Open access


Atrial fibrillation is the most frequent arrhythmia in adults, becoming more frequent with age. Recent clinical studies demonstrated that epicardial fat is linked with atrial fibrillation induction and recurrence. The arrhythmogenic mechanism consists in the fact that the epicardial adipose tissue is metabolically active, inducing local inflammation and enhancing the oxidative stress, which lead to atrial fibrillation as well as atherosclerosis. Having metabolic activity and secreting various anti- and pro-inflammatory biomarkers, the fat surrounding the heart has been linked to the complex process of coronary plaque vulnerabilization. This clinical update aims to summarize the role of epicardial adipose tissue in the pathogenesis, persistence, and severity of atrial fibrillation.

1. Fuster V, Ryden LE, Cannom DS, Crijns HJ, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006:114:e257-e354.

2. Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013;34:2746-2751.

3. Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA. 2004:292:2471-2477.

4. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med. 2002:347:305-313.

5. Wanahita N, Messerli FH, Bangalore S, Gami AS, Somers VK, Steinberg JS. Atrial fibrillation and obesity – results of a meta-analysis. Am Heart J. 2008:155:310-315.

6. Thanassoulis G, Massaro JM, O'Donnell CJ, et al. Pericardial fat is associated with prevalent atrial fibrillation: the Framingham Heart Study. Circ Arrhythm Electrophysiol. 2010;3:345-350.

7. Doesch C, Jochims J, Streitner F, et al. Novel prognostic markers derived from cardiovascular magnetic resonance imaging in patients with stable chronic coronary artery disease. InVivo. 2015;29:737-747.

8. Opincariu D, Mester A, Dobra M, et al. Prognostic value of epicardial fat thickness as a marker of increased inflammatory status in patients with type 2 diabetes mellitus and acute myocardial infarction. Journal of Cardiovascular Emergencies. 2016;2:11-18.

9. Mahabadi A, Berg M, Lehmann N, et al. Association of Epicardial Fat With Cardiovascular Risk Factors and Incident Myocardial Infarction in the General Population: The Heinz Nixdorf Recall Study. J Am Coll Cardiol. 2013;61:1388-1395.

10. Nakanishi K, Fukuda S, Tanaka A, et al. Persistent epicardial adipose tissue accumulation is associated with coronary plaque vulnerability and future acute coronary syndrome in nonobese subjects with coronary artery disease. Atherosclerosis. 2014;237:353-360.

11. Tamarappoo B, Dey D, Shmilovich H, et al. Increased pericardial fat volume measured from non-contrast CT predicts myocardial ischemia by SPECT. JACC Cardiovasc Imaging. 2010;3:1104-e1112.

12. Doesch C, Süselbeck T, Haghi D, et al. The relationship between the severity of coronary artery disease and epicardial adipose tissue depends on the left ventricular function. PLoS One. 2012;7:e48330.

13. Nakanishi K, Fukuda S, Tanaka A, et al. Persistent epicardial adipose tissue accumulation is associated with coronary plaque vulnerability and future acute coronary syndrome in nonobese subjects with coronary artery disease. Atherosclerosis. 2013;237:353-360.

14. Fukamachi D, Higuchi Y, Hiro T, et al. Association between the epicardial adipose tissue thickness and the presence of multivessel disease in patients with acute myocardial infarction. J Atheroscler Thromb. 2014;2:144-151.

15. Wong CX, Sun MT, Odutayo A, et al. Associations of Epicardial, Abdominal, and Overall Adiposity with Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2016;pii:e00437.

16. Iacobellis G, Corradi D, Sharma AM. Epicardial adipose tissue: anatomic, biomolecular and clinical relationships with the heart. Nat Clin Pract Cardiovasc Med. 2005;2:536-543.

17. Sawaya SE, Rajawat YS, Rami TG, et al. Downregulation of connexin40 and increased prevalence of atrial arrhythmias in transgenic mice with cardiac-restricted overexpression of tumor necrosis factor. Am J Physiol Heart Circ Physiol. 2007;292:H1561-H1567.

18. Marcus GM, Whooley MA, Glidden DV, Pawlikowska L, Zaroff JG, Olgin JE. Interleukin-6 and atrial fibrillation in patients with coronary artery disease: data from the Heart and Soul Study. Am Heart J. 2008;155:303-309.

19. Tselentakis EV, Woodford E, Chandy J, Gaudette GR, Saltman AE. Inflammation effects on the electrical properties of atrial tissue and inducibility of postoperative atrial fibrillation. J Surg Res. 2006;135:68-75.

20. Chung MK, Martin DO, Sprecher D, et al. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation. 2001;104:2886-2891.

21. Malouf JF, Kanagala R, Al Atawi FO, et al. High sensitivity Creactive protein: a novel predictor for recurrence of atrial fibrillation after successful cardioversion. J Am Coll Cardiol. 2005;46:1284-1287.

22. Aviles RJ, Martin DO, Apperson-Hansen C, et al. Inflammation as a risk factor for atrial fibrillation. Circulation. 2003;108:3006-3010.

23. Rotter M, Jais P, Vergnes MC, et al. Decline in C-reactive protein after successful ablation of long-lasting persistent atrial fibrillation. J Am Coll Cardiol. 2006;47:1231-1233.

24. Sacks HS, Fain JN. Human epicardial adipose tissue: a review. Am Heart J. 2007;153:907-917.

25. Verheule S, Sato T, Everett TT, et al. Increased vulnerability to atrial fibrillation in transgenic mice with selective atrial fibrosis caused by overexpression of TGF-beta1. Circ Res. 2004;94:1458-1465.

26. Hatem SN, Sanders P. Epicardial adipose tissue and atrial fibrillation. Cardiovasc Res. 2014;102:205-213.

27. Mahajan R, Lau DH, Brooks AG, et al. Electrophysiological, electroanatomical and structural remodeling of the atria as a consequence of sustained obesity. J Am Coll Cardiol. 2015;66:1-11.

28. Shirani J, Berezowski K, Roberts WC. Quantitative measurement of normal and excessive (cor adiposum) subepicardial adipose tissue, its clinical significance, and its effect on electrocardiographic QRS voltage. Am J Cardiol. 1995;76:414-418.

29. Nakagawa H, Scherlag BJ, Patterson E, Ikeda A, Lockwood D, Jackman WM. Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation. Heart Rhythm. 2009;6:S26-S34.

30. Schauerte P, Scherlag BJ, Pitha J, et al. Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation. Circulation. 2000;102:2774-2780.

31. Gaeta M, Bandera F, Tassinari F, et al. Is epicardial fat depot associated with atrial fibrillation? A systematic review and metaanalysis. Europace. 2017;19:747-752.

32. Al-Rawahi M, Proietti R, Thanassoulis G. Pericardial fat and atrial fibrillation: Epidemiology, mechanisms and interventions. Int J Cardiol. 2015;195:98-103.

33. Wong CX, Abed HS, Molaee P, et al. Pericardial fat is associated with atrial fibrillation severity and ablation outcome. J Am Coll Cardiol. 2011;57:1745-1751.

34. Batal O, Schoenhagen P, Shao M, et al. Left atrial epicardial adiposity and atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3:230-236.

35. Greif M, von Ziegler F, Wakili R, et al. Increased pericardial adipose tissue is correlated with atrial fibrillation and left atrial dilatation. Clin Res Cardiol. 2013;102:555-562.

36. Nagashima K, Okumura Y, Watanabe I, et al. Association between epicardial adipose tissue volumes on 3-dimensional reconstructed CT images and recurrence of atrial fibrillation after catheter ablation. Circ J. 2011;75:2559-2565.

37. Benedek T, Rat N, Hodas R, Opincariu D, Mester A, Benedek I. The Assessment of Epicardial Adipose Tissue in Acute Coronary Syndrome Patients. A Systematic Review. Journal of Cardiovascular Emergencies. 2017;3:18-29.

38. Bertaso A, Bertol D, Duncan B, Foppa M. Epicardial Fat: Definition, Measurements, and Systematic Review of Main Outcomes. Arq Bras Cardiol. 2013;101:18-28.

39. Iacobellis G, Assael F, Ribaudo M, et al. Epicardial fat from echocardiography: a new method for visceral adipose tissue prediction. Obes Res. 2003;11:304-310.

40. Iacobellis G, Willens H. Echocardiographic Epicardial Fat: A Review of Research and Clinical Applications. J Am Soc Echocardiogr. 2009;22:1311-1319.

41. Iacobellis G, Willens H, Barbaro G, Sharma AM. Threshold values of high risk echocardiographic epicardial fat thickness. Obesity (Silver Spring). 2008;16:887-892.

42. Iacobellis G, Singh N, Wharton S, Sharma A. Substantial changes in epicardial fat thickness after weight loss in severely obese subjects. Obesity (Silver Spring). 2008;16:1693-1697.

43. Jeong J, Jeong M, Yun K, et al. Echocardiographic epicardial fat thickness and coronary artery disease. Circ J. 2007;71:536-539.

44. Al Chekakie MO, Akar JG. Epicardial Fat and Atrial Fibrillation: A Review. J Atr Fibrillation. 2012;4:483.

45. Sarin S, Wenger C, Marwaha A, et al. Clinical significance of epicardial fat measured using cardiac multislice computed tomography. Am J Cardiol. 2008;102:767-771.

46. Tsao HM, Hu WC, Wu MH, et al. Quantitative analysis of quantity and distribution of epicardial adipose tissue surrounding the left atrium in patients with atrial fibrillation and effect of recurrence after ablation. Am J Cardiol. 2011;107:1498-1503.

47. Al Chekakie MO, Welles CC, Metoyer R, et al. Pericardial fat is independently associated with human atrial fibrillation. J Am Coll Cardiol. 2010;56:784-788.

48. Mahajan R, Kuklik P, Grover S, et al. Cardiovascular magnetic resonance of total and atrial pericardial adipose tissue: a validation study and development of a 3 dimensional pericardial adipose tissue model. J Cardiovasc Magn Reson. 2013;15:73.

49. Altun B, Colkesent Y, Gazi E, et al. Could Epicardial Adipose Tissue Thickness by Echocardiography be Correlated with Acute Coronary Syndrome Risk Scores. Echocardiography. 2013;30:1130-1134.

50. Gul I, Zungur M, Aykan A, et al. The relationship between GRACE score and Epicardial Fat thickness in non-STEMI Patients. Arq Bras Cardiol. 2016;106:194-200.

51. Ozcan F, Turak O, Canpolat U, et al. Association of epicardial fat thickness with TIMI risk score in NSTEMI/USAP patients. Herz. 2013;39:755-760.

52. Zencirci E, Zencirci A, Degirmencioglu A, et al. The relationship between epicardial adipose tissue and ST-segment resolution in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Heart Vessels. 2014;2:147-153.

53. Wang T, Liu Q, Liu C, et al. Correlation of Echocardiographic Epicardial Fat Thickness with Severity of Coronary Artery Disease in Patients with Acute myocardial infarction. Echocardiography. 2014;31:1177-1181.

54. Tanindi A, Erkan A, Ekici B. Epicardial adipose tissue thickness can be used to predict major adverse cardiac events. Coron Artery Dis. 2015;26:686-691.

55. Hajsadeghi F, Nabavi V, Bhandari A, et al. Increased epicardial adipose tissue is associated with coronary artery disease and major adverse cardiovascular events. Atherosclerosis. 2014;237:486-489.

56. Cheng V, Dey D, Tamarappoo B, et al. Pericardial fat burden on ECG-gated non-contrast CT in asymptomatic patients who subsequently experience adverse cardiovascular events. JACC Cardiovasc Imaging. 2010;3:352-360.

57. Bos D, Vernooij MW, Shahzad R, et al. Epicardial Fat Volume and the Risk of Atrial Fibrillation in the General Population Free of Cardiovascular Disease. JACC Cardiovasc Imaging. 2017;10:1405-1407.

58. Kim TH, Park J, Park JK, et al. Pericardial fat volume is associated with clinical recurrence after catheter ablation for persistent atrial fibrillation, but not paroxysmal atrial fibrillation: an analysis of over 600 patients. Int J Cardiol. 2014;176:841-846.

59. Wong CX, Abed HS, Molaee P, et al. Pericardial fat is associated with atrial fibrillation severity and ablation outcome. J Am Coll Cardiol. 2011;57:1745-1751.

Journal Information


All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 216 136 21
PDF Downloads 111 82 13