Dapagliflozin effect on pericardial fat deposition: lessons from the DAPA EAT

Epicardial adipose tissue (EAT) is increasingly recognized as an active cardio-metabolic organ that contributes to early myocardial dysfunction through inflammatory, oxidative, and fibrotic pathways. In heart failure (HF), expanded EAT has been associated with higher risks of HF hospitalization and mortality, and several cohort studies and meta-analyses now support EAT as an independent prognostic marker with incremental value beyond conventional clinical parameters. Importantly, EAT is modifiable: glucagon-like peptide-1 receptor agonists, thiazolidinediones, and more recently sodium–glucose cotransporter-2 inhibitors (SGLT2i) have demonstrated reductions in EAT, with dapagliflozin showing consistent effects across patients with type 2 diabetes, coronary artery disease, and HF. Against this background, the DAPA-EAT trial examined the impact of dapagliflozin on EAT in individuals with subclinical stage B HF. This multicenter, randomized, study enrolled 229 adults with asymptomatic structural HF and randomized them to dapagliflozin or standard therapy for 24 weeks, with blinded evaluation of cardiac CT and echocardiographic endpoints. Dapagliflozin produced significant reductions in EAT volume, myocardial fibrosis, and left-ventricular mass, together with modest improvements in diastolic indices, without significant change in NT-proBNP or hs-CRP. The study’s strengths include its randomized design, blinded image analysis, and comprehensive structural assessment. Although participants were classified as stage B HF, they represented a clinically high-risk cohort - older individuals with a predominance of ischemic disease and multiple cardiometabolic comorbidities. Several limitations warrant consideration, including the relatively short duration, modest sample size, and the reliance on CT and echocardiography rather than cardiac MRI for tissue characterization. Additionally, the lack of phenotype-specific analyses (HFrEF vs. HFmrEF vs. HFpEF) prevents phenotype-specific insight into how dapagliflozin affects remodeling. Despite these constraints, DAPA-EAT indicates that dapagliflozin is associated with reductions in EAT and selected early structural indices, although the clinical relevance of these changes remains to be fully established. Words counts: 293.