Regional cardiac ectopic fat: From pathophysiology to therapeutic perspectives

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide, while its pathogenesis is complex and has not been fully elucidated. Cardiac ectopic fat deposition, primarily including epicardial adipose tissue (EAT), perivascular adipose tissue (PVAT), and pericardial adipose tissue (PAT), is increasingly recognized for its role in cardiovascular dysfunction. In obesity and insulin resistance, these fat depots may undergo pathological expansion and functional remodelling. This pathological transition involves inflammatory activation, lipotoxicity, oxidative stress, fibrotic remodelling, and metabolic dysfunction, contributing to cardiovascular injury through distinct pathways. EAT is closely linked to myocardial and atrial remodelling, whereas PVAT contributes to vascular inflammation and dysfunction. PAT is more closely associated with systemic adiposity and cardiometabolic risk. With the increasing prevalence of obesity and metabolic syndrome, the clinical burden associated with cardiac ectopic fat is expected to increase. This review summarizes the anatomical localization, physiological functions, obesity-associated remodelling and pathogenic mechanisms of ectopic fat in distinct cardiac regions, along with potential intervention strategies. Lifestyle modification, pharmacological treatment, and bariatric surgery may modulate regional fat accumulation and function. Understanding the distinct characteristics of these depots may support improved cardiovascular risk assessment and more targeted therapeutic approaches.