Mediastinal adipose tissue as an active player in cardiovascular disease: a multimodality imaging narrative review

Mediastinal adipose tissue comprises several distinct fat depots, including epicardial, pericoronary, pericardial, and paracardial adipose tissue, which surround the heart and great vessels and actively contribute to cardiovascular pathophysiology. Under physiological conditions, these adipose compartments exert protective metabolic and mechanical functions; however, in pathological states, their expansion and remodeling promote inflammation, endothelial dysfunction, fibrosis, and atherosclerotic progression. This narrative review aims to summarize the current evidence regarding the anatomical distribution, imaging assessment, and clinical implications of mediastinal adipose tissue in cardiovascular disease.

A narrative review was conducted using PubMed, Scopus, and Web of Science databases, covering publications up to January 2026. Only articles published in English were considered. Original research articles and relevant reviews focusing on imaging, pathophysiology, and clinical implications of mediastinal adipose tissue were included. Reference lists of selected studies were additionally screened to identify additional relevant publications.

Computed tomography (CT) enables highly reproducible volumetric and qualitative assessment of cardiac adipose tissue, including inflammatory markers such as the fat attenuation index (FAI). Magnetic resonance imaging (MRI) provides excellent tissue characterization without ionizing radiation, whereas echocardiography represents a simple and widely available screening tool. Increased epicardial, pericoronary, and pericardial adipose tissue (PAT) burden has been consistently associated with coronary artery disease (CAD), atrial fibrillation (AF), and heart failure (HF), particularly HF with preserved ejection fraction (HFpEF). Emerging evidence also supports the potential role of artificial intelligence (AI) and radiomics for automated quantification and cardiovascular risk stratification.

Mediastinal adipose tissue is increasingly recognized as an active biomarker and potential therapeutic target in cardiovascular disease. Multimodality imaging plays a central role in its evaluation by providing complementary anatomical, functional, and inflammatory information. Further standardization of imaging methodologies and validation of treatment-related changes are needed to support future clinical applications and personalized cardiovascular risk assessment.