CT-derived adipose tissue density reflects systemic inflammatory burden and independently predicts mortality in elderly patients with HFpEF
K Shi, Q Y Wang, M Q Ye, X K QuAbstract
Background
Heart failure with preserved ejection fraction (HFpEF) is a complex systemic syndrome driven by chronic inflammation, predominantly affecting the elderly population. While conventional volumetric body composition measures (e.g., muscle or fat quantity) are widely used, they may inadequately capture the underlying biological vulnerability and "inflammaging" process. CT-derived adipose tissue attenuation (density) has emerged as a potential marker of tissue quality, yet its specific prognostic value and association with systemic inflammation in elderly HFpEF remains to be fully elucidated.
Methods
We retrospectively analyzed 467 elderly patients with HFpEF who underwent chest CT between July 2019 and June 2024 (mean age 78.2±9.1 years). Single-slice analysis at the T12 level quantified volumetric indices (SMI, IMATI, SATI, VATI) and tissue densities (SMD, IMATD, SATD, VATD). All-cause mortality was defined as the primary endpoint, with a median follow-up of 21 months. Multivariable Cox models were adjusted for age, sex, smoking, hypertension, diabetes, serum creatinine, and BNP. Associations with systemic inflammatory markers (CRP, NLR, SII) were evaluated.
Results
During follow-up, 122 deaths (26.1%) occurred. Restricted cubic spline analysis demonstrated a U-shaped association between SMI and mortality (P for nonlinearity=0.008), whereas IMATD and SATD showed linear positive relationships (Figure 1A). Although SMD demonstrated an overall association in preliminary analysis, it did not remain a significant independent predictor (P=0.068) after full adjustment for clinical confounders. In fully adjusted models, IMATD exhibited the strongest association with mortality (HR 1.55 per 10 HU, 95% CI 1.25–1.91, P<0.001), followed by SATD (HR 1.25 per 10 HU, 95% CI 1.12–1.37, P<0.001) (Figure 2A). Correlation analysis showed that IMATD and SATD were consistently and positively associated with systemic inflammatory markers, including CRP (r=0.17 and 0.15), NLR (r=0.23 and 0.23), and SII (r=0.18 and 0.16) (all P<0.01), while volumetric measures showed no such correlations (Figure 1B). Kaplan–Meier analysis confirmed significantly reduced survival in patients with elevated IMATD (log-rank P<0.001) and SATD (log-rank P=0.002) (Figure 2B).
Conclusion
In elderly patients with HFpEF, mortality risk is characterized by a dual pattern: a U-shaped relationship with skeletal muscle mass and a linear increase with higher adipose tissue density. These findings suggest that adipose tissue quality—rather than mere quantity—serves as a robust reflector of systemic inflammatory burden and an independent predictor of poor prognosis. Integrating CT-derived tissue quality assessment into clinical practice may refine inflammatory phenotyping and facilitate more precise risk stratification and targeted management for this high-risk population.Adipose Tissue Density Links InflammationAdipose Tissue Density Predicts Mortality