TABLE 1: DEMOGRAPHIC DATA 

The study population predominantly included middle-aged adults with mild gender predominance toward males (56%). The mean age of 56.8 ± 9.2 years reflects the age bracket where systemic hypertension typically manifests clinically. The mean BMI (27.4 ± 3.8 kg/m²) indicates that most patients were either overweight, aligning with established risk profiles for hypertension. The recorded mean systolic (146.2 ± 18.5 mmHg) and diastolic pressures (89.7 ± 10.6 mmHg) fall into the stage 1–2 hypertensive range, consistent with subjects undergoing long-term management for Systemic Hypertension (≥6 months). The elevated mean arterial pressure (MAP-LV = 108.5 ± 12.3 mmHg) suggests chronic elevation in systemic load and increased left ventricular (LV) afterload. LVEF (59.8 ± 6.4%) and SF (33.7 ± 4.1%) remained within normal physiological limits, indicating preserved systolic function in the majority of participants. However, the presence of concentric LV hypertrophy (as reported separately through wall thickness and mass indices) implies adaptive myocardial remodeling secondary to chronic pressure overload and the mean heart rate (74.6 ± 8.2 beats/min) suggests a normal sinus rhythm at rest, which is ideal for echocardiographic load assessment.

Table 2: Distribution & Diastolic Function Indices Among Clinical Subgroups 

TABLE 3: COMPARATIVE RESULTS BETWEEN THE 2 VARIABLES 

In our study we have found that, the percentage change (Δ%) from baseline for TMD and TD indices under preload and afterload, highlighting statistically significant variations with <0.05. This visualization emphasizes the comparatively smaller coefficient of variation in TD measures (1.8 to 2.7%) versus TMD (1.0 to 2.8%), illustrating tissue Doppler's relative stability and sensitivity under different hemodynamic condition.  

In our observation, we have found that, smokers demonstrated a marked reduction in the E/A and E′/A′ ratios, signifying impaired early diastolic filling and increased dependence on atrial contribution. Diastolic dysfunction was present in 68.9% of smokers compared with 44.3% among non-smokers (p < 0.001), indicating that chronic nicotine exposure and oxidative stress exacerbate LV relaxation impairment in hypertensive individuals. Further, patients with T2DM exhibited the lowest mean E′ values (7.9 ± 0.9 cm/s) and highest relative prevalence of diastolic dysfunction (72.5%). The significantly depressed E′/A′ ratio (0.90 ± 0.16) and reduced E/A ratio (0.91 ± 0.18) underscore the additive impact of metabolic derangements and myocardial fibrosis from hyperglycemia on LV relaxation. In contrast, non-diabetic hypertensives maintained near-normal diastolic indices. In addition to above, obese subjects (BMI ≥ 30 kg/m²) exhibited lower E velocities (68.8 ± 8.5 cm/s) and increased A velocities 

(76.1 ± 9.5 cm/s), with mean E/A ratio < 1.0, a characteristic pattern of impaired relaxation. Diastolic dysfunction prevalence reached 70.2%, significantly higher than 47.1% observed in non-obese patients (p < 0.001). Increased LV mass and wall stress in obesity likely contribute to these findings. Age showed a strong correlation with diastolic deterioration. Participants over 50 years had a 64.8% prevalence of LV diastolic dysfunction, accompanied by decreased E/A (0.96 ± 0.18) and E′/A′ (0.94 ± 0.16) ratios relative to younger participants (p < 0.001). Agerelated myocardial stiffening and elevated LV end-diastolic pressure were principal contributors. Furthermore , we also found that, at rest, all participants (n = 2000) exhibited preserved left ventricular systolic function, with a mean EF-LV of 59.8 ± 6.4 % and SF-LV of

33.7 ± 4.1 %. Systolic and diastolic pressures averaged 146.2 ± 18.5 mmHg and 

89.7 ± 10.6 mmHg, respectively, while the mean arterial pressure (MAP) was 108.5 ± 12.3 mmHg. Further, baseline TMD (E = 74.2 ± 9.6 cm/s) and atrial systolic velocity (A = 66.5 ± 8.2 cm/s) yielded a mean E/A ratio of 1.13 ± 0.24. Tissue Doppler-derived early diastolic velocity (E′) averaged 9.2 ± 1.3 cm/s and late diastolic (A′) 8.4 ± 1.0 cm/s, giving a mean E′/A′ ratio of 1.09 ± 0.18. These values suggest a trend toward mild relaxation abnormalities consistent with hypertensive diastolic adaptation. For comparison with condition 1 we found that, during leg elevation for 5 minutes, a modest but statistically significant increase was observed in early transmitral (E) and atrial (A) velocities (p < 0.05, paired t-test). The E/A ratio exhibited a mild nonsignificant decrease (–2.6 %, p > 0.05), indicating that preload enhancement improved ventricular filling without markedly altering diastolic function pattern. TD velocities also demonstrated slight augmentation: E′ increased by 7.6 % and A′ by 

2.4 %, but these changes did not reach statistical significance on Wilcoxon comparison (p > 0.05). The E′/A′ ratio rose from 1.09 ± 0.18 to 1.15 ± 0.17, showing improved early diastolic myocardial motion under volume load. Comparison with condition 2 showed a sustained handgrip maneuver induced a significant rise in afterload, reflected by higher endsystolic wall stress and a small but measurable decline in E velocity (–2.4 %, p < 0.05). A concomitant increase in A and A′ velocities (+5.4 % and +6.0 %, both p < 0.05) was detected, consistent with augmented atrial contribution to late diastolic filling under elevated LV pressure. The E/A and E′/A′ ratios decreased significantly (–8.8 % and –9.2 %, respectively; p < 0.05, Wilcoxon test), suggesting transient impairment in relaxation with elevated afterload. Thus, the overall percentage variations (Δ%) of transmitral Doppler (TMD) indices ranged from 1.0–2.8 %, while pulsed-wave tissue Doppler (TD) indices varied between 1.8–2.7 %. The Δ% values for both techniques were smaller than their respective standard deviations, confirming stability across preload and afterload modulation. Hence, there was significant variation seen between the 2 variables on comparison. This demonstrates that TD indices provide a more stable and sensitive measurement of LV diastolic function under varying hemodynamic conditions compared to TMD flow indices. While both techniques showed statistically significant changes from baseline to preload and afterload states, TD velocities exhibited smaller variability and were less influenced by loading conditions, supporting their clinical utility in assessing diastolic function more reliably. The findings are consistent with previous studies showing that, TD imaging better correlates with ventricular relaxation and filling pressures than conventional TMD, especially in patients with preserved systolic function.7-10 These advantages make TD imaging a valuable complementary tool in the ECHO evaluation of high BP patient. 

In a study, resarchers evaluated the clinical utility of TMD and TD . They found that, the mean 

± SD peak early and late diastolic mitral annulus velocity in group 1 was discovered to be 10.0 ± 1.3 cm/s and 9.5 ± 1.5 cm/s, respectively. In group 2, the mitral inflow velocity profile shifted towards the pseudonormalization pattern as a result of saline loading (deceleration time 311 ± 84 ms before intervention to 216 ± 40 ms after intervention, p < 0.001). On the other hand, the peak early diastolic mitral annulus velocity did not undergo a significant change (5.3 ± 1.2 cm/s to 5.7 ± 1.4 cm/s, p = NS). In group 3, while there was a notable alteration in the profile of mitral inflow velocity after the administration of nitroglycerin, there was no significant change in the peak early diastolic mitral annulus velocity (9.5 ± 2.2 cm/s decreasing to 9.2 ± 1.7 cm/s, p = NS). In the fourth group, there was a significant correlation between the peak early diastolic mitral annulus velocity (r = -0.56, p < 0.01) and the early/late ratio (r = -0.46, p < 0.01) and tau. When the combination of normal mitral inflow variables with extended tau (≥50 ms) was categorized as pseudonormalization, the peak early diastolic mitral annulus velocity that was less than 8.5 cm/s and the early/late ratio that was less than one were able to detect the pseudonormalization with a sensitivity of 88% and a specificity of 67%.They concluded that, TD load is less dependent than TMD load in detecting a pseudonormalization pattern of mitral inflow.11 In another study , authors found that, acute increases in afterload resulted in a significant reduction in the shortening of longitudinal fibers during the isovolumic contraction phase (Sw1 along the long axis), the shortening of circumferential fibers during the ejection phase (Sw2 along the short axis), and the relaxation of the LV during early diastole (early diastolic LV wall motion velocities along both axes) in healthy subjects. This was observed in the LV wall motion velocities along both axes during early diastole. Thus, they concluded that, when it comes to assessing the impact that various loading conditions have on the motion velocities of the LV wall along both the long and short axis, TD pulsed tissue Doppler imaging may prove to be advantageous.12   

In addition to above, researchers in their study evaluated whether the young normotensive offsprings of hypertensive parents were more likely to have an aberrant response of plasma endothelin-1 (ET-1) when they do handgrip exercise (HG), they conducted scientific research. They had found that, group A had higher norepinephrine levels than group B throughout the test (baseline 181 ± 32 [SEM] vs. 96 ± 12 pg/ml, p < 0.05; peak HG 467 ± 45 vs. 158 ± 12 pg/ml, p < 0.000001; R2 293 ± 46 vs. 134 ± 8 pg/ml, p < 0.01; R10 214 ± 27 vs. 129 ± 10 pg/ml, p < 0.0005); no significant difference in epinephrine levels was detected. Group A had higher baseline ET-1 levels (1.07 ± 0.14 vs. 0.59 ± 0.11 pg/ml, p = 0.02), which increased more at peak HG (1.88 ± 0.31 vs. 0.76 ± 0.09 pg/ml, p = 0.005) and R2 (2.46 ± 0.57 vs. 1.31 ± 0.23 pg/ml, p = 0.05) and remained elevated at R10 (3.16 ± 0.78 vs. 0.52 ± 0. The results of the multivariate analysis indicated that the only factors that were predictive of blood pressure response to hypertension were a family history of high BP (chi-square = 7.59, p = 0.0059) and changes in ET-1 during hypertension (chi-square = 4.23, p = 0.0398). Epinephrine and norepinephrine were not predictive of blood pressure response to hypertension. They concluded that, the response to handgrip exercise in offsprings of hypertensive parents produced greater ET-1 plasma levels and resulted in a sustained ET-1 increase into the circulation throughout recovery compared to normotensive parents.13 

Study Limitations 

1.       Exclusion of patients with left ventricular asynergy may limit generalization, as individuals with segmental kinesis abnormalities (e.g., basal interventricular septum) could show variable diastolic behavior not representative of the whole ventricle. 

2.       Myocardial velocity was measured near the annulus at the basal posterior interventricular septum, which, though less influenced by translational motion, becomes affected when right ventricular function is compromised (e.g., due to pulmonary hypertension or associated dysfunction). 

3.       Findings cannot be applied to patients not in sinus rhythm, such as those with atrial fibrillation, due to the study’s exclusion criteria. 

4.       Despite being less sensitive to acoustic artifacts than mitral Doppler, evaluation accuracy may still be constrained by inadequate acoustic windows. 

5.      Diastolic Doppler assessment remains vulnerable to interference from tachycardia, valvular heart disease, and cardiac rotational movements. 

In patients with LV adaptation to arterial hypertension, TD measurements of diastolic motion at the myocardial segment near the mitral annulus were found to be less influenced by preload changes compared to TMD. This supports the use of TD as a complementary index for evaluating LV diastolic function in hypertensive patients. Additionally, TD indices showed significant sensitivity to postload variations, indicating their usefulness in monitoring and assessing diastolic function during and after antihypertensive therapy with afterload-reducing agents. 

Conflict of Interest 

No relevant conflicts of interest related to this article were disclosed. 

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