Epicardial and pericardial adipose tissue: anatomy, physiology, imaging, segmentation, and treatment effects

Epicardial (EAT) and pericardial adipose tissue (PAT) are increasingly recognized as distinct fat depots with implications for cardiovascular disease. This review discusses their anatomical and physiological characteristics, as well as their pathophysiological roles. EAT, in direct contact with the myocardium, exerts local inflammatory and metabolic effects on the heart, while PAT influences cardiovascular health rather systemically. We sought to discuss the currently used imaging modalities to assess these fat compartments-CT, MRI, and echocardiography-emphasizing their advantages, limitations, and the urgent need for standardization for both scanning and image reconstruction. Advances in image segmentation, particularly deep learning-based approaches, have improved the accuracy and reproducibility of EAT and PAT quantification. This review also explores the role of EAT and PAT as risk factors for cardiovascular outcomes, summarizing conflicting evidence across studies. Finally, we summarize the effects of medical therapy and lifestyle interventions on reducing EAT volume. Understanding and accurately quantifying EAT and PAT is essential for cardiovascular risk stratification and may open new pathways for therapeutic interventions.