We have read with great interest the Letter to the Editor concerning our recently published paper on the association between an increased ratio of visceral to subcutaneous abdominal adipose tissue and higher risk of major adverse cardiovascular events, independently of traditional cardiovascular risk factors and coronary calcium.1
Epicardial adipose tissue (EAT) is an ectopic fat storage site in direct contact with adjacent coronary arteries and myocardium; therefore, it can have a paracrine effect on coronary atherosclerosis and myocardial function through the secretion of several adipokines that might regulate insulin resistance and inflammation.2
The putative association between EAT and visceral or subcutaneous abdominal fat is a promising research line that should continue to be addressed in future studies. Our group has already shown that EAT volume is positively correlated to coronary atherosclerotic burden, assessed by coronary artery calcium score, independently of abdominal visceral adipose tissue.3 Furthermore, in patients after a myocardial infarction, EAT volume was independently associated with decreased E’ velocity and increased E/E’ ratio, therefore suggesting impaired diastolic function.4
Thus, EAT seems to be associated not only with atherosclerotic burden and risk of cardiovascular disease, but also with maladaptive changes in myocardial function that increase the risk of heart failure. It is our opinion that ectopic adipose tissue, with special emphasis on EAT, greatly contribute to metabolic homeostasis and modulate activation of inflammatory cascades, therefore being a key player in cardiovascular health and disease.