The Role of Echocardiography in the Assessment of Epicardial Adipose Tissue: A Systematic Review and Meta-analysis

Figures

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  This graphical abstract summarizes the relationship between transthoracic echocardiography–derived epicardial adipose tissue (EAT) thickness and volumetric EAT assessment obtained by cardiac computed tomography or cardiac magnetic resonance imaging. While cross-sectional imaging techniques provide accurate three-dimensional quantification of EAT, their use is limited in preventive and longitudinal settings. Echocardiography offers a pragmatic, radiation-free alternative that allows rapid assessment of EAT. The figure highlights the significant association between one-dimensional echocardiographic measurements and volumetric EAT, as well as the clinical implications for large-scale screening and follow-up. Methodological heterogeneity and the need for standardization are emphasized as key limitations for clinical translation.

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  Fig. 1. (A) Epicardial adipose tissue assessment in parasternal long axis (linear assessment), (B) Epicardial adipose tissue assessment in parasternal short axis. (C) Epicardial adipose tissue assessment

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  Fig. 2. Prisma flow diagram of study selection

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  Fig. 3. Meta-analytic results of the association between TTE- EAT thickness and CMR-derived EAT

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  Fig. 4. Forest plot of the random-effects exploratory meta-analysis assessing the association between increased TTE- EAT thickness and major adverse CV events, including only studies reporting hazard ratios. Effect estimates are shown on the logarithmic scale (pooled HR 1.50, 95% CI 0.67–3.37; p = 0.326)

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  Fig. 5. Sensitivity analysis including one study reporting relative risks, treated as an approximation of hazard ratios. Effect estimates are shown on the logarithmic scale HR 1.81 (95% CI 0.88–3.74), p = 0.108)

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  Fig. 6. Proposed standardized protocol for transthoracic echocardiographic assessment of epicardial adipose tissue. The figure summarizes a pragmatic stepwise approach for TTE-derived EAT thickness assessment based on the most reproducible methodologies reported in the literature. Recommended acquisition includes measurement at end-systole in the parasternal long-axis view over the right ventricular free wall, using the aortic annulus as an anatomical reference and averaging at least three cardiac cycles. Technical optimization should include appropriate gain and compression settings and careful differentiation between epicardial fat, pericardial fat, and pericardial effusion. The protocol also emphasizes systematic reporting of imaging view, cardiac phase, and measurement methodology in order to reduce operator dependency and improve inter-study comparability. Prospective validation studies are warranted before clinical implementation