Epicardial fat necrosis is a benign and uncommon condition that presents with chest pain. Despite a sometimes impressive presentation, its course is generally favorable.
In this context, the term “necrosis” refers to a localized involvement of a very small amount of fatty tissue, without any impact on the functioning of the heart itself.
First described in 1957, this condition remains frequently overlooked and not immediately recognized, as its symptoms can resemble those of more serious diseases.
The diagnosis requires medical imaging, either a chest computed tomography (CT) scan or cardiac magnetic resonance imaging (MRI). These examinations are performed primarily to ensure that no other more serious underlying condition is responsible for the chest pain.
The Heart
To better understand this condition, a brief review of anatomy is helpful.
The heart is a muscular pump enclosed within a protective sac called the pericardiumThe pericardium is a sac surrounding the heart and containing a lubricating fluid that allows it to glide with each beat without friction.. On this envelope, mainly along its anterior portion and toward its lower end, there is a small accumulation of fatty tissue known as epicardial fat. This fat connects the pericardiumThe pericardium is a sac surrounding the heart and containing a lubricating fluid that allows it to glide with each beat without friction. to the anterior chest wall.
This fatty area is usually more abundant in people living with obesity, which may partly explain why this condition is observed more frequently in this population.
The Cause
At present, the exact cause of this necrosis remains unknown. It affects both women and men alike.
Obesity is considered a possible risk factor, but no clear direct relationship has yet been established.
Among the proposed hypotheses are torsion of the vascular pedicle supplying this fatty tissue or spontaneous bleeding within the fat itself. These mechanisms remain difficult to confirm due to the rarity of the condition.
It is estimated that necrosis of a small portion of this fatty tissue may account for approximately 2.5% of chest pain cases among people presenting to the emergency department.
It is important to emphasize that this condition is not related to an obstruction of the coronary arteriesThe two coronary arteries, the right and the left, form the blood network that supplies the heart with oxygen and nutrients. They are located directly on the surface of the heart and branch into smaller vessels that.
Clinical Presentation
The condition presents with chest pain that can sometimes be intense and may be comparable to pain experienced during a heart attack. This pain generally remains unchanged with deep breathing.
Shortness of breath may be associated, as well as nausea and vomiting.
The pain may be intermittent and, in some cases, persist for several weeks or even months before resolving completely.
Diagnostic Challenges
The symptoms can easily be confused with those of other potentially serious conditions, including:
- myocardial infarction;
- pulmonary embolism;
- aortic dissection.
This similarity explains why a complete diagnostic evaluation is often required, even when the clinical course ultimately proves to be benign.
Tests Used to Establish the Diagnosis
When evaluating chest pain, several complementary tests are required to rule out more serious conditions and, eventually, to identify epicardial fat necrosis. Each of these tests provides different information and helps guide the diagnosis.
1- BloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood Tests
BloodBlood is composed of red blood cells, white blood cells, platelets, and plasma. Red blood cells are responsible for transporting oxygen and carbon dioxide. White blood cells make up our immune defense system. Platelets contribute to blood tests usually show no evidence of injury to the heart muscle. Troponins—small proteinsProteins are fundamental components manufactured by the cells of our body. They play an essential role in many biological functions, acting as hormones, antibodies, and even cholesterol transporters, among others. >> released into the bloodstream when the heart muscle is damaged—remain within normal limits.
However, a mild elevation of certain inflammatory markers may be observed, reflecting a localized inflammatory process
2- Electrocardiogram
The electrocardiogram is most often normal. There are no findings consistent with a myocardial infarction, whether STEMI or NSTEMI.
3- Chest X-ray
The chest X-ray is generally normal. In some cases, a small amount of fluid may be seen in the lining of the left lung, without major clinical consequences.
4- Computed Tomography (CT Scan)
In a person presenting with chest pain associated with inflammatory markers, the healthcare professional must often rule out the possibility of a pulmonary embolism, particularly when D-dimer levels are elevated.
Chest computed tomography makes it possible to exclude this diagnosis and, at the same time, to establish the diagnosis of epicardial fat necrosis.
A classic clinico-radiological triad is described for this condition:
- chest pain;
- an encapsulated lesion within the epicardial fat (as indicated on the image here);
- localized thickening of the pericardiumThe pericardium is a sac surrounding the heart and containing a lubricating fluid that allows it to glide with each beat without friction..
Treatment
There is no specific treatment that directly targets this condition.
Management focuses primarily on relieving pain. Depending on its intensity, an anti-inflammatory medication may be prescribed, usually for a duration of 10 to 14 days.
What Happens Next
The course is benign, and complete recovery is the rule. Recurrences are rare.
In some cases, follow-up imaging may be suggested two to three months after the diagnosis to confirm complete resolution of the abnormalities initially observed.
When to See a Healthcare Professional Again
Reassessment is recommended if the pain persists, worsens, or if new symptoms appear. Ongoing diagnostic uncertainty also justifies medical follow-up.
Conclusion
Epicardial fat necrosis is a benign and uncommon condition that is often underrecognized, largely because its diagnosis requires imaging studies that are not performed routinely.
Depending on symptom severity, treatment relies on the temporary use of anti-inflammatory medication, with an overall course that is usually favorable and without long-term consequences.
Despite sometimes impressive chest pain, the cause is benign, the treatment is simple, and the prognosis is excellent.
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