question of whether EFT independently predicts CAD severity or largely reflects established risk captured by CAC [4]. Finally, while the authors minimized inter-operator variability by relying on a single echocardiographer, intra-operator variability remains an inherent limitation. Advances in artificial intelligence (AI) assisted echocardiography now enable standardized, reproducible EFT measurement, reducing both intra- and inter-operator error and offering greater precision than conventional techniques [5]. Importantly, despite these limitations, echocardiographic EFT measurement can be incorporated into routine cardiovascular evaluation, particularly in patients with diabetes, where it may aid early risk stratification and guide preventive management strategies. Future research should (a) validate EFT thresholds across ethnically diverse cohorts, (b) adopt continuous or dynamic modeling approaches, (c) test incremental prognostic value over CAC and other established biomarkers, and (d) evaluate AI-assisted echocardiography for reproducibility. These refinements, if confirmed, will help define the clinical role of EFT in cardiovascular risk stratification and its integration into patient care. In summary, Abdul Nadeem Akhter et al offer valuable evidence that EFT is closely linked to CAD in diabetes. Their findings should stimulate further research into standardization, prognostic utility, and integration with advanced imaging techniques to establish EFT as a reliable clinical tool. All Authors have equal contributions. The authors have nothing to report. The authors received no specific funding for this work. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Data can be made available upon reasonable request.

Objective:Nonalcoholic fatty liver disease is the most common cause of liver dysfunction in Western countries and an independent risk factor for atherosclerotic heart disease. Appropriate noninvasive parameters are lacking for optimal risk stratification of cardiovascular disease in these patients. We evaluated several recently discovered noninvasive parameters for atherosclerosis in patients with nonalcoholic fatty liver disease: epicardial fat thickness, aortic flow propagation velocity, and osteoprotegerin level.Methods:Forty-one patients (27 men and 14 women; mean age, 37.9±8.9 years) with nonalcoholic fatty liver disease and 37 control subjects (17 men and 20 women; mean age, 34.5±8.6 years) were enrolled in this observational case-control study. Patients with nonalcoholic fatty liver disease diagnosed at a gastroenterology outpatient clinic were included. Patients with cardiac pathology other than hypertension were excluded. Epicardial fat thickness and aortic flow propagation velocity were measured by echocardiography. The serum concentration of osteoprotegerin was measured using a commercial enzyme-linked immunosorbent assay kit.Results:Nonalcoholic fatty liver disease patients exhibited a significantly lower aortic flow propagation velocity (155.17±30.00 vs. 179.00±18.14 cm/s, p=0.000) and significantly higher epicardial fat thickness (0.51±0.25 vs. 0.29±0.09 cm, p=0.000) than control subjects. Osteoprotegerin levels were higher, but not significant, in patients with nonalcoholic fatty liver disease (28.0±13.0 vs. 25.2±10.8 pg/mL, p=0.244). Binary logistic regression analysis showed that aortic flow propagation velocity (OR, –0.973; 95% CI, 0.947–0.999) and waist circumference (OR, –1.191; 95% CI, 1.088–1.303) were independent predictors of nonalcoholic fatty liver disease.Conclusion:In this study, epicardial fat thickness and osteoprotegerin level were higher and aortic flow propagation velocity was lower in patients with nonalcoholic fatty liver disease. Early detection of abnormal epicardial fat thickness and aortic flow propagation velocity may warrant a search for undetected cardiovascular disease in patients with nonalcoholic fatty liver disease. (Anatol J Cardiol 2016; 16: 974-9)

We aimed to elucidate the frequency of polymorphic genotypes and alleles of patatin-like phospholipase domain containing 3 rs738409 polymorphism and its possible associations with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis in a cohort from Turkey.We enrolled 200 patients diagnosed with NAFLD and genotyped for rs738409 I148M polymorphism by real-time polymerase chain reaction, particularly by melting curve analysis. SPSS analysis software was used for statistical significance. Continuous variable values were expressed as mean ± standard deviation. Significant statistical level was chosen as p = 0.05.Our results demonstrate in a cohort from Turkey that rs738409 C > G polymorphism (I148M) of patatin-like phospholipase domain containing 3 gene is significantly able to affect individuals to have NAFLD in unadjusted regression model.Consistent with the previous studies in other populations, our study group showed a significantly higher risk of having NAFLD in unadjusted regression model but not in the adjusted model indicating that non-genetic factors such as age and sex may be responsible for the association. However, independent studies need to validate our findings with a larger group of NAFLD patients, as well as in different ethnic cohorts.

Comparative Early and Late Outcomes After Primary Percutaneous Coronary Intervention in ST-Segment Elevation and Non–ST-Segment Elevation Acute Myocardial Infarction (from the CADILLAC Trial)

Epicardial fat is recognized as active endocrine organ and as emerging risk factor for cardio-metabolic diseases. The aim of this study was to explore the relationship between epicardial fat and carotid intima-media thickness in type 2 diabetes patients. Epicardial fat thickness was measured in 76 type 2 diabetes patients without clinical atherosclerotic cardiovascular disease and 30 age- and sex-matched controls. In addition to laboratory tests, all patients underwent transthoracic echocardiography for epicardial fat thickness and ultrasonographic examination of carotid intima-media thickness. Patients with diabetes had higher epicardial fat thickness and carotid intima-media thickness than those of the controls (6.23 ± 1.27 mm vs 4.6 ± 1.03 mm, p < 0.001 and 0.77 ± 0.150 mm vs 0.58 ± 0.08 mm, p < 0.001, respectively). Epicardial fat thickness was correlated significantly with age, duration of type 2 diabetes, body mass index, waist circumference, HbA1c, carotid intima-media thickness, Homeostasis Model Assessment Index for insulin resistance and lipid profile in the type 2 diabetic patients. Stepwise regression analysis showed that carotid intima-media thickness, duration of diabetes, triglyceride and body mass index were the independent predictors of epicardial fat thickness, with carotid intima-media thickness the most important predictor (β = 3.078, t = 4.058, p < 0.001). Receiver operating characteristic curve analysis was done and cut-off high-risk epicardial fat thickness value of 6.1 mm was determined with a sensitivity and specificity of 71.4% and 72%, respectively. Patients with type 2 diabetes have higher carotid intima-media thickness and epicardial fat thickness. Epicardial fat thickness was found to be a strong predictor of subclinical atherosclerosis.

Background: Non alcoholic fatty liver disease (NAFLD) is an independent risk factor of cardiovascular disease (CVD). In this research, we want exploring the relationship between NAFLD, visceral fat thickness and the severity of coronary artery disease. Methods: 1, The relationship between NAFLD, visceral fat thickness and severity of coronary heart disease(323 people). 2, The correlation between severe NAFLD and visceral fat thickness in the severe stenosis of coronary heart disease(197 people). Results: 1, the proportion of NAFLD was significantly increased by 16% and 19% in different coronary artery stenosis than in the normal group. Along with the increasing degree of coronary artery stenosis, the total visceral fat thickness increase, especially the epicardial layer (the moderate stenosis increased by 23% and the severe stenosis increased by 54% than without stenosis). 2, In the severe coronary artery stenosis group, the patients were divided into NAFLD group and non NAFLD group. compared to non NAFLD group, the epicardial, liver, renal, before the perirenal fat and the coronary score significantly increased in the NAFLD group (10%, 22%, 32%, 36% and 27%, respectively) .Along with the increase of coronary score , the epicardial fat thickness was increased significantly (16% and 34%, respectively) in the non NAFLD group; but the epicardial thickness of the NAFLD group was slightly increased (8% and 8%, respectively), there was no significant difference among the subgroups. Furthermore,not only in NAFLD group but also in non NAFLD group, the visceral fat thickness of the other three sections have no significant change among the three subgroups. Conclusion: Both the NAFLD and the epicardial adipose layer thickening can increase the risk of coronary artery stenosis. In the patients with the severe coronary artery stenosis, the NAFLD patients are more likely to increase the accumulation of the visceral fat thickness than the non NAFLD patients. Under the same thickness of the epicardium, the degree of coronary artery lesions is lighter in the NAFLD patients; it may be related to AMPK wich may have the myocardial protective effects.

Effect of vitamin E supplementation on aminotransferase levels in patients with NAFLD, NASH, and CHC: Results from a meta-analysis

Context: More positive global longitudinal strain (GLS) and higher epicardial fat thickness (EFT) correlate with coronary artery disease (CAD) severity. Aim: The aim of the study was to assess the combined efficacy of GLS and EFT measurement in predicting severity of CAD measured by coronary angiography. Study and Design: Prospective, observational study conducted in Government Medical College, Kottayam, Kerala, for 2 years. One thousand patients with ≥50% coronary stenosis were grouped as cases and 500 patients who had normal coronaries or &lt;50% stenosis were taken as controls. Subjects and Methods: EFT and GLS were measured by transthoracic echo and the severity of CAD was by Gensini scoring. Statistical Analysis Used: Mean and standard deviation used for quantitative data and group differences were compared with Student’s t-test. Results: We observed a mean EFT of 7.2 mm ± 1.6 mm and mean GLS of–13.24 ± 1.6 among cases compared to a mean EFT of 3.4 mm ± 0.8 mm and mean GLS of–19.2 ± 1.2 in the controls with P &lt; 0.001. The cutoff values of EFT and GLS for predicting significant CAD were 4.85 mm and 14.9 with a sensitivity of 96% and specificity of 88%. Conclusion: Combined use of GLS and EFT measurement is less costly and very well correlates with CAD severity.

Evaluation and management of non-alcoholic steatohepatitis