Kenchaiah et al (1) reported that elevated pericardial fat volume (PFV) was associated with a greater risk of incident heart failure (mostly the risk of heart failure with preserved ejection fraction [HFpEF]) among participants from the MESA (Multi-Ethnic Study of Atherosclerosis), and this association was independent of established cardiovascular risk factors and abdominal (subcutaneous and visceral) fat depots, as measured with computed tomography (CT). The observations of this elegant multi-ethnic prospective cohort study of middle-aged overweight or obese participants without clinically apparent cardiovascular disease are in line with previous studies supporting that different ectopic fat depots may contribute to obesity-mediated cardiovascular complications and explain part of this risk differential (2). As the authors performed CT scans in at least one-quarter of the MESA participants, it would be interesting to know whether they have any data about the possible prognostic impact of nonalcoholic fatty liver disease (ie, an important and common condition ectopic fat depot that may systemically release multiple proinflammatory and proatherogenic mediators) on the risk of incident HFpEF, or whether the association between PFV and risk of incident HFpEF was attenuated after additional adjustment for the presence of fatty liver, as detected by CT scans. We believe that this information would be clinically relevant for the readers, because nonalcoholic fatty liver disease is not only associated with higher PFV (3), but also with left ventricular hypertrophy and impaired left ventricular diastolic function (4,5), which are pivotal processes in the development and progression of HFpEF..
S Bonapace;G Targher
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