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The Role of Diabetic Foot Treatment in Improving Left Ventricular Function: Insights From Global Longitudinal Strain Echocardiography

Mohammad Taghi Ashoobi, Hosein Hemmati, Maziar Moayerifar, Mani Moayerifar, Mahboobeh Gholipour, Mahsa Motiei, Mohammad Ali Yazdanipour, Habib Eslami Kenarsari


We decided to evaluate the effect of treatment of diabetic foot ulcers in improving heart function by strain echocardiography than conventional transthoracic echocardiography. This prospective cross-sectional study included patients with diabetic foot ulcer (DFU). Conventional and two-dimensional strain echocardiography performed before and after three months diabetic foot treatment. Then, we compared the echocardiographic parameters including left ventricular ejection fraction (LV-EF), left ventricular global longitudinal strain (LV-GLS). Multivariate and univariate logistic regression analysis were performed to find which variable was mainly associated with LV-GLS changes. 62 patients with DFU were conducted. After echocardiography, all patients underwent surgical or non-surgical treatments.


Diabetes mellitus (DM) associates with decreased insulin secretion from pancreas, which results in elevated blood glucose. Globally, one in every 11 adults involves with Diabetes mellitus(DM) [1]. Diabetic foot ulcer (DFU) as one of the most prevalent and debilitating complications of Diabetic mellitus, mainly results from peripheral vascular disease or neuropathy, and occurs in 15 to 25% of these patients during their lifetime [2]. Heart failure develops in diabetic patients over twice higher than non-diabetics [3]. Impaired microvascular endothelial function and altered metabolism of glucose, followed by free fatty acids oxidation in myocardium, can be the cause of systolic and diastolic dysfunction in diabetics [3].

Materials and method

Participants were prospectively evaluated (29 July 2022–30 April 2023) in this analytic cross-sectional study, approved by the local ethics committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1401.241). The study was conducted in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all participants.


Of the 85 patients with DFU enrolled in this study, 5 patients (5.8%) died during the follow-up period, 18 (21.1%) patients were excluded from all subsequent analyses because they were unwilling to participate in study and perform control echocardiography after receiving therapy for their diabetic foot. As a result, in 62 of 85 (72.9%) patients obtained three months’ follow-up data. Participants had a mean age of 61.6 ± 7.9 (range, 46–78) years. Hypertension (n = 58, 93.5%) and hyperlipidemia (n = 57, 91.9%) were the most prevalent underlying diseases in this sample (Table 1).


The most important finding of this study is that treating diabetic foot ulcers in patients who suffer from this condition can lead to an improvement in cardiac function, based on strain echocardiographic features. Heart diseases are the leading cause of morbidity and mortality in diabetic patients and are known to cause about two to six times more mortality in these patients than individuals without diabetes [5]. Patients with DFU syndrome are even at higher risk of developing cardiovascular diseases than diabetic patients without DFU. These patients usually have underlying metabolic disorders like hypertriglyceridemia and hyperglycemia which cause microvascular injury over time [6, 7].


Early detection and management of cardiac conditions are crucial to improve outcomes and reduce cardiovascular events in diabetic foot patients. The key message of our study is the use of global longitudinal strain echocardiography as a diagnostic tool allows for a more accurate assessment of myocardial function. This non-invasive technique provides detailed information on myocardial deformation, facilitating the identification of subtle changes in cardiac performance. LV-GLS is able to identify subclinical LV dysfunction earlier than LVEF measurement in patients with diabetic foot and lower in severe wound scale and use to guide early therapy both for diabetic foot and cardio-protective treatment.


We thank all the participants cooperating with us in this study. This research was the thesis of the author Dr. Mani Moayerifar.

Citation: Ashoobi MT, Hemmati H, Moayerifar M, Moayerifar M, Gholipour M, Motiei M, et al. (2024) The role of diabetic foot treatment in improving left ventricular function: Insights from global longitudinal strain echocardiography. PLoS ONE 19(3): e0299887.

Editor: Chikezie Hart Onwukwe, Isawiya General Hospital, Governorate of Gurayyat, SAUDI ARABIA

Received: December 12, 2023; Accepted: February 16, 2024; Published: March 29, 2024

Copyright: © 2024 Ashoobi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.


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