A 50-year-old man was referred to us with suspected angina. Here is his ECG.
Epicardial fat : One more cause for Low voltage QRS
He was an obese man weighing 105 Kgs. He was put on a tread mill .It was convincingly negative .
The echo cardiogram revealed a prominent epicardial pad of fat measuring 6mm throughout the anterior surface.He had normal valves and normal myocardial function.It was concluded the low voltage and poor R waves , and T wave inversion was due to the thick epicardial fat.
ECG -Fat correlation
The lack of R wave progression is attributable to the insulation effect of fat .Chest wall fat rarely dampen the electricity .Epicardial fat does it more.T wave inversion may not be due to dampening effect of fat .We think epicardial fat when adherent to true pericardial surface of the heart it alters the epicardial action potential .It is possible electrical neutralisation by the fatty infiltration of epicardium reverses the direction of repolarisation towards the epicardium .
Other ECG manifestation of thick epicardial fat
- Poor R wave progression
- Anterior Q waves
- T wave inversion in ;leads v1 to v4 or V5
Final message
Epicardial fat deposits can have clinically important influence on the surface ECG recording .
Simple chest wall obesity causes only diminutive R wave . If fat encircles epicardium it has high chances of producing repolarisation abnormalities in the form of T wave inversion or flattish ST segment.
Dr.S.Venkatesan MD 
The patient with chest pain has performed an evaluation to rule out coronary artery disease? If the coronary arteries are patent, the patient may have had necrosis of the epicardial fat