The Metabolic Footprint on Right Ventricular Function: A Prospective Observational Study

The Metabolic Footprint on Right Ventricular Function: A Prospective Observational Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Metabolic Footprint on Right Ventricular Function: A Prospective Observational Study Adhiya NSS, Sadhanandham Shanmugasundaram, Ramesh Sankaran, Nagendra Boopathy Senguttuvan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7742838/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background & Aim: Diabetes mellitus and hypertension are major contributors to adverse cardiovascular outcomes, significantly elevating the risk of heart failure, vascular disease, and premature mortality. Right ventricular (RV) function, though historically under-evaluated, is increasingly recognized as a critical determinant of cardiac performance, especially in metabolic diseases. This study evaluates and compares RV systolic and diastolic function among normal individuals, patients with DM, and those with both DM and HTN, excluding those with coronary artery disease (CAD). Methods: This prospective observational study included 211 adults aged 30–65 years, categorized into three groups: controls (n = 75), DM (n = 60), and DM with HTN (n = 76). Participants underwent clinical evaluation, laboratory testing (HbA1c, lipid profile), and comprehensive transthoracic echocardiography. RV systolic function was assessed via TAPSE, RV FAC, and tissue Doppler-derived S′ wave. RV diastolic function was evaluated using tricuspid annular E′, A′ velocities, E/E′ ratio, and deceleration time. Data were analyzed using SPSS v25; p < 0.05 was considered statistically significant. Results: TAPSE was reduced in both DM (2 ± 0.18 cm) and DM with HTN (2.01 ± 0.20 cm) groups compared to controls (2.13 ± 0.19 cm, p < 0.001), indicating RV systolic dysfunction. RV wall thickness was highest in the DM with HTN group (6.62 ± 0.99 mm, p < 0.001). TRPG and pulmonary artery pressure were elevated in the DM with HTN group (p = 0.037 and p = 0.025, respectively). A-wave velocity and deceleration time were significantly increased in the DM with HTN group, indicating diastolic dysfunction. Conclusions: Patients with DM and especially those with coexisting HTN exhibit significant subclinical impairments in RV systolic and diastolic function. Early echocardiographic detection of right ventricular dysfunction in diabetic and hypertensive patients enables timely intervention, potentially preventing progression to overt heart failure and pulmonary hypertension. Right ventricular function diabetes mellitus hypertension echocardiography tissue Doppler imaging RESEARCH INSIGHTS What is currently known about this topic? Diabetes mellitus and hypertension are primary drivers of cardiovascular morbidity, primarily linked to left ventricular dysfunction. However, the direct effects of these metabolic conditions on right ventricular function, particularly in the absence of coronary artery disease and in diverse populations, remain incompletely understood. What is the key research question? This study evaluates and compares subclinical right ventricular systolic and diastolic function among healthy controls, patients with diabetes mellitus, and those with coexisting diabetes and hypertension, using non-invasive echocardiographic parameters. What is new in our study? We demonstrate a progressive, subclinical impairment of both right and left ventricular function, which is most severe in patients with coexisting diabetes and hypertension. Our findings show that these conditions lead to significant RV systolic dysfunction, impaired LV diastolic filling, and RV remodeling, all of which are detectable before the onset of overt heart failure. How might this study influence clinical practice? The findings highlight the prognostic value of routine echocardiographic screening, including specific right ventricular parameters, in high-risk patients. Early identification of this subclinical biventricular dysfunction could enable timely, targeted interventions to prevent the progression to overt heart failure and pulmonary hypertension. Introduction The coexistence of diabetes mellitus and hypertension profoundly accelerates cardiovascular disease progression, making it a critical driver of long-term morbidity and mortality in affected individuals. One area of growing interest is evaluating right ventricular (RV) function, which has traditionally received less attention than left ventricular (LV) function. However, emerging evidence suggests that RV systolic and diastolic dysfunction play a critical role in determining overall cardiac performance and prognosis in patients with metabolic diseases, including diabetes and hypertension. 1 These pathologies can lead to compounded structural and functional cardiac alterations that extend beyond the left ventricle. This dual pathology accelerates the development of biventricular cardiomyopathy, with a particular impact on the right ventricle. These changes, often subclinical in early stages, include RV systolic dysfunction, impaired diastolic filling, myocardial fibrosis, and microvascular dysfunction, even in the absence of overt coronary artery disease (CAD). 2 In patients with DM and HTN, elevated systemic pressures contribute to increased pulmonary artery pressures and RV afterload, eventually leading to RV hypertrophy and progressive RV functional decline. 3 According to the World Health Organization (WHO) classification, Group 2 pulmonary hypertension (PH) is attributed to left heart disease, particularly LV diastolic dysfunction, which is commonly seen in diabetes and hypertension. Meanwhile, Group 5 PH includes multifactorial causes, such as insulin resistance and metabolic dysfunction, which can impair pulmonary microvascular integrity and contribute to pulmonary hypertension via pulmonary microangiopathy 4 Moreover, diabetes alone has been proposed as an independent risk factor for both pulmonary hypertension and RV dysfunction, due to chronic hyperglycemia-induced endothelial dysfunction, increased vascular stiffness, and inflammatory vascular remodeling. Studies have shown that diabetic patients, even without structural heart disease or CAD, may develop pulmonary arterial stiffness and elevated pulmonary vascular resistance, resulting in RV overload and dysfunction. 5 Several echocardiographic parameters have been developed to assess RV function, including tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (RVMPI), and tissue Doppler imaging (TDI)-derived velocities. Studies have demonstrated that these indices are altered in diabetic patients, particularly those with coexisting hypertension, indicating subclinical RV dysfunction. 6 Despite growing evidence, comparative studies assessing RV function among healthy individuals, diabetic patients, and those with both diabetes and hypertension in the absence of coronary artery disease remain scarce. Additionally, the direct role of diabetes in contributing to pulmonary hypertension and RV failure, independent of left heart involvement, has not been thoroughly investigated in the Indian population, where the prevalence of DM and HTN is rapidly rising. Understanding these distinctions is crucial for the early identification of at-risk individuals and for initiating targeted interventions aimed at preventing advanced cardiac and pulmonary vascular complications. This study aims to evaluate and compare systolic and diastolic RV function among three distinct groups - normal individuals, patients with diabetes mellitus, and patients with both diabetes and hypertension-excluding those with known CAD, using echocardiographic parameters supported by current clinical guidelines and literature. We hypothesized that right ventricular systolic and diastolic dysfunction would be more prevalent and severe in patients with both diabetes mellitus and systemic hypertension compared to those with diabetes alone or healthy individuals. Materials and Methods This prospective observational study was conducted to evaluate and compare the right ventricular (RV) systolic and diastolic functions among three distinct groups: patients with diabetes mellitus (DM), patients with both diabetes and hypertension (DM + HTN), and normal individuals without known coronary artery disease (CAD). A total of 211 subjects were included in the study, divided into three groups such as control (n = 75), patients with diabetes (n = 75), and patients with both diabetes and hypertension (n = 76). This study was approved by the Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (REF: CSP/24/OCT/152/373) and informed consent was obtained from all participants prior to enrolment. Inclusion Criteria Adults aged 30 to 65 years Group 1: Diagnosed with type 2 diabetes mellitus Group 2: Diagnosed with both type 2 diabetes mellitus and hypertension Group 3: Healthy controls without diabetes, hypertension, or known CAD Exclusion Criteria Known history of CAD, valvular heart disease, or congenital heart defects History of pulmonary hypertension, chronic obstructive pulmonary disease (COPD), or cor pulmonale Renal failure or hepatic dysfunction Poor echocardiographic window Study Procedure All participants underwent a detailed clinical examination and laboratory evaluation, including fasting blood glucose, HbA1c, and blood pressure monitoring. A comprehensive two-dimensional transthoracic echocardiography (2D-TTE) was performed using a standardized protocol. RV systolic function was assessed using: Tricuspid Annular Plane Systolic Excursion (TAPSE) Right Ventricular Fractional Area Change (RV FAC) Tissue Doppler Imaging (TDI) of the tricuspid annulus (S’ wave) RV diastolic function was evaluated using: TDI-derived E’ and A’ velocities at the tricuspid annulus E/E’ ratio Equipment Echocardiographic assessments were performed using a GE Vivid E9 machine with a 3.5 MHz transducer. All measurements were averaged over three cardiac cycles and performed by an experienced cardiologist blinded to group allocation. Statistical Analysis Data were analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages. Comparisons among the three groups were performed using a one-way ANOVA test. A p-value < 0.05 was considered statistically significant. Results In the present study comparing anthropometric and biochemical parameters among control subjects (75 patients), patients with diabetes mellitus (DM) (60 patients), and those with both diabetes mellitus and hypertension (DM with HT) (76 patients), several significant differences were observed (Table 1 ). The weight did not differ significantly across the groups (P = 0.781). Body Surface Area (BSA) was comparable among the three groups (P = 0.986). However, Body Mass Index (BMI) was significantly higher in the DM with HT group (28.02 ± 4.88) compared to the control and DM-only groups (P = 0.030). The mean age was significantly higher in the DM with HT group (57.65 ± 11.25 years) compared to the DM group (51.08 ± 12.27 years) and control group (42 ± 12.78 years), with a P value < 0.001. Systolic and diastolic blood pressures (SBP and DBP) showed statistically significant variation across the groups (both P < 0.001). HbA1c levels were significantly different among the groups (P < 0.001). While LDL levels showed a statistically significant difference (P = 0.045), HDL levels did not (P = 0.255). These findings indicate variable metabolic and hemodynamic profiles among the groups, warranting further evaluation of their cardiovascular implications. While HDL levels were not significantly different across the groups (P = 0.255), LDL levels showed a significant reduction in the DM (116.73 ± 42.72 mg/dl) and DM with HT (113.63 ± 37.29 mg/dl) groups compared to controls (129.71 ± 35.40 mg/dl), with a P value of 0.045. These findings suggest that the coexistence of diabetes and hypertension is significantly associated with higher BMI, highlighting the compounded cardiovascular risk in this subgroup. Table 1 Comparison of anthropometric and biochemical parameters Parameters Control (n = 76) DM (n = 60) DM with HT (n = 75) P Value Age in years 42 ± 12.78 51.08 ± 12.27 57.65 ± 11.25 < 0.001 Height in cm 164.22 ± 9.48 164.51 ± 8.35 161.05 ± 9.81 0.049 Weight in kg 71.61 ± 14.18 70.96 ± 12.62 72.58 ± 13.56 0.781 BSA 1.82 ± 0.21 1.81 ± 0.19 1.82 ± 0.20 0.986 BMI 26.46 ± 4.31 26.17 ± 3.94 28.02 ± 4.88 0.030 SBP mmHg 117.46 ± 14.17 119.67 ± 10.24 147.12 ± 14.55 < 0.001 DBP mmHg 74.13 ± 8.23 73.5 ± 7.08 83.87 ± 7.35 < 0.001 HBA1c % 5.62 ± 1.06 7.98 ± 2.08 7.8 ± 1.93 < 0.001 HDL mg/dl 44.31 ± 12.84 41.23 ± 14.09 45.83 ± 18.64 0.255 LDL mg/dl 129.71 ± 35.40 116.73 ± 42.72 113.63 ± 37.29 0.045 In this study, several echocardiographic parameters showed statistically significant differences among the groups (Table 2 ). TAPSE was significantly reduced in both the DM (2 ± 0.18 cm) and DM with HT (2.01 ± 0.20 cm) groups compared to controls (2.13 ± 0.19 cm), with a P value < 0.001, indicating early right ventricular systolic dysfunction. Right ventricular (RV) thickness was markedly higher in the DM with HT group (6.62 ± 0.99 mm), followed by the DM group (5.07 ± 0.92 mm), compared to controls (4.32 ± 1.07 mm), showing a P value < 0.001, suggestive of RV remodeling due to combined disease burden. Tricuspid regurgitation pressure gradient (TRPG) was significantly elevated in the DM with HT group (18.73 ± 6.29 mmHg) compared to the control and DM groups (P = 0.037), and pulmonary artery pressure (PAP) was also higher in this group (21.81 ± 6.27 mmHg), with a P value of 0.025, reflecting increased pulmonary pressure. Additionally, the late diastolic A-wave velocity (A) was significantly higher in the DM with HT group (0.5 ± 0.14 m/s) compared to the other groups (P = 0.010), and deceleration time (DT) was significantly prolonged (177.12 ± 38.94 ms), with a P value of 0.001, indicating impaired diastolic relaxation in this group. These findings highlight significant impairments in right ventricular function and diastolic filling parameters in patients with coexisting diabetes and hypertension. Table 2 Distribution of echocardiographic findings regarding systolic and diastolic functions of the RV and LV Parameters Control (n = 76) DM (n = 60) DM with HT (n = 75) P Value EF (%) 64.23 ± 3.23 64 ± 3.84 63.56 ± 3.38 0.480 LVEDD (mm) 43.27 ± 3.68 44.10 ± 3.40 43.36 ± 3.93 0.456 LVESD (mm) 28.67 ± 2.65 29.08 ± 2.61 28.76 ± 2.87 0.658 TAPSE (cm) 2.13 ± 0.19 2 ± 0.18 2.01 ± 0.20 < 0.001 RV FAC (%) 46.04 ± 7.94 44.21 ± 7.51 44.44 ± 8.73 0.343 RV Systolic area 7.86 ± 1.74 7.71 ± 1.57 7.82 ± 1.96 0.881 RV Diastolic area 14.55 ± 2.52 13.88 ± 2.49 14.06 ± 2.75 0.286 RV Thickness (mm) 4.32 ± 1.07 5.07 ± 0.92 6.62 ± 0.99 < 0.001 TRPG 16.24 ± 5.66 17.08 ± 6.08 18.73 ± 6.29 0.037 PAP 19.16 ± 5.67 20.13 ± 6.08 21.81 ± 6.27 0.025 E(T) 0.5 ± 0.11 0.5 ± 0.14 0.5 ± 0.13 0.298 A(T) 0.41 ± 0.10 0.41 ± 0.15 0.5 ± 0.14 0.010 E/A (T) 1.24 ± 0.31 1.17 ± 0.26 1.12 ± 0.37 0.091 DT (m/s) 154.19 ± 32.17 166.71 ± 42.27 177.12 ± 38.94 0.001 This study compared tissue Doppler imaging parameters among three groups (Table 3 ). The early diastolic mitral annular velocity (E’) showed a significant decline across the groups, with mean values of 0.13 ± 0.08 m/s in controls, 0.10 ± 0.02 m/s in the DM group, and 0.09 ± 0.02 m/s in the DM with HT group (p = 0.001), indicating impaired diastolic function with the presence of diabetes and further deterioration when hypertension coexists. The late diastolic velocity (A’) progressively increased from 0.12 ± 0.03 m/s in controls to 0.13 ± 0.03 m/s in DM and 0.14 ± 0.04 m/s in DM with HT, which was statistically significant (p < 0.001). The E/E’ ratio, a marker of left ventricular filling pressure, also showed a significant rise from 4.61 ± 1.01 in controls to 5.11 ± 1.35 in DM and 5.89 ± 1.61 in the DM with HT group (p < 0.001), suggesting worsening diastolic dysfunction. In contrast, proper right ventricular systolic velocity (RVS) remained similar across all groups, with a uniform value of 0.12 ± 0.02 cm/s, showing no significant difference (p = 0.269). Table 3 Comparison of Doppler echocardiographic findings of the RV function Parameters Control (n = 76) DM (n = 60) DM with HT (n = 75) P Value E’(T) (m/s) 0.13 ± 0.08 0.10 ± 0.02 0.09 ± 0.02 0.001 A’(T) (m/s) 0.12 ± 0.03 0.13 ± 0.03 0.14 ± 0.04 < 0.001 E/E’ (T) 4.61 ± 1.01 5.11 ± 1.35 5.89 ± 1.61 < 0.001 RVS (cm/s) 0.12 ± 0.02 0.12 ± 0.02 0.12 ± 0.02 0.269 Discussion The present study demonstrates significant impairments in both right ventricular (RV) and left ventricular (LV) functions in patients with diabetes mellitus (DM) and those with coexisting diabetes and hypertension (DM + HT), compared to controls. These findings are consistent with accumulating evidence highlighting the detrimental effects of metabolic and hemodynamic stressors on cardiac structure and function. Right Ventricular Function Tricuspid annular plane systolic excursion (TAPSE), a reliable marker of RV systolic function, was significantly reduced in both DM and DM + HT groups compared to controls. This is in agreement with prior studies showing reduced TAPSE in diabetic patients, indicating subclinical RV dysfunction. 7 Increased RV wall thickness observed in the DM + HT group further suggests RV remodeling, likely due to chronic pressure overload from systemic hypertension and diabetic microvascular damage. 8 Diabetes may contribute directly to RV remodeling via myocardial fibrosis, lipotoxicity, and microvascular rarefaction. These structural changes impair RV contractility and compliance, ultimately compromising RV systolic performance. The additive burden of hypertension may further exacerbate RV wall stress and promote compensatory hypertrophy. Pulmonary Pressures The elevation of the tricuspid regurgitation pressure gradient (TRPG) and pulmonary artery systolic pressure (PASP) in the DM + HT group indicates increased pulmonary vascular resistance and possible pulmonary hypertension. Doppler-derived TRPG has been validated as a surrogate for PASP and serves as a non-invasive tool to screen for elevated pulmonary pressures. 9 The observed increases may reflect both left-sided diastolic dysfunction and pulmonary vascular remodeling in diabetic and hypertensive states. The increase in PASP and TRPG among diabetic and hypertensive patients in this study can be interpreted in the context of both Group 2 PH, due to left heart disease (e.g., LV diastolic dysfunction), and Group 5 PH, due to multifactorial metabolic causes. 4 Left Ventricular Diastolic Function Tissue Doppler imaging revealed impaired LV relaxation (reduced E′ velocity) and elevated E/E′ ratios in both DM and DM + HT groups. These findings are consistent with previous research identifying E/E′ as a reliable surrogate for LV filling pressure, especially in diabetic populations. 10 , 11 A recent study also showed that patients with type 2 diabetes exhibit higher E/E′ ratios, confirming subclinical diastolic dysfunction associated with diabetic cardiomyopathy. 12 The combination of diabetes and hypertension further compounds this dysfunction, likely due to the additive effects of myocardial fibrosis, endothelial dysfunction, and altered ventricular compliance. Clinical Implications The coexistence of diabetes and hypertension appears to amplify adverse cardiac remodeling, promoting both LV diastolic and RV systolic dysfunction. This biventricular involvement significantly increases the risk of developing pulmonary hypertension and heart failure. Importantly, TAPSE and E/E′ are known independent predictors of cardiovascular morbidity and mortality, making their routine echocardiographic assessment critical in high-risk populations. 13 Given that early RV dysfunction and pulmonary vascular changes may remain subclinical, especially in diabetic patients, their identification through non-invasive imaging could enable timely intervention. These findings underscore the need for comprehensive echocardiographic evaluation, including RV parameters and pulmonary pressures, in patients with diabetes and hypertension, particularly in Indian clinical practice, where routine RV assessment is often overlooked. Limitations The cross-sectional design of the study prevents the establishment of a causal relationship between diabetes/hypertension and right ventricular (RV) dysfunction. Secondly, advanced imaging modalities like cardiac MRI or speckle-tracking echocardiography , which provide a more detailed assessment of RV strain and mechanics, were not utilized. Finally, this was a single-center, hospital-based study, which may limit the generalizability of our findings to a broader population. Potential confounders such as medication use and duration of disease were not controlled for in the analysis. Future research should focus on longitudinal studies to track the progression of RV dysfunction in these patient populations and to determine if early echocardiographic changes predict future cardiac events. The use of more advanced imaging techniques , such as speckle-tracking echocardiography and cardiac MRI, would provide a more in-depth understanding of the subclinical changes in RV mechanics. Furthermore, studies should investigate the impact of specific medication regimens and different lifestyle interventions on RV function in diabetic and hypertensive patients. A larger, multicenter study would also help to validate these findings in a more diverse population. Conclusion This study highlights that both diabetes mellitus and its coexistence with hypertension are associated with significant impairments in right and left ventricular functions, as evidenced by reduced TAPSE and altered diastolic indices (E′ and E/E′). The presence of both conditions exacerbates cardiac dysfunction, emphasizing the need for early echocardiographic screening in such high-risk groups to guide timely interventions and prevent progression to heart failure. Declarations Ethics approval and consent to participate This study was approved by the Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (Reference number: CSP/24/OCT/152/373). Written informed consent including consent for publication was obtained from all individual participants included in the study. Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no funding or specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions Sadhanandham S conceived the study and participated in its design and coordination. Adhiya NSS performed the statistical analysis and wrote the manuscript. Ramesh S performed and supervised the echocardiography protocols. Nagendra Boopathy S helped in participant enrolment. Akshay PG helped draft the manuscript. Keerthana PS was blinded to the allocation and performed the echocardiography. All authors read and approved the final manuscript. References Bhupal VS, R Kumar, P. Sampath. Assessment of Right Ventricular Function before and after Primary Percutaneous Coronary Intervention in Patients with Acute Inferior Wall ST-elevation Myocardial Infarction by Tissue Doppler Imaging. Research in Cardiovascular Medicine 2024; 13(4):105-109. Zhang G, Shi R, Li XM, Yan WF, Xu HY, Li Y, Guo YK, Shi K, Yang ZG. Impact of diabetes mellitus on right ventricular dysfunction and ventricular interdependence in hypertensive patients with heart failure with reduced ejection fraction assessed via 3.0 T cardiac MRI. Cardiovasc Diabetol 2024;23(1):375. Namazi M, Eftekhar SP, Mosaed R, Shiralizadeh Dini S, Hazrati E. Pulmonary Hypertension and Right Ventricle: A Pathophysiological Insight. Clinical Medicine Insights 2024;18. Simonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, Olschewski H, Robbins IM, Souza R. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-41 Whitaker ME, Nair V, Sinari S, Dherange PA, Natarajan B, Trutter L, Brittain EL, Hemnes AR, Austin ED, Patel K, Black SM, Garcia JGN, Yuan Md PhD JX, Vanderpool RR, Rischard F, Makino A, Bedrick EJ, Desai AA. Diabetes Mellitus Associates with Increased Right Ventricular Afterload and Remodeling in Pulmonary Arterial Hypertension. Am J Med. 2018;131(6):702.e7-702.e13. Zhang G, Shi R, Li XM. et al. Impact of diabetes mellitus on right ventricular dysfunction and ventricular interdependence in hypertensive patients with heart failure with reduced ejection fraction assessed via 3.0 T cardiac MRI. Cardiovasc Diabetol 2024;23: 375. Norouzi S, Hosseinsabet A, Mohseni-Badalabadi R. The evaluation of right ventricular function in patients with diabetes mellitus and significant stenosis at the proximal portion of the right coronary artery. J Ultrasound. 2022;25(1):9-17. Li Y, Liu Y, Liu S. et al. Diabetic vascular diseases: molecular mechanisms and therapeutic strategies. Sig Transduct Target Ther 2023;8:152. Gerges M, Gerges C, Lang IM. How to define pulmonary hypertension due to left heart disease. Eur Respir J. 2016;48(2):553-5. From AM, Scott CG, Chen HH. The development of heart failure in patients with diabetes mellitus and pre-clinical diastolic dysfunction a population-based study. J Am Coll Cardiol. 2010;55(4):300-5. Zoppini G, Bergamini C, Mantovani A, Dauriz M, Targher G, Rossi A, Bonora E. The E/e' ratio difference between subjects with type 2 diabetes and controls. A meta-analysis of clinical studies. PLoS One. 2018;13(12):e0209794. Hassan Ayman, K.M., Abdallah Mahmoud, A., Abdel-Mageed Eman, A. et al. Correlation between left ventricular diastolic dysfunction and dyslipidaemia in asymptomatic patients with new-onset type 2 diabetes mellitus. Egypt J Intern Med 2021;33: 8. Guazzi M, Bandera F, Pelissero G, Castelvecchio S, Menicanti L, Ghio S, Temporelli PL, Arena R. Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol. 2013;305(9):H1373-81. Additional Declarations No competing interests reported. Supplementary Files RVDMThesisspreadsheet.xlsx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 11 Oct, 2025 Reviews received at journal 11 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers agreed at journal 07 Oct, 2025 Reviewers invited by journal 07 Oct, 2025 Editor assigned by journal 07 Oct, 2025 Submission checks completed at journal 07 Oct, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7742838","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":528041265,"identity":"4ee8bcbf-4e0c-4b73-81e7-6af310edcda7","order_by":0,"name":"Adhiya NSS","email":"","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Adhiya","middleName":"","lastName":"NSS","suffix":""},{"id":528041266,"identity":"1852cc62-1539-4fb0-9308-c7a4f5b1cf6a","order_by":1,"name":"Sadhanandham Shanmugasundaram","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYJACiQQQeYOB8QEDAzMPe/MBBoaEAuK0MBuAtPAcA3ITDAhoYYBoYQMymBnAWhjwaOFvP/vwxoOKOnm+283PqisqrGV42LgTPzwwYJDnFzuA3YYz6cYWCWcOG868c8zs5pkz6Tw8bLybJYAOM5w5OwGrFgOGNDaJxLYDjBtuJJjdbGw7zGMv37sBpCXB4DYOLfzPQFrq7DfcSP9W2PjvMNiWH3i1SIBtYU7ccCPHjLGxAaxlG15bJG48Ywb5JXnmjZxiyYZjYL9ss0gwkMDpF/7+NMabPyrqbPtupG/82FBjbQ9yGFDERp5fGrsWnECCNOWjYBSMglEwClAAAF9kXXkY8RMHAAAAAElFTkSuQmCC","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":true,"prefix":"","firstName":"Sadhanandham","middleName":"","lastName":"Shanmugasundaram","suffix":""},{"id":528041267,"identity":"4708e595-2583-48b8-9546-b5198a8baa43","order_by":2,"name":"Ramesh Sankaran","email":"","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Ramesh","middleName":"","lastName":"Sankaran","suffix":""},{"id":528041268,"identity":"84a8659a-016c-4b8a-83a4-b14eba5f4671","order_by":3,"name":"Nagendra Boopathy Senguttuvan","email":"","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Nagendra","middleName":"Boopathy","lastName":"Senguttuvan","suffix":""},{"id":528041269,"identity":"e1c8e603-c02a-4761-b5f6-3ed07129db98","order_by":4,"name":"Akshay Prashanth","email":"","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Akshay","middleName":"","lastName":"Prashanth","suffix":""},{"id":528041270,"identity":"32638273-d5f1-4cf9-9cd3-016ad32f2c71","order_by":5,"name":"Keerthana Panchatcharam Sivakumar","email":"","orcid":"","institution":"Sri Ramachandra Institute of Higher Education and Research","correspondingAuthor":false,"prefix":"","firstName":"Keerthana","middleName":"Panchatcharam","lastName":"Sivakumar","suffix":""}],"badges":[],"createdAt":"2025-09-29 13:53:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7742838/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7742838/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93911987,"identity":"127407ca-436f-4893-8366-af7d32e6d3ef","added_by":"auto","created_at":"2025-10-20 08:18:08","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40351,"visible":true,"origin":"","legend":"","description":"","filename":"RVDMNewdraft1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/849ef2f38f39695beb6e2716.docx"},{"id":93911727,"identity":"14d75d5d-32ac-4ac9-bf4f-ec954383944e","added_by":"auto","created_at":"2025-10-20 08:10:08","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7958,"visible":true,"origin":"","legend":"","description":"","filename":"3b27003e7430429c84c0c3f431580bc0.json","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/b74a304964cc8af6e445c3be.json"},{"id":93911732,"identity":"b548dca1-f65f-4744-8929-f0b40ce99a01","added_by":"auto","created_at":"2025-10-20 08:10:08","extension":"xlsx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80998,"visible":true,"origin":"","legend":"","description":"","filename":"RVDMThesisspreadsheet.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/abf0f8b77dc9e30176510acf.xlsx"},{"id":93911733,"identity":"e4bf8fef-55e7-4fa0-88eb-085129581ca4","added_by":"auto","created_at":"2025-10-20 08:10:08","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69391,"visible":true,"origin":"","legend":"","description":"","filename":"3b27003e7430429c84c0c3f431580bc01enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/2a4f3096d63b06c075a1484a.xml"},{"id":93911726,"identity":"a048161c-96c4-4ce4-b5d8-7d6b70ef5251","added_by":"auto","created_at":"2025-10-20 08:10:07","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":71062,"visible":true,"origin":"","legend":"","description":"","filename":"3b27003e7430429c84c0c3f431580bc01structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/f4164727a76ef4b200b7b4ad.xml"},{"id":93911730,"identity":"5adb7509-08cb-461f-bff8-9fdbecc366e0","added_by":"auto","created_at":"2025-10-20 08:10:08","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76876,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/8ea0c16e0989d3fe4f6a53fc.html"},{"id":93913124,"identity":"de3354d5-88cc-4e24-9118-233cf25cf00d","added_by":"auto","created_at":"2025-10-20 08:34:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":844563,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/24f6f268-c1c5-43a5-8a94-620368e7eccd.pdf"},{"id":93912768,"identity":"577b8441-2c36-4479-b2f7-32f52605be93","added_by":"auto","created_at":"2025-10-20 08:26:08","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":80998,"visible":true,"origin":"","legend":"","description":"","filename":"RVDMThesisspreadsheet.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7742838/v1/a943845ce6dea50ac4bd8df3.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Metabolic Footprint on Right Ventricular Function: A Prospective Observational Study\u003c/p\u003e","fulltext":[{"header":"RESEARCH INSIGHTS","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is currently known about this topic?\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eDiabetes mellitus and hypertension are primary drivers of cardiovascular morbidity, primarily linked to left ventricular dysfunction.\u003c/li\u003e\n \u003cli\u003eHowever, the direct effects of these metabolic conditions on right ventricular function, particularly in the absence of coronary artery disease and in diverse populations, remain incompletely understood.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is the key research question?\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eThis study evaluates and compares subclinical right ventricular systolic and diastolic function among healthy controls, patients with diabetes mellitus, and those with coexisting diabetes and hypertension, using non-invasive echocardiographic parameters.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is new in our study?\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eWe demonstrate a progressive, subclinical impairment of both right and left ventricular function, which is most severe in patients with coexisting diabetes and hypertension.\u003c/li\u003e\n \u003cli\u003eOur findings show that these conditions lead to significant RV systolic dysfunction, impaired LV diastolic filling, and RV remodeling, all of which are detectable before the onset of overt heart failure.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow might this study influence clinical practice?\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eThe findings highlight the prognostic value of routine echocardiographic screening, including specific right ventricular parameters, in high-risk patients. Early identification of this subclinical biventricular dysfunction could enable timely, targeted interventions to prevent the progression to overt heart failure and pulmonary hypertension.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe coexistence of diabetes mellitus and hypertension profoundly accelerates cardiovascular disease progression, making it a critical driver of long-term morbidity and mortality in affected individuals. One area of growing interest is evaluating right ventricular (RV) function, which has traditionally received less attention than left ventricular (LV) function. However, emerging evidence suggests that RV systolic and diastolic dysfunction play a critical role in determining overall cardiac performance and prognosis in patients with metabolic diseases, including diabetes and hypertension.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e These pathologies can lead to compounded structural and functional cardiac alterations that extend beyond the left ventricle.\u003c/p\u003e\u003cp\u003eThis dual pathology accelerates the development of biventricular cardiomyopathy, with a particular impact on the right ventricle. These changes, often subclinical in early stages, include RV systolic dysfunction, impaired diastolic filling, myocardial fibrosis, and microvascular dysfunction, even in the absence of overt coronary artery disease (CAD).\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e In patients with DM and HTN, elevated systemic pressures contribute to increased pulmonary artery pressures and RV afterload, eventually leading to RV hypertrophy and progressive RV functional decline.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e According to the World Health Organization (WHO) classification, Group 2 pulmonary hypertension (PH) is attributed to left heart disease, particularly LV diastolic dysfunction, which is commonly seen in diabetes and hypertension. Meanwhile, Group 5 PH includes multifactorial causes, such as insulin resistance and metabolic dysfunction, which can impair pulmonary microvascular integrity and contribute to pulmonary hypertension via pulmonary microangiopathy \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eMoreover, diabetes alone has been proposed as an independent risk factor for both pulmonary hypertension and RV dysfunction, due to chronic hyperglycemia-induced endothelial dysfunction, increased vascular stiffness, and inflammatory vascular remodeling. Studies have shown that diabetic patients, even without structural heart disease or CAD, may develop pulmonary arterial stiffness and elevated pulmonary vascular resistance, resulting in RV overload and dysfunction.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSeveral echocardiographic parameters have been developed to assess RV function, including tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (RVMPI), and tissue Doppler imaging (TDI)-derived velocities. Studies have demonstrated that these indices are altered in diabetic patients, particularly those with coexisting hypertension, indicating subclinical RV dysfunction.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDespite growing evidence, comparative studies assessing RV function among healthy individuals, diabetic patients, and those with both diabetes and hypertension in the absence of coronary artery disease remain scarce. Additionally, the direct role of diabetes in contributing to pulmonary hypertension and RV failure, independent of left heart involvement, has not been thoroughly investigated in the Indian population, where the prevalence of DM and HTN is rapidly rising. Understanding these distinctions is crucial for the early identification of at-risk individuals and for initiating targeted interventions aimed at preventing advanced cardiac and pulmonary vascular complications.\u003c/p\u003e\u003cp\u003e This study aims to evaluate and compare systolic and diastolic RV function among three distinct groups - normal individuals, patients with diabetes mellitus, and patients with both diabetes and hypertension-excluding those with known CAD, using echocardiographic parameters supported by current clinical guidelines and literature. We hypothesized that right ventricular systolic and diastolic dysfunction would be more prevalent and severe in patients with both diabetes mellitus and systemic hypertension compared to those with diabetes alone or healthy individuals.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis prospective observational study was conducted to evaluate and compare the right ventricular (RV) systolic and diastolic functions among three distinct groups: patients with diabetes mellitus (DM), patients with both diabetes and hypertension (DM\u0026thinsp;+\u0026thinsp;HTN), and normal individuals without known coronary artery disease (CAD). A total of 211 subjects were included in the study, divided into three groups such as control (n\u0026thinsp;=\u0026thinsp;75), patients with diabetes (n\u0026thinsp;=\u0026thinsp;75), and patients with both diabetes and hypertension (n\u0026thinsp;=\u0026thinsp;76).\u003c/p\u003e\u003cp\u003e This study was approved by the Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (REF: CSP/24/OCT/152/373) and informed consent was obtained from all participants prior to enrolment.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInclusion Criteria\u003c/h2\u003e\u003cp\u003eAdults aged 30 to 65 years\u003c/p\u003e\u003cp\u003eGroup 1: Diagnosed with type 2 diabetes mellitus\u003c/p\u003e\u003cp\u003eGroup 2: Diagnosed with both type 2 diabetes mellitus and hypertension\u003c/p\u003e\u003cp\u003eGroup 3: Healthy controls without diabetes, hypertension, or known CAD\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003eKnown history of CAD, valvular heart disease, or congenital heart defects\u003c/p\u003e\u003cp\u003eHistory of pulmonary hypertension, chronic obstructive pulmonary disease (COPD), or cor pulmonale\u003c/p\u003e\u003cp\u003eRenal failure or hepatic dysfunction\u003c/p\u003e\u003cp\u003ePoor echocardiographic window\u003c/p\u003e\n\u003ch3\u003eStudy Procedure\u003c/h3\u003e\n\u003cp\u003eAll participants underwent a detailed clinical examination and laboratory evaluation, including fasting blood glucose, HbA1c, and blood pressure monitoring. A comprehensive two-dimensional transthoracic echocardiography (2D-TTE) was performed using a standardized protocol. RV systolic function was assessed using:\u003c/p\u003e\u003cp\u003eTricuspid Annular Plane Systolic Excursion (TAPSE)\u003c/p\u003e\u003cp\u003eRight Ventricular Fractional Area Change (RV FAC)\u003c/p\u003e\u003cp\u003eTissue Doppler Imaging (TDI) of the tricuspid annulus (S\u0026rsquo; wave)\u003c/p\u003e\u003cp\u003eRV diastolic function was evaluated using:\u003c/p\u003e\u003cp\u003eTDI-derived E\u0026rsquo; and A\u0026rsquo; velocities at the tricuspid annulus\u003c/p\u003e\u003cp\u003eE/E\u0026rsquo; ratio\u003c/p\u003e\n\u003ch3\u003eEquipment\u003c/h3\u003e\n\u003cp\u003eEchocardiographic assessments were performed using a GE Vivid E9 machine with a 3.5 MHz transducer. All measurements were averaged over three cardiac cycles and performed by an experienced cardiologist blinded to group allocation.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 25. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and categorical variables as percentages. Comparisons among the three groups were performed using a one-way ANOVA test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the present study comparing anthropometric and biochemical parameters among control subjects (75 patients), patients with diabetes mellitus (DM) (60 patients), and those with both diabetes mellitus and hypertension (DM with HT) (76 patients), several significant differences were observed (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The weight did not differ significantly across the groups (P\u0026thinsp;=\u0026thinsp;0.781). Body Surface Area (BSA) was comparable among the three groups (P\u0026thinsp;=\u0026thinsp;0.986). However, Body Mass Index (BMI) was significantly higher in the DM with HT group (28.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.88) compared to the control and DM-only groups (P\u0026thinsp;=\u0026thinsp;0.030). The mean age was significantly higher in the DM with HT group (57.65\u0026thinsp;\u0026plusmn;\u0026thinsp;11.25 years) compared to the DM group (51.08\u0026thinsp;\u0026plusmn;\u0026thinsp;12.27 years) and control group (42\u0026thinsp;\u0026plusmn;\u0026thinsp;12.78 years), with a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003cp\u003eSystolic and diastolic blood pressures (SBP and DBP) showed statistically significant variation across the groups (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). HbA1c levels were significantly different among the groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While LDL levels showed a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.045), HDL levels did not (P\u0026thinsp;=\u0026thinsp;0.255). These findings indicate variable metabolic and hemodynamic profiles among the groups, warranting further evaluation of their cardiovascular implications.\u003c/p\u003e\u003cp\u003eWhile HDL levels were not significantly different across the groups (P\u0026thinsp;=\u0026thinsp;0.255), LDL levels showed a significant reduction in the DM (116.73\u0026thinsp;\u0026plusmn;\u0026thinsp;42.72 mg/dl) and DM with HT (113.63\u0026thinsp;\u0026plusmn;\u0026thinsp;37.29 mg/dl) groups compared to controls (129.71\u0026thinsp;\u0026plusmn;\u0026thinsp;35.40 mg/dl), with a P value of 0.045. These findings suggest that the coexistence of diabetes and hypertension is significantly associated with higher BMI, highlighting the compounded cardiovascular risk in this subgroup.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of anthropometric and biochemical parameters\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDM\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDM with HT\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge in years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e42\u0026thinsp;\u0026plusmn;\u0026thinsp;12.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e51.08\u0026thinsp;\u0026plusmn;\u0026thinsp;12.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e57.65\u0026thinsp;\u0026plusmn;\u0026thinsp;11.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight in cm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e164.22\u0026thinsp;\u0026plusmn;\u0026thinsp;9.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e164.51\u0026thinsp;\u0026plusmn;\u0026thinsp;8.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e161.05\u0026thinsp;\u0026plusmn;\u0026thinsp;9.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.049\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight in kg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e71.61\u0026thinsp;\u0026plusmn;\u0026thinsp;14.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e70.96\u0026thinsp;\u0026plusmn;\u0026thinsp;12.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e72.58\u0026thinsp;\u0026plusmn;\u0026thinsp;13.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.781\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBSA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.986\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e26.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e26.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e28.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSBP mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e117.46\u0026thinsp;\u0026plusmn;\u0026thinsp;14.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e119.67\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e147.12\u0026thinsp;\u0026plusmn;\u0026thinsp;14.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDBP mmHg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e74.13\u0026thinsp;\u0026plusmn;\u0026thinsp;8.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e73.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e83.87\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHBA1c %\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e5.62\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.98\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHDL mg/dl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e44.31\u0026thinsp;\u0026plusmn;\u0026thinsp;12.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e41.23\u0026thinsp;\u0026plusmn;\u0026thinsp;14.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e45.83\u0026thinsp;\u0026plusmn;\u0026thinsp;18.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.255\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDL mg/dl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e129.71\u0026thinsp;\u0026plusmn;\u0026thinsp;35.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e116.73\u0026thinsp;\u0026plusmn;\u0026thinsp;42.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e113.63\u0026thinsp;\u0026plusmn;\u0026thinsp;37.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn this study, several echocardiographic parameters showed statistically significant differences among the groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). TAPSE was significantly reduced in both the DM (2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18 cm) and DM with HT (2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20 cm) groups compared to controls (2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19 cm), with a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, indicating early right ventricular systolic dysfunction. Right ventricular (RV) thickness was markedly higher in the DM with HT group (6.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 mm), followed by the DM group (5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92 mm), compared to controls (4.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07 mm), showing a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001, suggestive of RV remodeling due to combined disease burden.\u003c/p\u003e\u003cp\u003eTricuspid regurgitation pressure gradient (TRPG) was significantly elevated in the DM with HT group (18.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.29 mmHg) compared to the control and DM groups (P\u0026thinsp;=\u0026thinsp;0.037), and pulmonary artery pressure (PAP) was also higher in this group (21.81\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27 mmHg), with a P value of 0.025, reflecting increased pulmonary pressure. Additionally, the late diastolic A-wave velocity (A) was significantly higher in the DM with HT group (0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 m/s) compared to the other groups (P\u0026thinsp;=\u0026thinsp;0.010), and deceleration time (DT) was significantly prolonged (177.12\u0026thinsp;\u0026plusmn;\u0026thinsp;38.94 ms), with a P value of 0.001, indicating impaired diastolic relaxation in this group.\u003c/p\u003e\u003cp\u003eThese findings highlight significant impairments in right ventricular function and diastolic filling parameters in patients with coexisting diabetes and hypertension.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of echocardiographic findings regarding systolic and diastolic functions of the RV and LV\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDM\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDM with HT\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEF (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e64.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e63.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.480\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLVEDD (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e43.27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e44.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e43.36\u0026thinsp;\u0026plusmn;\u0026thinsp;3.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.456\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLVESD (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e28.67\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e29.08\u0026thinsp;\u0026plusmn;\u0026thinsp;2.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e28.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.658\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTAPSE (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRV FAC (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e46.04\u0026thinsp;\u0026plusmn;\u0026thinsp;7.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e44.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e44.44\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.343\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRV Systolic area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e7.86\u0026thinsp;\u0026plusmn;\u0026thinsp;1.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e7.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.82\u0026thinsp;\u0026plusmn;\u0026thinsp;1.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.881\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRV Diastolic area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e14.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e13.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e14.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.286\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRV Thickness (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTRPG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e16.24\u0026thinsp;\u0026plusmn;\u0026thinsp;5.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e17.08\u0026thinsp;\u0026plusmn;\u0026thinsp;6.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e18.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.037\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e19.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e20.13\u0026thinsp;\u0026plusmn;\u0026thinsp;6.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e21.81\u0026thinsp;\u0026plusmn;\u0026thinsp;6.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.025\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE(T)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.298\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA(T)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.010\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE/A (T)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e1.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e1.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDT (m/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e154.19\u0026thinsp;\u0026plusmn;\u0026thinsp;32.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e166.71\u0026thinsp;\u0026plusmn;\u0026thinsp;42.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e177.12\u0026thinsp;\u0026plusmn;\u0026thinsp;38.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis study compared tissue Doppler imaging parameters among three groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The early diastolic mitral annular velocity (E\u0026rsquo;) showed a significant decline across the groups, with mean values of 0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08 m/s in controls, 0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02 m/s in the DM group, and 0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02 m/s in the DM with HT group (p\u0026thinsp;=\u0026thinsp;0.001), indicating impaired diastolic function with the presence of diabetes and further deterioration when hypertension coexists. The late diastolic velocity (A\u0026rsquo;) progressively increased from 0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 m/s in controls to 0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 m/s in DM and 0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04 m/s in DM with HT, which was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The E/E\u0026rsquo; ratio, a marker of left ventricular filling pressure, also showed a significant rise from 4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01 in controls to 5.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35 in DM and 5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61 in the DM with HT group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), suggesting worsening diastolic dysfunction. In contrast, proper right ventricular systolic velocity (RVS) remained similar across all groups, with a uniform value of 0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02 cm/s, showing no significant difference (p\u0026thinsp;=\u0026thinsp;0.269).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eComparison of Doppler echocardiographic findings of the RV function\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;76)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDM\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDM with HT\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE\u0026rsquo;(T) (m/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u0026rsquo;(T) (m/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE/E\u0026rsquo; (T)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e5.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRVS (cm/s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.269\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study demonstrates significant impairments in both right ventricular (RV) and left ventricular (LV) functions in patients with diabetes mellitus (DM) and those with coexisting diabetes and hypertension (DM\u0026thinsp;+\u0026thinsp;HT), compared to controls. These findings are consistent with accumulating evidence highlighting the detrimental effects of metabolic and hemodynamic stressors on cardiac structure and function.\u003c/p\u003e\n\u003ch3\u003eRight Ventricular Function\u003c/h3\u003e\n\u003cp\u003eTricuspid annular plane systolic excursion (TAPSE), a reliable marker of RV systolic function, was significantly reduced in both DM and DM\u0026thinsp;+\u0026thinsp;HT groups compared to controls. This is in agreement with prior studies showing reduced TAPSE in diabetic patients, indicating subclinical RV dysfunction.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Increased RV wall thickness observed in the DM\u0026thinsp;+\u0026thinsp;HT group further suggests RV remodeling, likely due to chronic pressure overload from systemic hypertension and diabetic microvascular damage.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Diabetes may contribute directly to RV remodeling via myocardial fibrosis, lipotoxicity, and microvascular rarefaction. These structural changes impair RV contractility and compliance, ultimately compromising RV systolic performance. The additive burden of hypertension may further exacerbate RV wall stress and promote compensatory hypertrophy.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePulmonary Pressures\u003c/h2\u003e\u003cp\u003eThe elevation of the tricuspid regurgitation pressure gradient (TRPG) and pulmonary artery systolic pressure (PASP) in the DM\u0026thinsp;+\u0026thinsp;HT group indicates increased pulmonary vascular resistance and possible pulmonary hypertension. Doppler-derived TRPG has been validated as a surrogate for PASP and serves as a non-invasive tool to screen for elevated pulmonary pressures.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e The observed increases may reflect both left-sided diastolic dysfunction and pulmonary vascular remodeling in diabetic and hypertensive states. The increase in PASP and TRPG among diabetic and hypertensive patients in this study can be interpreted in the context of both Group 2 PH, due to left heart disease (e.g., LV diastolic dysfunction), and Group 5 PH, due to multifactorial metabolic causes.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLeft Ventricular Diastolic Function\u003c/h2\u003e\u003cp\u003eTissue Doppler imaging revealed impaired LV relaxation (reduced E\u0026prime; velocity) and elevated E/E\u0026prime; ratios in both DM and DM\u0026thinsp;+\u0026thinsp;HT groups. These findings are consistent with previous research identifying E/E\u0026prime; as a reliable surrogate for LV filling pressure, especially in diabetic populations.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e A recent study also showed that patients with type 2 diabetes exhibit higher E/E\u0026prime; ratios, confirming subclinical diastolic dysfunction associated with diabetic cardiomyopathy.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The combination of diabetes and hypertension further compounds this dysfunction, likely due to the additive effects of myocardial fibrosis, endothelial dysfunction, and altered ventricular compliance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eClinical Implications\u003c/h2\u003e\u003cp\u003eThe coexistence of diabetes and hypertension appears to amplify adverse cardiac remodeling, promoting both LV diastolic and RV systolic dysfunction. This biventricular involvement significantly increases the risk of developing pulmonary hypertension and heart failure. Importantly, TAPSE and E/E\u0026prime; are known independent predictors of cardiovascular morbidity and mortality, making their routine echocardiographic assessment critical in high-risk populations.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eGiven that early RV dysfunction and pulmonary vascular changes may remain subclinical, especially in diabetic patients, their identification through non-invasive imaging could enable timely intervention. These findings underscore the need for comprehensive echocardiographic evaluation, including RV parameters and pulmonary pressures, in patients with diabetes and hypertension, particularly in Indian clinical practice, where routine RV assessment is often overlooked.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe \u003cb\u003ecross-sectional design\u003c/b\u003e of the study prevents the establishment of a causal relationship between diabetes/hypertension and right ventricular (RV) dysfunction. Secondly, advanced imaging modalities like \u003cb\u003ecardiac MRI or speckle-tracking echocardiography\u003c/b\u003e, which provide a more detailed assessment of RV strain and mechanics, were not utilized. Finally, this was a single-center, hospital-based study, which may limit the \u003cb\u003egeneralizability\u003c/b\u003e of our findings to a broader population. Potential confounders such as medication use and duration of disease were not controlled for in the analysis.\u003c/p\u003e\u003cp\u003eFuture research should focus on \u003cb\u003elongitudinal studies\u003c/b\u003e to track the progression of RV dysfunction in these patient populations and to determine if early echocardiographic changes predict future cardiac events. The use of more \u003cb\u003eadvanced imaging techniques\u003c/b\u003e, such as speckle-tracking echocardiography and cardiac MRI, would provide a more in-depth understanding of the subclinical changes in RV mechanics. Furthermore, studies should investigate the impact of specific \u003cb\u003emedication regimens\u003c/b\u003e and different lifestyle interventions on RV function in diabetic and hypertensive patients. A larger, multicenter study would also help to validate these findings in a more diverse population.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights that both diabetes mellitus and its coexistence with hypertension are associated with significant impairments in right and left ventricular functions, as evidenced by reduced TAPSE and altered diastolic indices (E\u0026prime; and E/E\u0026prime;). The presence of both conditions exacerbates cardiac dysfunction, emphasizing the need for early echocardiographic screening in such high-risk groups to guide timely interventions and prevent progression to heart failure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of Sri Ramachandra Institute of Higher Education and Research (Reference number: CSP/24/OCT/152/373). Written informed consent including consent for publication was obtained from all individual participants included in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no funding or specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSadhanandham S conceived the study and participated in its design and coordination. Adhiya NSS performed the statistical analysis and wrote the manuscript. Ramesh S performed and supervised the echocardiography protocols. Nagendra Boopathy S helped in participant enrolment. Akshay PG helped draft the manuscript. Keerthana PS was blinded to the allocation and performed the echocardiography. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBhupal VS, R Kumar, P. Sampath. Assessment of Right Ventricular Function before and after Primary Percutaneous Coronary Intervention in Patients with Acute Inferior Wall ST-elevation Myocardial Infarction by Tissue Doppler Imaging. Research in Cardiovascular Medicine 2024; 13(4):105-109.\u003c/li\u003e\n \u003cli\u003eZhang G, Shi R, Li XM, Yan WF, Xu HY, Li Y, Guo YK, Shi K, Yang ZG. Impact of diabetes mellitus on right ventricular dysfunction and ventricular interdependence in hypertensive patients with heart failure with reduced ejection fraction assessed via 3.0 T cardiac MRI. Cardiovasc Diabetol 2024;23(1):375.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNamazi M, Eftekhar SP, Mosaed R, Shiralizadeh Dini S, Hazrati E. Pulmonary Hypertension and Right Ventricle: A Pathophysiological Insight.\u0026nbsp;Clinical Medicine Insights 2024;18.\u003c/li\u003e\n \u003cli\u003eSimonneau G, Gatzoulis MA, Adatia I, Celermajer D, Denton C, Ghofrani A, Gomez Sanchez MA, Krishna Kumar R, Landzberg M, Machado RF, Olschewski H, Robbins IM, Souza R. Updated clinical classification of pulmonary hypertension. J Am Coll Cardiol. 2013;62(25 Suppl):D34-41\u003c/li\u003e\n \u003cli\u003eWhitaker ME, Nair V, Sinari S, Dherange PA, Natarajan B, Trutter L, Brittain EL, Hemnes AR, Austin ED, Patel K, Black SM, Garcia JGN, Yuan Md PhD JX, Vanderpool RR, Rischard F, Makino A, Bedrick EJ, Desai AA. Diabetes Mellitus Associates with Increased Right Ventricular Afterload and Remodeling in Pulmonary Arterial Hypertension. Am J Med. 2018;131(6):702.e7-702.e13.\u003c/li\u003e\n \u003cli\u003eZhang G, Shi R, Li XM. et al. Impact of diabetes mellitus on right ventricular dysfunction and ventricular interdependence in hypertensive patients with heart failure with reduced ejection fraction assessed via 3.0 T cardiac MRI. Cardiovasc Diabetol \u0026nbsp;2024;23: 375.\u003c/li\u003e\n \u003cli\u003eNorouzi S, Hosseinsabet A, Mohseni-Badalabadi R. The evaluation of right ventricular function in patients with diabetes mellitus and significant stenosis at the proximal portion of the right coronary artery. J Ultrasound. 2022;25(1):9-17.\u003c/li\u003e\n \u003cli\u003eLi Y, Liu Y, Liu S. \u003cem\u003eet al.\u003c/em\u003e Diabetic vascular diseases: molecular mechanisms and therapeutic strategies. Sig Transduct Target Ther \u0026nbsp;2023;8:152.\u003c/li\u003e\n \u003cli\u003eGerges M, Gerges C, Lang IM. How to define pulmonary hypertension due to left heart disease. Eur Respir J. 2016;48(2):553-5.\u003c/li\u003e\n \u003cli\u003eFrom AM, Scott CG, Chen HH. The development of heart failure in patients with diabetes mellitus and pre-clinical diastolic dysfunction a population-based study. J Am Coll Cardiol. 2010;55(4):300-5.\u003c/li\u003e\n \u003cli\u003eZoppini G, Bergamini C, Mantovani A, Dauriz M, Targher G, Rossi A, Bonora E. The E/e\u0026apos; ratio difference between subjects with type 2 diabetes and controls. A meta-analysis of clinical studies. PLoS One. 2018;13(12):e0209794.\u003c/li\u003e\n \u003cli\u003eHassan Ayman, K.M., Abdallah Mahmoud, A., Abdel-Mageed Eman, A. \u003cem\u003eet al.\u003c/em\u003e Correlation between left ventricular diastolic dysfunction and dyslipidaemia in asymptomatic patients with new-onset type 2 diabetes mellitus. Egypt J Intern Med 2021;33: 8.\u003c/li\u003e\n \u003cli\u003eGuazzi M, Bandera F, Pelissero G, Castelvecchio S, Menicanti L, Ghio S, Temporelli PL, Arena R. Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis. Am J Physiol Heart Circ Physiol. 2013;305(9):H1373-81.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":false,"email":"","identity":"cardiovascular-diabetology-endocrinology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Cardiovascular Diabetology – Endocrinology Reports","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"Unsupported Journal","inReviewEnabled":false,"inReviewRevisionsEnabled":false},"keywords":"Right ventricular function, diabetes mellitus, hypertension, echocardiography, tissue Doppler imaging","lastPublishedDoi":"10.21203/rs.3.rs-7742838/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7742838/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground \u0026amp; Aim:\u003c/h2\u003e\u003cp\u003eDiabetes mellitus and hypertension are major contributors to adverse cardiovascular outcomes, significantly elevating the risk of heart failure, vascular disease, and premature mortality. Right ventricular (RV) function, though historically under-evaluated, is increasingly recognized as a critical determinant of cardiac performance, especially in metabolic diseases. This study evaluates and compares RV systolic and diastolic function among normal individuals, patients with DM, and those with both DM and HTN, excluding those with coronary artery disease (CAD).\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eThis prospective observational study included 211 adults aged 30\u0026ndash;65 years, categorized into three groups: controls (n\u0026thinsp;=\u0026thinsp;75), DM (n\u0026thinsp;=\u0026thinsp;60), and DM with HTN (n\u0026thinsp;=\u0026thinsp;76). Participants underwent clinical evaluation, laboratory testing (HbA1c, lipid profile), and comprehensive transthoracic echocardiography. RV systolic function was assessed via TAPSE, RV FAC, and tissue Doppler-derived S\u0026prime; wave. RV diastolic function was evaluated using tricuspid annular E\u0026prime;, A\u0026prime; velocities, E/E\u0026prime; ratio, and deceleration time. Data were analyzed using SPSS v25; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eTAPSE was reduced in both DM (2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18 cm) and DM with HTN (2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20 cm) groups compared to controls (2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19 cm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating RV systolic dysfunction. RV wall thickness was highest in the DM with HTN group (6.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 mm, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). TRPG and pulmonary artery pressure were elevated in the DM with HTN group (p\u0026thinsp;=\u0026thinsp;0.037 and p\u0026thinsp;=\u0026thinsp;0.025, respectively). A-wave velocity and deceleration time were significantly increased in the DM with HTN group, indicating diastolic dysfunction.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003ePatients with DM and especially those with coexisting HTN exhibit significant subclinical impairments in RV systolic and diastolic function. Early echocardiographic detection of right ventricular dysfunction in diabetic and hypertensive patients enables timely intervention, potentially preventing progression to overt heart failure and pulmonary hypertension.\u003c/p\u003e","manuscriptTitle":"The Metabolic Footprint on Right Ventricular Function: A Prospective Observational Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-20 08:10:03","doi":"10.21203/rs.3.rs-7742838/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-11T10:07:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T06:28:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170447477566909544744990765625269074418","date":"2025-10-09T02:25:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156225692363772944467892284857111853628","date":"2025-10-08T09:04:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T14:03:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13364523056418865642930853623229622703","date":"2025-10-07T13:56:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239834920056753628974087742460188470747","date":"2025-10-07T13:29:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330314944492827762821408518470512809363","date":"2025-10-07T13:16:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-07T13:12:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T13:04:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-07T13:03:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cardiovascular Diabetology – Endocrinology Reports","date":"2025-09-29T13:50:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":false,"email":"","identity":"cardiovascular-diabetology-endocrinology-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Cardiovascular Diabetology – Endocrinology Reports","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"Unsupported Journal","inReviewEnabled":false,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3ec5c651-3ad7-4832-8938-617f077c5dd2","owner":[],"postedDate":"October 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T14:23:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-20 08:10:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7742838","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7742838","identity":"rs-7742838","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}