When it comes to the risk of coronary artery disease (CAD), not all fat is created equal, say Hungarian researchers. They found that at least one type of visceral fat correlates with the presence of coronary artery disease.
Dr. Zsofia Drobni from the Cardiovascular Imaging Research Group at Semmelweis University in Budapest.Investigators from Semmelweis University examined healthy patients from the Burden of Atherosclerotic Plaque Study in Twins (BUDAPEST) to look for a relationship between fat in different regions of the abdomen and the presence of coronary artery disease using low-dose CT of the abdomen, as well as coronary CT angiography (CCTA).
They found that regions of visceral adipose tissue surrounding the heart were associated with the presence of coronary artery disease, while fat in other regions had no effect.
"Epicardial fat volume is an independent predictor of coronary artery disease," said Dr. Zsofia Drobni, from the Cardiovascular Imaging Research Group, in a presentation at ECR 2016. "This finding supports the hypothesis that epicardial fat promotes atherosclerosis development."
Visceral obesity a danger sign
The study measured epicardial fat volume (EFV), subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT), comparing each type to the presence of coronary artery disease as assessed by CCTA.
"Ectopic fat is defined as fat accumulation in tissues other than adipose tissue, which normally contains only small amounts of fat -- for example in the liver, in the heart, and in the pancreas," Drobni said. "Epicardial fat can be defined as fat found inside the pericardium."
CT can look for two main types of fat: subcutaneous fat, which accumulates under the skin, and fat that accumulates between the abdominal organs in the case of visceral obesity.
Visceral adipose tissue (VAT) is known to be more dangerous to health than subcutaneous adipose tissue (SAT). In particular, visceral fat surrounding the heart raises the risk of coronary artery disease. All images courtesy of Dr. Zsofia Drobni.The study included 195 healthy asymptomatic subjects with no history of coronary disease from the BUDAPEST study. All of them underwent low-dose noncontrast-enhanced CT, from which the study team quantified the epicardial fat volume. Every patient also underwent coronary CT angiography.
In the CCTA studies, readers assessed every coronary artery segment for the presence of atherosclerotic plaque, classifying the patients into groups with CAD and without CAD. For patients who were positive for coronary disease, they calculated the segment involvement score, representing the total number of arterial segments with plaque.
The researchers also measured epicardial fat volume from the CCTA data, while measuring the SAT and VAT fat types on a single CT slice acquired at the level of the L3/L4 vertebrae.
3D reconstruction of epicardial fat volume. Epicardial fat (in yellow) is associated with a higher risk of coronary artery disease.Drobni and her team quantified epicardial fat volume semiautomatically by tracing the border of the epicardium from the bifurcation to the pulmonary artery. They then used software to calculate volume from the outlined area in cubic centimeters, and the group also used logistic regression to assess independent predictors of the presence of CAD.
Logistic regression analysis of study data shows that age, hypertension, and visceral adipose tissue, particularly the epicardial fat volume, were significantly associated with the risk of coronary artery disease.Enhanced risk profile
Independent of traditional risk factors, the study team found the following characteristics to be independent predictors of coronary artery disease:
- Epicardial fat volume, which had an odds ratio (OR) for predicting CAD of 1.32 (p = 0.001)
- Age, OR of 1.1 (p < 0.001)
- Male gender, OR of 10.0 (p < 0.001)
- Hypertension, OR of 3.3 (p < 0.05)
"With an odds ratio of 1.30 it means that if you have 10 cm more of epicardial fat volume, your risk for epicardial disease is 32% higher," Drobni said.
Epicardial fat volume is an independent predictor of coronary artery disease, supporting the hypothesis that epicardial fat promotes the development of atherosclerosis, she said.
"By measuring epicardial fat volume, prediction could be more accurate, and this could be also a great step in the development of patient-based risk stratification," Drobni concluded.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
