Echocardiographic reference values for epicardial adipose tissue: insights from a large population-based study

Abstract Background Epicardial adipose tissue (EAT) is increasingly recognized as a marker and potential mediator of cardiovascular disease. Purpose To evaluate the association between EAT thickness and echocardiographic parameters, identify predictors of increased EAT in patients with pathological findings, and establish reference values in individuals with normal cardiac structure and function. Methods In total, 4,364 transthoracic echocardiograms were analysed to detect EAT thickness at the Rindfleisch fold and correlated with demographic, anthropometric, and cardiac parameters. Patients were stratified by echocardiographic findings, and regression analyses were performed to identify independent associations. Mean EAT thickness was 11.1 (IQR: 11.0; 11.3) mm. Results Patients with pathological echocardiographic findings (n=3,253) had significantly higher EAT (12.7 mm; IQR: 12.6; 12.9) than those with normal echocardiograms (6.4 mm; IQR: 6.2; 6.7; p 0.0001). In multiple regression analysis, LAVI (β = 0.07, p 0.0001), TAPSE (β = –0.23, p 0.0001), and RA area (β = 0.15, p = 0.0009) remained independently associated with EAT. No gender differences were observed. Reference values for EAT increased progressively across age and BMI categories in the healthy subgroup. Elevated EAT was predictive of adverse cardiac remodelling and may contribute to disease progression. Conclusion This study provides novel insights into the clinical relevance of EAT as a marker of cardiac dysfunction. We propose the first echocardiographic reference values for EAT thickness, stratified by age and BMI. A standardized measurement technique and decision tree model offer a practical approach for integrating EAT assessment into routine echocardiography, potentially enhancing cardiovascular risk stratification and guiding future therapeutic strategies.