The Role of Epicardial Fat Thickness and B-type Natriuretic Peptide (BNP)/N-terminal Pro B-type Natriuretic Peptide (NT-proBNP) in Heart Failure Risk Stratification: A Systematic Review.

Heart failure (HF) remains a global health challenge, necessitating improved risk stratification tools. This systematic review evaluates the combined role of epicardial fat thickness (EFT) and B-type natriuretic peptide (BNP)/N-terminal pro B-type natriuretic peptide (NT-proBNP) in HF risk stratification, examining their pathophysiological interplay and clinical utility across diverse populations, including a wide age range, various comorbidities (e.g., obesity, diabetes, and systemic sclerosis), and geographic regions. EFT, a measurable marker of epicardial adipose tissue (EAT) located between the myocardium and visceral pericardium, was evaluated alongside BNP/NT-proBNP, established biomarkers of cardiac stress. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, 12 case-control studies were included after screening 192 records from PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library. Studies assessed EFT and BNP/NT-proBNP in HF or at-risk populations. Methodological quality was appraised using the Newcastle-Ottawa Scale (NOS). EFT consistently correlated with elevated BNP/NT-proBNP, though patterns differed by HF phenotype. In HF with reduced ejection fraction (HFrEF), NT-proBNP associated more strongly with muscle loss than adiposity, while in HF with preserved ejection fraction (HFpEF), EFT was linked to metabolic comorbidities and inflammatory markers. Paradoxically, lower EFT predicted worse outcomes in nonischemic cardiomyopathy (NICMP), potentially reflecting disease-related fat depletion or cachexia; this finding underscores the need for phenotype-specific interpretation of EFT in risk stratification. Mechanistically, EAT contributed to myocardial remodeling via adipokine secretion and inflammatory signaling. Four studies had a low risk of bias (NOS ≥ 8), while one showed a high risk. The combined assessment of EFT and BNP/NT-proBNP offers complementary prognostic insights, EFT capturing subclinical inflammation and adiposity-related remodeling, while BNP/NT-proBNP reflects myocyte stress, potentially guiding personalized treatment decisions, including closer monitoring of HFpEF patients with elevated EFT and early nutritional or anti-inflammatory interventions in those with muscle loss and elevated NT-proBNP. Inclusion criteria encompassed adult populations with HF or related conditions, with exclusion of reviews, case reports, and non-English articles, supporting the methodological rigor of this synthesis. Standardized EFT measurement and targeted EAT-modulating therapies warrant further investigation.