Narrative review explores aged epicardial adipose tissue as a target for mitigating age-related coronary artery calcification in the elderly.

Coronary artery calcification (CAC) is a hallmark of vascular aging and a major contributor to cardiovascular morbidity in the elderly. Recent evidence has identified epicardial adipose tissue (EAT) as a metabolically active endocrine organ whose age-related dysfunction critically contributes to this process. During aging, EAT undergoes a profound phenotypic switch—from a protective metabolic reservoir to a pathogenic secretory neighbor—that actively drives CAC progression. This review synthesizes current evidence to propose a novel conceptual framework: aged EAT orchestrates a multi-tiered and interactive metabolic-endocrine network that accelerates vascular calcification. At the core of this network lies a mutually reinforcing axis of chronic inflammation and oxidative stress, both fueled by underlying metabolic dysregulation. Built upon this foundation, dysregulated autophagy and apoptosis govern cellular fate decisions, while pathological vascular remodeling reshapes the extracellular matrix. Superimposed on these layers, a spectrum of dysregulated microRNAs acts as a master regulatory tier, integrating metabolic, inflammatory, and oxidative signals to amplify the entire network. By deciphering the complex crosstalk within this system, we identify key nodes where metabolic and endocrine signals converge—positioning the aged EAT as both a sensor and driver of vascular pathology. We conclude that targeting this metabolic-endocrine network offers a promising strategic avenue for mitigating age-related CAC, opening new frontiers for therapeutic intervention.