Evaluation of Left Ventricular Functions in Hypertensive Diabetic Patients by Speckle Tracking Imaging and its Correlation with Brain Natriuretic Peptide Levels: A systematic Review

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Introduction
Cardiovascular diseases (CVD) are conditions of the heart and blood vessels that cause significant mortality and morbidity and place a significant burden on global public health.In addition, CVDs are considered the world's most common death cause.The term "cardiovascular disease" (CVD) is used to describe a variety of conditions that affect the heart and blood vessels [1].These include heart failure and other cardiac disorders, as well as high blood pressure (HTN), coronary heart disease (heart attack), cerebrovascular illness (stroke), and.Since the environment in which the field of cardiology operates has been changing quickly, reliable and timely CVD statistics are crucial for tracking and predicting the progression of the illness [2].Furthermore, HTN is the most prevalent cause of disability in the world and a separate, manageable risk factor associated with cardiovascular disease (CVD) [3].Besides, for those with type 2 diabetes (T2D) and type 1 diabetes, CVD continues to be the leading cause of mortality and morbidity due to the morphological and functional changes that persistent hyperglycemia produces on artery walls, which are assumed to be the cause of the development of atherosclerotic plaque [4].
The finding that people with diabetes and hypertension have a greater LV end-diastolic pressure than those with hypertension alone may help to explain some of the increased risk of developing heart failure in these patients [5].Additionally, independent abnormalities of diastolic function are rare and are typically brought on by a subclinical impairment of systolic function.Since LV re-modelling or hypertrophy is clearly seen in the advanced stages of hypertensive heart disease (HHD), traditional echocardiography only reveals problems in LV systolic function in these cases [6].Additionally, speckle tracking echocardiography (STE) is a non-invasive, angle-independent method that monitors myocardial characteristics throughout the cardiac cycle.Each myocardial region has its own distinct characteristics, and they are unaffected by heart translational movements [7].Additionally, STE is more adept at identifying early cardiac dysfunction in hypertensive patients than both tissue Doppler imaging (TDI) and conventional echocardiography.Additionally, it can be used to evaluate diabetics' subclinical cardiac impairment prior to the onset of diabetic cardiomyopathy [8].
Brain natriuretic peptide (BNP) is a hormone produced by the heart in response to volume overload and increased pressure.It acts on the kidneys and blood vessels to promote fluid excretion and vasodilation [9].In patients suffering from heart failure and acute myocardial infarction, BNP levels are increased and considered a strong predictor of cardiovascular events.BNP expression upregulation is frequently employed in the clinic as a diagnostic indicator for heart failure, diastolic dysfunction, and LV hypertrophy [10].According to the literature, by acting as an endogenous brake on the LV myocardium, BNP can reduce the signaling pathways that cause the transition from LV hypertrophy to re-modeling, heart failure, and death [11,12].
The purpose of this study was to evaluate left ventricular function using speckle tracking echocardiography in individuals with diabetes and hypertension and to make a correlation with the results of the brain natriuretic peptide levels.

Search strategy
The recommendations of Preferred Reporting Items for Systematic Reviews (PRISMA) were followed when conducting this systematic review [13].Using PubMed, Web of Science, Cochrane, and Scopus, a literature search was conducted to look for potential studies that had been published.The search strategy includes "left ventricular/left ventricle/left ventricles," "hypertensive /hypertensive diabetic," "strain/ deformation/ speckle tracking," and "brain natriuretic peptide/BNP-32/brain natriuretic peptide-32.".In addition, this study did not require the permission of a university review board.

Patients
were diagnosed with hypertension if their SBP and/or DBP were consistently elevated to ≥140 mmHg and ≥90 mmHg, respectively.Bedside, patients were diagnosed with diabetes if their FPG and/or 2hPG were consistently elevated to ≥126 mg/dl and ≥200 mg/dl, respectively.

Intervention
Speckle tracking imaging.

Comparison
None.

Outcome
Left ventricular function.

Inclusion criteria
Patients in the included trials were hypertension or diabetic hypertensive, while control group were non-hypertensive and nondiabetic persons who free of any CVD disease.However, hypertensive individuals were diagnosed using ESH/ESC guidelines for hypertension therapy if their SBP was 140 mmHg and/or their DBP was 90 mmHg on two or more hospital visits at one-week intervals.Diabetic individuals were identified using the American Diabetes Association's criteria: fasting plasma glucose 126 mg/dl (7.0mmol/l) or two-hour plasma glucose 200 mg/dl (11.1mmol/l).

Exclusion criteria
Patients with reduced left ventricular systolic function, arrhythmias, coronary artery disease, valve disease, congenital heart diseases, pericardial disorders, secondary causes of hypertension, or unsatisfactory echocardiographic pictures were excluded from the study.

Study selection
Both entire full-text and abstracts underwent conventional, blind review.Selected publications' references to pertinent studies were reviewed for potential inclusion.The Excel program was utilized.Moreover, any differences among scholars were settled by senior contributors prior to final clearance.

Data extraction
Before screening, each database's search results were aggregated, and duplicates were removed.The title/abstract were initially screened, the full-texts of selected publications were collected, in addition, the eligibility was double-checked by a specified eligibility form, and data was collected using a prepared form.Two authors working independently, carried out the citation screening and extraction and conflicts were resolved through consensus.
Bias risk assessment, quality, and validity of included studies.The author evaluated the included studies for quality and bias risk, including using the Newcastle-Ottawa Scale.

Search results and study selection
A PRISMA diagram is shown in Figure 1.A total of 300 records were found.After deleting duplicates, 279 of 300 items were discarded based on title and abstract.The eligibility of ten full-text articles was determined.
The other seven papers from ten investigations were suitable (n = 2: demonstrate an association with brain natriuretic peptide levels; n = 5: use

Speckle tracking to assess left ventricular function).
Table 1 shows the characteristics of the papers that were included.Most (2/7) were based on Egyptian samples.The remainder included one paper from China, Turkey, Germany, the USA, and India.The total number of participants in the seven trials mentioned was 601.

Evaluation of left ventricular functions and its correlation with brain natriuretic peptide levels
A study by El-Noamany 2020 et al.
reported that plasma BNP levels were greater in hypertension groups (groups II and III) than in controls, and that group III was significantly higher than group II (P = 0.001) [14].

LV and Speckle Tracking Imaging
A study by Han et al. (2008) reported that, in comparison to the healthy control group, patients with hypertension had a higher peak LV twist and delayed diastolic untwisting.This shows that STI can be used to assess early LV function changes in hypertensive patients [15].
Furthermore, a study by Kosmala et al. (2008) reported that in individuals with hypertension, speckle tracking can be used to evaluate the severity of cardiac damage and forecast how it will evolve over time.Radial strain measures' reproducibility, however, might be less trustworthy than Doppler strain measurements [17].A study by Nakai et al. (2009) found that in diabetic patients, 2DSTE can identify subclinical LV systolic dysfunction, which may be helpful for risk assessment [18].

Publication bias and study quality
The small number of included studies made it impossible to assess publication bias.
However, the quality of the studies was good.

Discussion
Using speckle tracking echocardiography, this systematic review summarizes the most recent research on the assessment of left ventricular functions in patients with hypertension and/or diabetes who appear to maintain LV. systolic function and compares the results to plasma brain natriuretic peptide levels.
To evaluate LV systolic function, conventional echocardiographic measures have been developed over time.The most clinically pertinent metric for this reason is LVEF, which is one of them.LVEF, however, has a number of drawbacks.Second, it is impacted by factors including heart rate, loading conditions, and other factors.The first of these three problems, which is the most important, is that it lacks the sensitivity to recognize minute alterations in contractile performance, making it unsuitable for detecting sub-clinical myocardial injury, Thus, depending on the clinical context, could have significant therapeutic and prognostic implications.
Measurement of LV systolic function that can precisely identify minor changes in myocardial function is the most important function of STE.In this study, conventional echocardiogram measurements of LV systolic function revealed no appreciable differences between the two groups in terms of LV.However, these results were consistent with those of Wang et al., (2015) who included 90 diabetes patients, 36 of whom had concurrent hypertension, and classified them into three groups.: controls, individuals with diabetes, and individuals who also had hypertension [20].The study found that the three groups displayed comparable LVEF values when it came to heart function as measured by traditional echocardiography.
The results for early diastolic strain rate agreed with those from Hamed et al., (2014) who found that early diastolic strain rate was considerably lower in hypertension patients than in controls [14].According to Yu Kolesnyk patients with diabetes and hypertension exhibited a considerably early diastole, reduced longitudinal strain rate than the other study groups [21].
The results of this study support earlier studies' findings that TDI or 2DSTE could detect early subclinical alterations in heart function [22][23][24].However, TDI only reports velocity and strain information in the long axis direction and is angle dependent.Although 2DSTE eliminates TDI's angle dependency [25].
However, according to the current study, all patient groups had BNP levels that were significantly higher than those of healthy controls.These levels rose from the hypertension group to the diabetic group over time, peaking in the diabetic hypertensive group.In all patients, BNP levels were associated with LV strain and rate measurements, along with findings from traditional echocardiography and TDI.Our findings differed slightly from those of Wang et al., (2015) that is concluded that the most of the diabetic research participants' BNP levels were normal, and echocardiography revealed diastolic dysfunction and abnormal strain.[20].Despite the apparent discrepancy among diverse studies, BNP's examination is beneficial for excluding cardiac dysfunction in emergency situations with symptoms that may mirror those of cardiac origin because of its negative predictive value, which cannot be disregarded [14].
It has been demonstrated that natriuretic peptides are linked to left ventricular hypertrophy, changes in cardiac function, and overt heart failure in people with chronic renal illness.They are also linked to LV systolic and/or diastolic dysfunction in those with CVDs [28,29].Additionally, earlier research has demonstrated that BNP is elevated in the presence of asymptomatic LV systolic failure [30,31].

Conclusion
This systematic review found that in individuals with diabetes or hypertension who appear to have intact LV systolic function, speckle tracking echocardiography was found to be able to detect sub-clinical alterations in left ventricular function.Speckle tracking echocardiography was able to detect significant reductions in early diastolic strain rate in all three patient groups, in comparison to controls.Additionally, all patient groups had BNP levels that significantly greater than those of healthy controls, and BNP levels were associated with LV strain and strain rate measurements.These findings suggest that speckle tracking echocardiography might be a useful tool for early identification of subclinical heart failure in patients with hypertension and/or diabetes.

Table 1 :
Summery of included studies.

Table 2 :
Bias Risk Assessment Using Newcastle-Ottawa Scale.
These results contradict those of Bakhoum et al., who claimed that there was no significant difference between control subjects and patients in terms of serum BNP level [26].