Longitudinal change in epicardial adipose tissue attenuation on serial non-contrast chest CT in finerenone-treated patients: a real-world cohort study
X Zhang, C Q Zhang, Z Zhang, J She, B LouAbstract
Background
Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot adjacent to the myocardium and coronary arteries and can be quantified on routine non-contrast CT. Beyond volume, CT-derived EAT attenuation (HU) has been proposed as a marker of adipose tissue composition and inflammatory remodelling, capturing qualitative changes not reflected by volume alone. Finerenone, a non-steroidal mineralocorticoid receptor antagonist, reduces cardiovascular and kidney events in chronic kidney disease, including type 2 diabetes–associated kidney disease. Whether finerenone therapy is associated with longitudinal changes in EAT attenuation or volume on serial non-contrast chest CT remains unknown.
Methods
We conducted a single-centre retrospective real-world cohort study of 187 finerenone-treated patients with two diagnostic-quality non-contrast chest CT scans 90–730 days apart. EAT was semi-automatically segmented within the pericardial sac (−190 to −30 HU) to quantify volume (mL) and mean attenuation (HU). Baseline and follow-up were compared using paired t-tests (two-sided p<0.05; Δ=follow-up−baseline). Exploratory subgroup analyses were performed by primary diagnosis (DKD vs non-DKD), heart failure history, BMI categories, and sex.
Results
We included 187 patients (58.5±13.5 years; 78.1% men) with a median inter-scan interval of 249 days (IQR 168–365). Baseline EAT attenuation was −72.5±7.7 HU and EAT volume 123.2±48.8 mL. Overall, mean EAT attenuation increased by +1.05 HU (95% CI 0.03–2.06; p=0.043), while EAT volume did not change significantly. The attenuation increase was evident in DKD (n=121; Δ +1.88 HU, 95% CI 0.65–3.11; p=0.003) but not in non-DKD (n=66; Δ −0.48 HU; p=0.584). It was observed in patients without heart failure (n=132; Δ +1.63 HU, 95% CI 0.34–2.93; p=0.014) and in those with 24≤BMI<28 kg/m² (n=80; Δ +1.82 HU; p=0.009). In DKD, attenuation increased in men (n=102; Δ +2.33 HU; p<0.001) but not in women (n=19; p=0.737). Accompanying measures showed a modest blood pressure reduction (SBP Δ −3.79 mmHg, p=0.043; DBP Δ −2.79 mmHg, p=0.020), an increase in potassium (Δ +0.179 mmol/L; p=0.001; hyperkalaemia >5.0 and >5.5 mmol/L: 10.1% and 1.9%), and a decline in eGFR (Δ −17.22 mL/min/1.73 m²; p<0.001), with no clear improvement in BNP (p=0.095) or LVEF (p=0.130).
Conclusion
Finerenone-treated patients showed a small but measurable within-patient rise in CT-derived EAT attenuation on serial non-contrast chest CT, particularly among DKD patients and specific subgroups, indicating a qualitative shift in CT-derived EAT phenotype rather than volumetric loss. Prospective studies with appropriate comparators and adjudicated outcomes are needed to establish its prognostic implications.Figure