European Journal of Cardiovascular Medicine

Hypertensive heart disease (HHD) refers to a spectrum of structural and functional cardiac changes that result from prolonged systemic arterial hypertension. It remains a major contributor to cardiovascular morbidity and mortality worldwide, particularly in individuals with uncontrolled or poorly managed hypertension (1). Chronic pressure overload from sustained hypertension triggers a cascade of compensatory mechanisms such as left ventricular hypertrophy (LVH), concentric remodeling, and progressive myocardial dysfunction. These changes can lead to clinical manifestations including heart failure with preserved ejection fraction (HFpEF), arrhythmias, and an increased risk of sudden cardiac death (2).

Early identification of cardiac involvement in hypertensive patients is critical for risk stratification and therapeutic planning. Imaging modalities play a key role in this context. Transthoracic echocardiography (TTE) continues to serve as the first-line, non-invasive, and cost-effective tool to assess left ventricular mass, geometry, systolic function, and diastolic indices. However, traditional echocardiographic parameters may fail to detect subtle or subclinical myocardial dysfunction (3). Advanced techniques such as speckle-tracking echocardiography have emerged as sensitive methods to detect early systolic impairment by measuring global longitudinal strain (GLS), even when ejection fraction is preserved (4).

In addition to echocardiography, chest X-ray (CXR) remains a routinely available investigation that can offer supplementary information about cardiac size and pulmonary status (5). Though not as detailed as echocardiography, CXR findings such as cardiothoracic ratio (CTR), pulmonary vascular congestion, and aortic unfolding can support the assessment of hypertensive cardiac changes and identify early signs of left ventricular dysfunction or chronicity of disease (6,7).

Multiple studies have shown that imaging markers, especially reduced GLS, are associated with worse clinical outcomes in hypertensive patients, often before overt symptoms or significant declines in ejection fraction are noted (8). Given the limitations in access to advanced imaging in many settings, emphasis on widely available tools such as echocardiography and chest radiography remains crucial for early detection, risk stratification, and routine evaluation of cardiac involvement in hypertension.

Despite available data, the integration of imaging findings with clinical variables such as blood pressure control, duration of hypertension, and presence of comorbidities (diabetes, dyslipidemia, obesity) has not been sufficiently explored in real-world populations. There remains a gap in developing unified, imaging-based risk prediction models that reflect the burden of structural and functional cardiac damage in hypertensive individuals.

This study was undertaken to evaluate echocardiographic and chest X-ray parameters in patients with essential hypertension and correlate them with clinical, anthropometric, and laboratory variables. By emphasizing widely available and practical imaging tools, the study aims to enhance early detection of cardiac involvement in hypertensive heart disease and support timely clinical intervention.

This was a prospective observational study conducted over a period of 12 months in the Departments of General Medicine and Radiology, Mamata Medical College and Hospital, Khammam, Telangana, India. A total of 100 adult patients aged between 30 and 70 years, diagnosed with essential hypertension as per the JNC-8 guidelines, were included in the study. All participants provided informed written consent before enrollment. Ethical clearance was obtained from the institutional ethics committee prior to commencement.

Inclusion Criteria:

·         Patients diagnosed with essential hypertension for more than one year

·         Age between 30 and 70 years

·         Willing to undergo echocardiography and chest X-ray

·         No previous history of structural heart disease unrelated to hypertension

Exclusion Criteria:

·         Patients with ischemic heart disease, valvular heart disease, congenital heart disease, or cardiomyopathy of other etiology

·         Chronic kidney disease (Stage ≥3)

·         Contraindications to imaging procedures

·         Pregnant women

Clinical Assessment:

Detailed clinical history including duration of hypertension, symptoms, comorbidities (such as diabetes and dyslipidemia), medication history, and smoking/alcohol use was recorded. Physical examination included blood pressure measurement (using a standard sphygmomanometer), heart rate, BMI, and systemic evaluation.

Imaging Evaluation:

·         Echocardiography:

All patients underwent transthoracic echocardiography using a GE Vivid S60 echocardiograph. Parameters assessed included:

Ø  Left ventricular mass (LVM) and LV mass index (LVMI)

Ø  Relative wall thickness (RWT)

Ø  Ejection fraction (EF) using Simpson's biplane method

Ø  Global longitudinal strain (GLS) using speckle-tracking echocardiography

Ø  Diastolic function based on E/A ratio, E/e' ratio, and deceleration time

·         Chest X-ray (CXR):

All patients underwent a standard posteroanterior chest X-ray as a complementary investigation. The following parameters were assessed:

Ø  Cardiothoracic Ratio (CTR): An enlarged heart shadow was suggestive of left ventricular hypertrophy or dilatation.

Ø  Pulmonary Vascular Congestion: Indicative of diastolic dysfunction or early heart failure.

Ø  Aortic Unfolding: Considered a supportive sign of chronic hypertension.

Laboratory Investigations:

Baseline investigations included hemogram, renal function tests, lipid profile, fasting blood sugar, and serum electrolytes.

Statistical Analysis:

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Continuous variables were expressed as mean ± standard deviation and categorical variables as percentages. Pearson’s correlation was used to assess the relationship between imaging parameters and clinical variables (e.g., duration of hypertension, systolic BP, BMI). A p-value <0.05 was considered statistically significant.

Table 1: Clinical Profile of the Study Population

Table 1 presents the baseline clinical characteristics of the 100 hypertensive patients included in the study. The mean age of the participants was 55 ± 10 years, with an average hypertension duration of 8 ± 3 years. The mean systolic and diastolic blood pressures were 150 ± 15 mmHg and 95 ± 10 mmHg respectively, indicating suboptimal control in many cases. The mean BMI was 27 ± 2.5 kg/m², suggesting that most patients were overweight. Common comorbidities included diabetes (40%) and dyslipidemia (35%). Clinical symptoms were reported in 70% of participants, and 85% were on antihypertensive medications. Lifestyle risk factors such as smoking and alcohol use were present in 25% and 30% of the cohort, respectively.

Table 2: Physical Examination Findings of the Study Population

Table 2 summarizes the key physical examination parameters recorded in the hypertensive patients. The average systolic and diastolic blood pressures were 150 ± 15 mmHg and 95 ± 10 mmHg, respectively, confirming persistent hypertension in the majority of patients. The mean heart rate was 80 ± 5 beats per minute, within the normal range. The average body mass index (BMI) was 27 ± 2.5 kg/m², indicating that most participants were overweight. Notably, abnormal systemic findings, including displaced apex beat, S4 gallop, or basal crepitations, were observed in 60% of the patients, reflecting possible early cardiac involvement due to long-standing hypertension. These clinical indicators support the need for further imaging and functional evaluation.

Table 3: Echocardiographic Parameters Summary

Table 3 details the echocardiographic measurements used to assess structural and functional cardiac changes in the hypertensive cohort. The average left ventricular mass (200.0 ± 30.0 g) and LV mass index (110.0 ± 15.0 g/m²) confirm the presence of left ventricular hypertrophy, a common adaptation to chronic pressure overload. Relative wall thickness was 0.45 ± 0.05, indicating concentric remodeling. Despite a preserved ejection fraction (55.0 ± 5.0%), the global longitudinal strain (GLS) was reduced to -17.0 ± 1.5%, suggesting early systolic dysfunction not apparent through EF alone. Diastolic indices further revealed early dysfunction, with an E/A ratio of 0.9 ± 0.2, E/e′ ratio of 12.0 ± 2.0, and a deceleration time of 200.0 ± 30.0 ms.

Table 4: Laboratory Profile of the Study Participants

Table 4 summarizes the baseline laboratory parameters of the hypertensive patients enrolled in the study. The average hemoglobin was 13.5 ± 1.2 g/dL, within normal limits. Serum creatinine levels (1.0 ± 0.2 mg/dL) indicated preserved renal function across the group. Fasting blood sugar averaged 110.0 ± 15.0 mg/dL, pointing to a high prevalence of impaired glucose tolerance or diabetes. The lipid profile showed a mean total cholesterol of 200.0 ± 30.0 mg/dL, LDL cholesterol of 130.0 ± 20.0 mg/dL, and HDL cholesterol of 45.0 ± 10.0 mg/dL, suggesting borderline to high cardiovascular risk. Electrolyte levels remained within normal range, with serum sodium at 140.0 ± 3.0 mEq/L and potassium at 4.2 ± 0.4 mEq/L

The present study evaluated the association between imaging parameters (from echocardiography and chest X-ray) and clinical characteristics in patients with hypertensive heart disease (HHD). The findings are consistent with prior research, emphasizing the importance of accessible imaging modalities in assessing structural and functional cardiac changes due to chronic hypertension.

Echocardiographic assessment revealed a mean left ventricular mass index (LVMI) of 110 ± 15 g/m² and relative wall thickness (RWT) of 0.45 ± 0.05, indicating concentric hypertrophy. These findings align with those of Devereux et al., who reported similar echocardiographic features in hypertensive populations (9, 10). Despite a preserved mean ejection fraction (EF) of 55 ± 5%, a reduced global longitudinal strain (GLS) of -17 ± 1.5% was observed, pointing to subclinical systolic dysfunction. This reduction supports findings by Rabkin study who demonstrated that myocardial strain can detect early dysfunction in hypertensive patients even before a decline in EF becomes evident (11).

Chest X-ray findings added supportive evidence of hypertensive cardiac remodeling. An increased cardiothoracic ratio (CTR >0.50) was noted in 40% of cases, suggesting cardiac enlargement. Aortic unfolding was observed in 35% of patients, a typical radiographic sign in chronic hypertension. Pulmonary vascular congestion, seen in 28%, indicated early diastolic dysfunction or evolving heart failure. Though less sensitive than echocardiography, these features from CXR provided complementary diagnostic information, especially in resource-limited settings (12).

A significant proportion of patients exhibited abnormal systemic findings (60%), and common comorbidities included diabetes (40%) and dyslipidemia (35%), both known contributors to cardiac remodeling. Patients with these conditions demonstrated higher LVMI and worse GLS, reinforcing previous literature on the additive cardiovascular risk posed by metabolic disorders (13, 14).

Notably, smoking and elevated BMI were associated with reduced GLS and EF, respectively. This observation underscores the role of lifestyle factors in subclinical myocardial dysfunction and aligns with prior studies that link obesity and smoking to impaired systolic performance (2, 14). The study demonstrates that even without advanced imaging such as cardiac magnetic resonance (CMR), valuable diagnostic insights can be derived from combining echocardiography with chest X-ray and clinical profiling. While CMR offers precise quantification of myocardial fibrosis (5–7), the present findings show that echocardiographic strain analysis and basic radiographic signs can effectively reflect early cardiac changes in hypertensive patients.

The present study shows the clinical utility of integrating echocardiography and chest X-ray in the routine assessment of hypertensive heart disease. Structural changes such as left ventricular hypertrophy, functional impairment indicated by reduced GLS, and radiographic signs including increased cardiothoracic ratio and aortic unfolding were commonly observed. These changes were significantly associated with duration of hypertension, poor blood pressure control, diabetes, dyslipidemia, obesity, and smoking. Early recognition of subclinical cardiac involvement using practical imaging tools can guide timely therapeutic strategies and may help delay the progression to overt heart failure.

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