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\begin{document}

\title{Gastric wall fat falo sign as a risk factor for cardiovascular diseases}



\author[1]{Ali Kupeli}%
\author[2]{Ethem Unver}%
\author[3]{Gurkan Danisan}%
\author[1]{Eser Bulut}%
\affil[1]{Trabzon Kanuni Eğitim ve Araştırma Hastanesi}%
\affil[2]{Erzincan Binali Yildirim Universitesi}%
\affil[3]{Sakarya Universitesi}%


\vspace{-1em}



  
  \date{May 04, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
A B S T R A C T Objective: To investigate the relationship between
gastric wall fat halo sign and potentially associated cardiovascular
disease (CVD) in thoracic computed tomography (CT). Material and
Methods: Between October 2018 and June 2019, 62 patients with gastric
wall fat halo sign and 97 controls were prospectively evaluated. Patient
height, weight, body mass index (BMI), sex, age, ascending aorta,
descending aorta, main pulmonary artery, right and left pulmonary
artery, long and short cardiac axis and maximum transverse thorax
diameters; and ascending, arcus, descending aorta and coronary artery
calcium scores were recorded for the two groups. Results: No significant
differences were found in sex, age, height, body weight or BMI between
the two groups (p \textgreater{} 0.125). Patients with gastric wall fat
halo sign had significantly larger diameters of the ascending aorta, the
descending aorta, the main pulmonary artery, the right and left
pulmonary arteries, and the short and long cardiac axes and a higher
cardiothoracic ratio (CTR) than the control group (p \textless{} 0.001).
Additionally, the calcium scores of the ascending, arcus, and descending
aortas and the coronary arteries were significantly higher detected in
patients group (p \textless{} 0.001). Conclusion: The gastric wall fat
halo is the result of excessive fat accumulation and can be observed in
overweight people, especially those with increased visceral fat tissue.
Additionally, patients with a gastric wall fat halo have a higher
cardiovascular risk because of increased vascular diameters, CTR, heart
sizes and calcium scores.%
\end{abstract}%



\sloppy


\textbf{Gastric wall fat falo sign as a risk factor for cardiovascular
diseases}

\textbf{A B S T R A C T}

\textbf{Objective:} To investigate the relationship between gastric wall
fat halo sign and potentially associated cardiovascular disease (CVD) in
thoracic computed tomography (CT).

\textbf{Material and Methods:} Between October 2018 and June 2019, 62
patients with gastric wall fat halo sign and 97 controls were
prospectively evaluated. Patient height, weight, body mass index (BMI),
sex, age, ascending aorta, descending aorta, main pulmonary artery,
right and left pulmonary artery, long and short cardiac axis and maximum
transverse thorax diameters; and ascending, arcus, descending aorta and
coronary artery calcium scores were recorded for the two groups.

\textbf{Results:} No significant differences were found in sex, age,
height, body weight or BMI between the two groups (p \textgreater{}
0.125). Patients with gastric wall fat halo sign had significantly
larger diameters of the ascending aorta, the descending aorta, the main
pulmonary artery, the right and left pulmonary arteries, and the short
and long cardiac axes and a higher cardiothoracic ratio (CTR) than the
control group (p \textless{} 0.001). Additionally, the calcium scores of
the ascending, arcus, and descending aortas and the coronary arteries
were significantly higher detected in patients group (p \textless{}
0.001).

\textbf{Conclusion:} The gastric wall fat halo is the result of
excessive fat accumulation and can be observed in overweight people,
especially those with increased visceral fat tissue. Additionally,
patients with a gastric wall fat halo have a higher cardiovascular risk
because of increased vascular diameters, CTR, heart sizes and calcium
scores.

\textbf{Keywords:} Cardiovascular disease, CT, gastric wall fat halo
sign, obesity

\textbf{What is ready known about this topic?}

A fat halo sign refers to fat accumulation in the submucosal layer of
the gastric, colonic and small bowel wall. The fat halo can also be
commonly detected in overweight people, especially those with
increased\emph{v} isceral fat tissue.

\textbf{What does this article add?}

Obesity is a remarkably heterogeneous condition, and \emph{v} isceral
fat tissue has been revealed to be more deeply related to cardiovascular
diseases than subcutaneous or total fat tissue. To the best of our
knowledge, no study has investigated the gastric wall fat halo sign as a
risk factor for cardiovascular diseases.

\textbf{INTRODUCTION}

Despite preventative and therapeutic efforts, cardiovascular diseases
(CVDs), especially heart disease and stroke, are prominent causes of
mortality and morbidity around the world\textsuperscript{1}. The main
risk factors and pathological mechanisms resulting in CVD can be traced
back to childhood\textsuperscript{2}. There are several controllable and
uncontrollable risk factors for CVD, such as male sex, family history,
old age, smoking, hypertension, physical inactivity,
hypercholesterolemia, diabetes mellitus and obesity\textsuperscript{3}.

The unfavorable consequences of overweight and obesity have increased
worldwide and can be seen beginning in childhood\textsuperscript{4}.
Obesity is thought to be an independent risk factor for CVD, and
increased body mass index (BMI) facilitates the development of
comorbidities that contribute to CVD\textsuperscript{5,6}. The generally
preferred anthropometric technique to evaluate relative weight and
classify obesity is BMI, which is the ratio of total body weight to
height squared. Additionally, obesity is a remarkably heterogeneous
condition, and \emph{v} isceral fat tissue has been revealed to be more
deeply related to CVD than subcutaneous or total fat
tissue\textsuperscript{7,8}.

A fat halo sign refers to fat accumulation in the submucosal layer of
the gastric colonic and small bowel wall\textsuperscript{9}. The fat
halo in the intestinal wall was first associated with chronic
inflammatory bowel diseases, but it can also be commonly detected in
overweight people, especially those with increased \emph{v} isceral fat
tissue\textsuperscript{10,11}. Additionally, fat halo sign can be
observed in approximately 21\% of patients who underwent computed
tomography (CT) examinations\textsuperscript{10}.

There are only a few studies on gastric wall fat halo
sign\textsuperscript{12,13}. To the best of our knowledge, no study has
investigated the gastric wall fat halo sign as a risk factor for CVD. In
this study, we aimed to investigate the relationship between gastric
wall fat halo sign and potentially associated CVD based on thorax CT.

\textbf{MATERIAL AND METHODS}

Study Population

Between October 2018 and June 2019, data from 71 patients who underwent
unenhanced thorax CT and who had gastric wall fat halo sign were
prospectively recorded. Three patients with chronic inflammatory bowel
disease history and six patients with implanted coronary artery stents
were not included in the study. Therefore, 62 patients were included in
the final study.

For the control group, 97 patients with no gastric wall fat halo sign
were selected from the clinical database of patients who underwent
unenhanced thorax CT. Age, sex, height (m) and body weight (kg) were
noted for the patient and control groups. Additionally, BMI
(kg/m\textsuperscript{2}) was calculated as the ratio of total body
weight to height squared for both groups. This study was approved by the
Institutional Ethics Committee.

CT Protocol

The thorax CT examinations were performed with the participants in the
supine position, and the patients were scanned from the lung apices to
the adrenal gland level during a breath hold at the end of inspiration
with using 16 slices (Siemens Somatom Sensation, Forchheim, Germany).
All patients were examined using the standard scanning protocol without
intravenous contrast agent. The CT protocol was as follows: 120 kVp,
tube current of 150--165 mAs, maximum 2.5 mm collimation, slice
thickness of 1.5 mm and rotation time of 0.5 s. Then, the images were
reconstructed into multiplanar reformations.

Analysis of CT Images

The thorax CT images were evaluated by two radiologists (A.K. 8 years of
thoracic radiology experience and M.K. 7 years of thoracic radiology
experience) to reach a joint consensus. The images were transferred to
the Syngo workstation (Siemens Medical Solutions). Linear fat
accumulation in the submucosal layer of the gastric wall with
attenuation of \textless{}-10 Hounsfield units (HUs) was described as a
gastric wall fat halo sign (Figure 1). The measurements of the outer
wall of the ascending aorta, the descending aorta, the main pulmonary
artery, and the right and left pulmonary arteries were recorded in the
axial plane at the level of the pulmonary artery bifurcation (Figure 2).
After detecting the axial slice level that represented the maximum size
of the heart, the long and short cardiac axes and the maximum transverse
thoracic diameter were measured at the same level (Figure 3). Then, the
cardiothoracic ratio (CTR) was calculated as the ratio of the long
diameter of the cardiac axis to the maximum transverse thoracic
diameter. The calcification of the ascending, arcus, and descending
aortas and total coronary artery calcification were quantified by the
method defined by Agatston et al.\textsuperscript{13}. A region of
interest (ROI) was positioned manually on the calcification of the
ascending, arcus, and descending aortas and the coronary arteries. After
selecting the total number of pixels over 130 HUs, the Agatston calcium
score was computed with the software.

Statistical Analysis

All of the data were analyzed using the Statistical Package for the
Social Sciences (SPSS 13.0 Statistical Software, SPSS Inc., Chicago, IL,
USA) and the MedCalc package of Statistical Software version 16.8
(MedCalc Software bvba, Ostend, Belgium). Descriptive statistics,
including the means and ranges, were calculated for age, height, BMI,
CTR, the calcium scores of the ascending, arcus, and descending aortas
and the coronary arteries, and the diameters of the ascending aorta, the
descending aorta, the main pulmonary artery, the right and left
pulmonary arteries, the short and long cardiac axes and the transverse
thorax in the patient and control groups. The Kolmogorov--Smirnov test
was used to identify deviations from anormal distribution. Additionally,
the parametric Student's t-test was used to compare the age, height,
BMI, and the diameters of the ascending aorta, the descending aorta, the
main pulmonary artery, the right and left pulmonary arteries, the short
and long cardiac axes and the transverse thorax. The nonparametric
Mann-Whitney U test and the parametric Student's t-test were used to
compare the calcium scores of the ascending, arcus, and descending
aortas and the coronary arteries. A p value of less than 0.05 was
considered to indicate a significant difference.

\textbf{RESULTS}

In this study, we analyzed 62 patients (45 male, 17 female) with gastric
wall fat halo sign and 97 control patients (64 male, 33 female). The
mean ages of the patient and control groups were 63.5 \selectlanguage{ngerman}± 8.1 and 62.1 ±
8.8 years, respectively. The mean height (m), body weight (kg) and BMI
(kg/m\textsuperscript{2}) of the patient and control groups were 1.62 ±
0.1 m and 1.63 ± 0.1 m; 80.8 ± 13.4 kg and 77.4 ± 13.7 kg; and 30.6 ±
4.9 and 29.4 ± 5.6 kg/m\textsuperscript{2}, respectively. There were no
statistically significant differences in sex or the mean values of age,
height, body weight or BMI between the two groups (p \textgreater{}
0.125).

The mean diameters of the ascending aorta, the descending aorta, the
main pulmonary artery, the right and left pulmonary arteries, the short
and long cardiac axes and the transverse thorax, the CTR, and the
calcium scores of the ascending, arcus, and descending aortas and the
coronary arteries are presented in Table 1. Patients with gastric wall
fat halo sign had significantly larger diameters of the ascending aorta,
the descending aorta, the main pulmonary artery, and the right and left
pulmonary arteries than the control group (p \textless{} 0.001).
Although the short and long diameters of the cardiac axis and CTR were
observed to be significantly higher in patients with gastric wall fat
halo sign (p \textless{} 0.001), no statistically significant difference
was detected in the transverse thoracic diameter between the two groups
(p=0.861). Additionally, the calcium scores of the ascending, arcus, and
descending aortas and the total and coronary arteries were significantly
higher in patients with gastric wall fat halo sign than in patients
without a gastric wall fat halo sign (p \textless{} 0.001) (Figure 4).

\textbf{DISCUSSION}

In the present study, we investigated the relationship between gastric
wall fat halo sign detected by thorax CT and CVD. We found that gastric
wall fat halo sign might be detected in patients with increased aorta
and pulmonary artery diameters and calcium scores.

Although there are several studies of the fat halo sign in the
gastrointestinal tract, there are few studies involving the fat halo
sign in the gastric wall\textsuperscript{10-16}. To the best of our
knowledge, this is the first study investigating the relationship
between gastric wall fat halo sign and associated CVD based on thorax
CT.

The fat halo sign was first thought to indicate the presence of
inflammatory bowel disease. However, fat halo sign can be seen
especially in overweight people. Additionally, gastric wall fat halo
sign can be observed in patients without gastrointestinal disease and
with increased visceral fat tissue\textsuperscript{12,13}. After fat is
stored in normal adipose tissues, free fatty acids are discharged into
the blood\textsuperscript{17}. The fat halo sign could be related to an
increase in the blood concentration of free fatty acids and could be an
indicator of excessive fat accumulation\textsuperscript{17}.

The ascending and descending aorta diameters are easily evaluated
through chest CT. In our study, we found that patients with gastric wall
fat halo sign had significantly higher ascending and descending aorta
diameters than those without fat halo sign. One of the causes of aortic
diameter increase is visceral obesity. The increase in aortic diameter
associated with visceral obesity could be related to the process of
adaptation to hypertension, increased blood volume and underlying
structural or functional aortic abnormalities\textsuperscript{18}.
Additionally, visceral obesity can stimulate vascular aging, resulting
in future cardiovascular events\textsuperscript{8}. Visceral obesity and
gastric wall fat halo sign are associated with each other, so increased
aortic diameters may be related to this relationship.

Although pulmonary hypertension may appear to be a sporadic disease with
undetectable risk factors, it can occur as a result of preexisting
medical conditions\textsuperscript{19}. Pulmonary hypertension and
obesity are generally two coexisting conditions in the clinic, and
increased BMI induces the development of pulmonary
hypertension\textsuperscript{20}. Chan et al. reported that there were
more obese participants in the pulmonary hypertension group than in the
control group, whereas most patients were not obese in both
groups\textsuperscript{21}. In this study, we revealed that patients
with gastric wall fat halo sign had significantly higher main, right and
left pulmonary artery diameters than those without fat halo sign. This
relationship may be the reason for pulmonary artery enlargement in our
study.

Obesity is connected with most CVDs, such as coronary heart disease,
hypertension and heart failure\textsuperscript{22}. In particular,
visceral adipose tissue is hormonally active tissue that contributes to
vascular inflammation by producing adipokines and is a risk factor for
mortality and CVD\textsuperscript{23}. Additionally, obesity is related
to some hemodynamic changes, such as increased cardiac output, diastolic
filling pressure, left ventricle hypertrophy and ventricular
dilatation\textsuperscript{24}. The CTR is usually used to evaluate
cardiomegaly in chest radiography, cardiomegaly indicating underlying
CVD, is evidenced by hypertrophy or dilation of the
heart\textsuperscript{25}. CT imaging is a simple and effective method
for assessing cardiomegaly. Despite a lack of significant difference in
the transverse thoracic diameter, we found that patients with gastric
wall fat halo sign had significantly higher short and long diameters of
the cardiac axis and CTRs than the control group. These results may be
related to cardiovascular changes caused by visceral adipose tissue.

Atherosclerosis is a major cause of death and morbidity in
industrialized societies due to its association with cardiovascular
events and peripheral vascular disease. Atherosclerosis has different
stages, and calcification indicates advanced atherosclerotic
lesions\textsuperscript{26}. Atherosclerosis starts with fatty streaks
and advances further to calcified plaques in adulthood. Although the
cause of vascular calcification is not fully understood, inflammation,
dysregulated metabolism, and osteogenesis are some processes associated
with vascular calcification\textsuperscript{27}. Thoracic aortic
calcification represents a systemic atherosclerotic burden and results
in an increased risk of cardiovascular events\textsuperscript{28}.
Visceral fat tissue is an endocrine organ that can produce atherogenic
agents. Additionally, this condition can induce vascular aging resulting
in an increased risk of CVDs, hypertension and calcified atherosclerotic
plaques\textsuperscript{29}. It has been reported that the risk of
aortic atherosclerosis increases as the amount of visceral fat tissue
increases\textsuperscript{30}. Moreover, aortic wall calcification can
be assessed with CT and lateral X-ray\textsuperscript{31}. In our study,
we used non contrast thoracic CT to evaluate thoracic aortic
calcification and found that patients with gastric wall fat halo sign
had significantly higher calcium scores in the ascending, arcus, and
descending aortas than patients without fat halo sign.

Coronary artery disease, caused by atherosclerosis, is a main cause of
morbidity and mortality worldwide, so the early diagnosis of subclinical
atherosclerosis is crucial for preventing coronary artery disease.
Similar to thoracic aortic calcification, obesity is an independent risk
factor for atherosclerosis and coronary artery
calcification\textsuperscript{32}. The calcium score of coronary
arteries indicates the burden of atherosclerotic plaque in arteries and
is a helpful, noninvasive method for the assessment of subclinical
atherosclerosis in asymptomatic patients\textsuperscript{33}.
Additionally, the calcium score of coronary arteries is connected with
cardiovascular events and obesity\textsuperscript{33}. In this study, we
showed that higher calcium scores of coronary arteries were detected in
patients with gastric wall fat halo sign related to visceral obesity.

This study has a number of limitations. First, the CT images were
evaluated based on a consensus, and we did not evaluate the inter- or
intraobserver variability in our study. The second limitation was that
the number of patients was also relatively small. The third limitation
was that participants in the patient and control groups did not undergo
abdominal CT imaging, so visceral fat tissue measurement could not be
performed in our study. Fourth, we did not have access to laboratory
parameters such as lipid panels.

\textbf{CONCLUSION}

The gastric wall fat halo results from excessive fat accumulation and
can be observed in overweight people, especially those with increased
visceral fat tissue. Additionally, patients with a gastric wall fat halo
have higher cardiovascular risk because of increased vascular diameters,
CTR, heart sizes and calcium scores. However, extensive studies with
larger populations are needed to clearly confirm the relationships of
gastric wall fat halo sign with cardiovascular diseases.

.

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\textbf{Figure Legends}

\textbf{Fig. 1.} 45 year-old man with pneumonia. Unenhanced thorax CT
image represents thin linear fatty infiltration in submucosal layer of
gastric wall with attenuation value\textless{}\selectlanguage{english}-10 HU.

\textbf{Fig. 2.} 43 year-old man with cough complaint. The measurements
of the ascending aorta, the descending aorta, the main pulmonary artery,
and the right and left pulmonary arteries were recorded in the axial
plane at the level of the pulmonary artery bifurcation.

\textbf{Fig. 3.} 51 year-old man with solitary pulmonary nodule. The
measurements of the long and short cardiac axes and the maximum
transverse thoracic diameter were obtained at the axial slice level that
represented the maximum size of the heart.

\textbf{Fig. 4.} 59-year-old man with gastric wall fat halo sign.

\textbf{A,} Unenhanced sagittal CT image shows extensive calcific
atherosclerotic plaques in aorta

\textbf{B,} Unenhanced axial CT image shows extensive calcific
atherosclerotic plaques in coronary arteries\selectlanguage{english}
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\end{figure}

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