Abstract
Background: Visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) are increasingly recognized as relevant contributors to cardiometabolic alterations and subclinical myocardial dysfunction, independently of overall obesity. Their pathogenic role extends beyond simple fat accumulation, encompassing inflammatory activation, lipotoxicity, and altered myocardial metabolism. Objective: This narrative review synthesizes current evidence on the relationships between VAT/EAT and myocardial strain parameters, with emphasis on subclinical cardiovascular risk detection and nutritional interventions. Methods: We conducted a comprehensive review of studies published between 2003-2025, focusing on imaging-based assessments of adipose tissue distribution and strain parameters using echocardiography, computed tomography, and cardiac magnetic resonance. Results: Increased EAT and, to a lesser extent, VAT showed significant associations with impaired global longitudinal strain (GLS) across imaging-based studies. In patients with type 2 diabetes, VAT mediated a substantial proportion of the association between insulin resistance and left ventricular dysfunction. Mediterranean diet adherence was associated with lower epicardial adipose tissue burden, while higher EAT was associated with persistent atrial fibrillation among patients with atrial fibrillation undergoing catheter ablation. Speckle-tracking echocardiography consistently showed superior prognostic value compared to ejection fraction for detecting subclinical dysfunction. Conclusions: VAT and EAT represent important mechanistic links between body composition and early myocardial dysfunction, identifiable through advanced strain imaging before clinical disease becomes apparent. These findings support the integration of multimodal cardiac imaging and nutritional interventions into cardiovascular prevention strategies, providing novel opportunities for early risk stratification and personalized treatment approaches.