Epicardial adipose tissue between biological complexity and clinical readiness

Epicardial adipose tissue (EAT) is gaining visibility as an imaging biomarker, yet its clinical maturity remains limited. The recent exchange between Angeli et al. and Momot et al. highlights persistent gaps in measurement standardisation, methodological transparency, and reproducibility-prerequisites for any translational advance. Mechanistic plausibility alone is insufficient: the key question is whether EAT adds meaningful prognostic value beyond established metabolic and imaging markers, and whether such gains are calibrated and clinically actionable. Phenotype‑specific signals, such as in atrial fibrillation, are intriguing but not definitive. Emerging indices of tissue "quality", including density and perivascular fat attenuation, require validated thresholds and outcome‑based evidence. The field now needs pragmatic trials testing EAT‑ or FAI‑guided strategies to determine whether adipose tissue imaging can genuinely improve patient outcomes.