TABLE 1.

Features of included studies.

Authors	AS (n)	Control (n)	Mean age of AS (years)	Mean age of control (years)	Quality	Findings	Conclusion	Sex ratio
Midtbø H et al. 13	139	126	49.1 ± 11.7	52.1 ± 11.4	4/2/2	Hypertension and diabetes were similar among patients and controls, but the prevalence of LVH was higher in patients with AS compared to controls	AS is linked to an increased prevalence of (LVH), independent of cardiovascular disease (CVD) risk factors.	60% AS males vs. 58% male controls
Gould BA et al. 25	21	24	33 ± 6	35.7 ± 6	3/1/2	Individuals with AS exhibited lower peak filling rates and higher time‐to‐peak filling rates during exercise, alongside significantly elevated angiographic scores compared to normal subjects.	Improvement with anti‐inflammatory treatment may indicate the inflammatory nature of this myocardial tissue.	81% AS males, and 83% male controls
Sun JP et al. 26	20	25	45 ± 11	44 ± 11	3/2/2	Atrial, ventricular, and aortic dimensions were comparable between AS patients and controls, with normal ejection indexes and systolic wall motion observed in both groups; however, AS patients exhibited diastolic dysfunction characterized by a shortened diastolic filling period, decreased velocity of early mitral inflow, and lower ratios of early/late inflow velocities.	AS can result in changes to ventricular diastolic function.	85% AS males vs. 80% male controls
Francisco Javier Jiménez‐Balderas et al. 27	31	20	21 ± 1.2	NA	3/0/2	Cardiomyopathy was more prevalent in individuals with adult‐onset ankylosing spondylitis (AOAS) compared to juvenile‐onset ankylosing spondylitis (JOAS) and controls. Patients with JOAS exhibited a higher mitral valve gradient than AOAS patients and controls. Abnormal aortic ring reflectance was observed in 19% of AOAS, with no abnormalities in JOAS and controls. Aortic root diameter was significantly increased in 58% of AOAS, 30% of JOAS, and 0% of controls.	Cardiopulmonary asymptomatic spondylitis patients exhibited an increased frequency of 2DECHO abnormalities. JOAS had a lower occurrence of aortic abnormalities compared to AOAS. Both JOAS and AOAS showed mitral valve gradients.	100% AS males vs. 100% male controls
Aylin Yildirir et al. 10	88	31	33 ± 9	33 ± 9	4/2/2	AS patients had a decreased peak of E‐wave velocity (E) and E/A ratio, an increased peak of A‐wave velocity (A) and acceleration rate of the A‐wave, along with an extended deceleration time of E‐wave velocity and isovolumic relaxation time. However, the mean filtered P‐wave duration (PWD) was similar in both groups.	Cardiac involvement in AS may occur without apparent clinical manifestations. Early detection enables aggressive anti‐inflammatory treatment, potentially slowing disease progression.	50% AS males vs. 52% male controls
Peregud‐Pogorzelska et al. 23	38	25	51 ± 11	47 ± 12	4/2/2	Echocardiographic abnormalities were found in 67% of the study group and 32% of controls, with aortic incompetence in 21% of patients and 4% of controls. No statistical differences were noted in ejection fraction, fractional shortening, or chamber diameters, except for the left atrium. Mitral valve prolapse occurred in 8% of study group patients, and interatrial septum aneurysm in 13%.	Patients with AS often experience cardiovascular abnormalities that progress with the disease duration.	92% AS males vs. 88% male controls
Okan T 14	49	33	38 ± 11	36 ± 9	4/2/2	No right ventricular function involvement was observed. However, AS patients had a 3.7 times higher risk of developing left ventricular diastolic dysfunction.	Diastolic dysfunction is common in AS without prior cardiovascular disease, possibly impacting cardiovascular mortality.	51% AS males vs. 52% male controls
Caliskan M et al. 8	40	35	38.9 ± 10.2	37.5 ± 6.4	3/2/2	The coronary flow reserve (CFR) was reduced in AS group. Left ventricular diastolic function, including the mitral A‐wave and E/A ratio, showed borderline significance, while mitral E‐wave deceleration time and isovolumic relaxation time were significantly different between the two groups.	Reduced CFR could indicate early sign of cardiac involvement in AS.	65% AS males vs. 66% male controls
Acar G et al. 29	40	42	37.82 ± 10.22	35.74 ± 9.98	2/1/2	In AS patients, mitral A‐wave, E/A ratio, mitral E‐wave deceleration time (DT), Am, and Em/Am, demonstrated significant differences when compared to control.	AS patients exhibit impaired left ventricular diastolic function.	55% AS males vs. 52% male controls
Ioannis Moyssakis et al. 3	57	78	41.78 ± 10.02	39.92 ± 9.11	3/0/2	Aortic distensibility (AoD) in AS was reduced compared to controls, indicating increased aortic stiffness. AS patients also showed higher left ventricular Tei index, while the EF remained comparable. AoD showed significant associations with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and LV isovolumic relaxation time (IVRT), while the LV Tei index was associated with BASDAI and the LV mass index.	AS without clinical cardiac disease shows increased aortic stiffness and reduced myocardial performance, correlating with disease activity. The abnormal Tei index may indicate early cardiac dysfunction.	95% AS males vs. 94% male controls
Aksoy et al. 30	28	30	28.7 ± 5.7	29.3 ± 5.8	3/2/2	The AS and control groups showed similarity in terms LVEF. However, patients with AS exhibited significantly higher P‐wave duration (PWD) compared to controls. Additionally, interatrial electromechanical delay (Inter‐AEMD) and intra‐left atrial electromechanical delay (Intra‐left AEMD) were significantly higher in AS patients. There was no statistically significant difference in Intra‐right AEMD between the two groups.	In patients with AS, prolonged PWD, Inter‐AEMD, and intra‐left AEMD suggest an association with atrial electromechanical abnormalities.	86% AS males vs. 87% male controls
Kaya EB et al. 31	28	30	28.7 ± 5.7	29.3 ± 5.8	3/2/2	LVEF was similar in both AS and control groups. However, AS showed increased Low frequency and Low frequency / High frequency compared to control.	Cardiac autonomic functions may be affected in AS, even without cardiac symptoms.	86% AS males vs. 87% male controls
Park SH et al. 32	70	25	30.3 ± 5.3	27.0 ± 2.5	4/2/2	In AS, aortic and mitral valve thickness is significantly increased, particularly in the aortic valve (AV), where thickness is >1.3 mm can predict AS. AV thickening is higher in AS, and is linked to longer disease duration, high blood pressure, disease activity, and inflammatory markers.	In early AS, aortic and mitral valve thickening without regurgitation is seen, despite negative cardiac symptoms.	100% AS males vs. 100% male controls
Kırış A et al. 33	77	40	36.4 ± 10	39.1 ± 8.2	4/0/2	AS echocardiographic characteristics at baseline were similar to controls. In AS patients, all time‐to‐peak tissue synchrony imaging (TSI) parameters indicating LV asynchrony were extended compared to controls. Notably, these asynchrony parameters displayed significant correlations with the index of myocardial performance (Tei index) and peak systolic mitral annular velocity.	TSI revealed the existence of LV systolic asynchrony in AS, potentially contributing to their cardiovascular complications.	79% AS males vs. 86% male controls
Kuloglu O et al. 34	30	30	37.2 ± 10.23	33.2 ± 8.12	3/0/2	Echocardiography indicated higher end‐diastolic interventricular septum and posterior wall diameters in AS. AS exhibited a significantly lower E/A ratio, prolonged deceleration time, lower Em, Em/Am ratio, and CTm, longer IVRTm, and higher MPI.	AS patients exhibit impaired diastolic but preserved systolic function.	60% AS males vs. 53% male controls
Ercan S et al. 35	66	21	30.9 ± 6	27.1 ± 4	4/2/2	Mitral early diastolic flow speed (mE) and late diastolic flow speed (mA) scores were reduced in AS. The Em ratio in AS was notably lower than in control subjects. Differences in mA and mE/mA ratios were significant between patients with a BASDAI score of > 4 and those with a BASDAI score of <4. However, aortic elasticity did not show significant differences between the groups.	AS patients exhibited significantly impaired myocardial diastolic functions, which were associated with disease activity.	76% AS males vs. 76% male controls
Nilgün Üstün et al. 36	26	26	43.7 ± 11.8	42.5 ± 9.5	3/1/2	In AS, the mitral early/late diastolic inflow velocity ratio and the mitral E‐wave velocity were lower than in controls. However, EF was similar between the two groups. Additionally, AS patients exhibited a significant reduction in LV diastolic and systolic strain values across all segments compared to healthy controls.	AS patients may have impaired LV systolic function despite no clinical evidence of cardiovascular disease.	81% AS males vs. 85% male controls
Sabri Onur Çağlar et al. 37	42	40	39.4 ± 8.5	37.3 ± 8.7	4/2/2	In AS, both interatrial left and right intraatrial electromechanical delay (EMD) intervals were prolonged. Also, AS patients exhibited higher values of left and right carotid intima‐media thickness (CIMT) and epicardial fat thickness (EFT).	Atrial EMD, CIMT, and EFT, indicative of cardiovascular involvement, were higher in AS patients.	67% AS males vs. 60% male controls
Ümit İnci et al. 38	60	40	32 ± 7.8	30.0 ± 7.3	3/1/2	No significant difference in left ventricular diastolic dysfunction was observed between AS and control groups, as assessed by both conventional and tissue Doppler echocardiography.	Increased ADMA levels suggest impaired nitric oxide metabolism in young AS patients without classical cardiovascular risk factors.	% AS males vs. % male controls
Gür et al. 39	75	30	41 ± 9.18	37.53 ± 10.69	3/1/2	In AS patients compared to controls, systolic aortic diameter, diameter at the level of sinus valsalva, and central pulse wave velocity (cPWV) increased, while transverse strain of anterior and posterior aortic walls decreased. Disease activity (BASDAI) correlated with aortic strain, compliance, distensibility, and elastic modulus, and cPWV correlated with various aortic parameters. Logistic regression identified cPWV, transverse strain of the posterior wall (TS of PW), and transverse strain of the anterior wall (TS of AW) as independent predictors of AS.	AS patients showed elevated aortic diameters, cPWV, and impaired TS of AW and PW, indicating aortic vasculopathy.	63% AS males vs. 60% male controls
Murathan Kucuk et al. 40	30	30	41.0 ± 9.2	37.5 ± 10.7	4/2/2	The mean deceleration time (DT) was extended in ankylosing spondylitis (AS) patients compared to the control group. Additionally, in AS patients, left atrial (LA) S‐S, LA S‐E, and LA S‐A values were statistically lower than those in the control group. Furthermore, a negative correlation was noted between the Bath Ankylosing Spondylitis Metrology Index (BASMI) and LA S‐S.	2D‐STE is valuable for detecting left atrial involvement in AS patients without clinical cardiovascular disease.	73% AS males vs. 63% male controls
Law et al. 41	92	38	53 ± 12	57 ± 10	3/1/2	In patients, LVEF, posterior wall (PW) thickness, and transmitral E/A ratio were significantly reduced, while left atrial (LA) and left ventricular (LV) volumes were significantly increased compared to controls. Despite the majority of individual patient results falling within standard reference ranges, measured global longitudinal strain (GLS) values showed that 53% of individuals had a mean GLS below the lower limit of the normal range, in contrast to controls.	GLS analysis demonstrated reduced LV long‐axis function in AS patients, highlighting its utility as a measure for cardiac involvement in this population.	67% AS males vs. 42% male controls
Mustafa Zungur et al. 42	64	70	55.7 ± 9.2	54.9 ± 8.5	4/2/2	While standard TTE showed no significant differences in right ventricular (RV) function parameters, speckle tracking echocardiography (STE), revealed impaired RV function in AS patients. Lower values were observed in RV‐free wall longitudinal strain, RV‐free wall longitudinal systolic strain rate, RV‐free wall longitudinal early diastolic strain rate, and RV‐free wall longitudinal late diastolic strain rate, with a higher RV‐early diastolic strain rate/RV‐late diastolic strain rate ratio for AS patients.	AS is linked to impaired RV function, as demonstrated by STE, even in the absence of clinical or laboratory signs of cardiac abnormalities.	83% AS males vs. 79% male controls
Emren SV et al. 43	72	56	39.2 ± 9.9	40.9 ± 7.2	4/2/2	Although the AS, non‐radiographic axial spondyloarthritis (nr‐axSpA), and control groups exhibited similar EF values, there was a difference in global longitudinal peak systolic strain (GLS) between the groups. In a post‐hoc analysis, GLS was not different between the nr‐axSpA and control groups, but it was significantly lower in patients with AS.	Subclinical myocardial dysfunction, as evaluated by GLS, was observed in AS patients but not in nr‐axSpA.	72% AS males vs. 54% male controls
Ozen et al. 44	55	20	43.33 ± 7.87	44.60 ± 8.06	3/1/2	AS patients exhibited elevated aortic stiffness compared to controls. LV global longitudinal strain (LVGLS) values were worse in AS patients.	Subclinical cardiac dysfunction, manifested through increased aortic stiffness and deteriorated LVGLS, is evident in AS patients even when their musculoskeletal disease is well‐controlled.	% AS males vs. % male controls
Demet Özkaramanlı Gür et al. 45	75	30	41.7 ± 10.1	38.5 ± 9.9	4/2/2	In AS, reductions were observed in carotid‐to‐femoral pulse wave velocity (cPWV), E and e' velocities, longitudinal strain, strain rates at all myocardial layers, and transverse strains of both anterior and posterior aortic walls. Gal‐3 levels, along with strain and strain rates at circumferential and radial axes, were similar between the groups. Independently, AS was associated with LV dysfunction, expressed by longitudinal strain, and aortic impairment, expressed by transverse strain of the anterior wall.	Functional impairment in AS manifests early in the disease course, and strain imaging proves to be an effective tool for discriminating involvement.	63% AS males vs. 57% male controls
Almasi S et al. 46	67	40	35 (26‐59)	33.5 (20.5‐59)	4/2/2	LV systolic dysfunction was significantly higher in AS patients compared to controls, as was LV diastolic dysfunction. AS patients also showed a significantly higher occurrence of left‐axis deviation and left anterior fascicular block compared to the control group. However, the number of patients with aortic valve involvement was comparable between the two groups.	Common cardiac involvement in AS includes LV dysfunction, rhythm disturbances, and aortic valve insufficiency, independent of age, AS severity, and disease duration.	75% AS males vs. 84% male controls
Turkmen S et al. 47	40	40	32.1 ± 5.5	31.2 ± 3.9	4/2/2	AS patients, in comparison to controls, showed lower early (Em)/late (Am) diastolic myocardial velocities, mitral annular plane systolic excursion, and end‐diastolic distance from the mitral annulus to the LV apex. Conversely, AS patients exhibited higher systolic myocardial velocity (Sm), isovolumetric relaxation time, and displacement index. Elevated hs‐cTnT levels in AS patients independently predicted LV diastolic dysfunction.	AS patients demonstrated impaired LV functions and elevated hs‐cTnT levels. Tissue Doppler imaging proves to be a useful tool for detecting early functional LV abnormalities, and hs‐cTnT emerges as a valuable biomarker for diastolic LV dysfunction in AS patients.	58% AS males vs. 50% male controls
Baniaamam M et al. 12	193	70	60 ± 7	63 ± 7	3/1/2	The prevalence of diastolic dysfunction and Conduction disturbances in AS patients and controls were trivial and comparable, with limited clinical relevance. However, AS patients exhibited a significantly higher prevalence of aortic valve regurgitation (AVR) compared to controls while the prevalence of mitral valve regurgitation (MVR) was similar.	AS patients have up to a fivefold increased odds of developing aortic valve regurgitation (AVR) compared to controls.	72% AS males vs. 58% male controls
Kenan Demır et al. 48	60	60	46.68 ± 8.72	44.90 ± 8.93	4/2/2	There were no differences in basal characteristics and echocardiographic parameters between patients with AS and the control group. However, epicardial adipose tissue thickness (EATT) and pulse wave velocity (PWV) were higher in AS patients. Additionally, PWV showed significant correlations with EATT, age, and central blood pressure in AS patients.	In patients with AS, markers of atherosclerosis and cardiovascular disease, including EATT and PWV, were significantly higher than in the control group. Furthermore, the study revealed a significant relationship between PWV and EATT in patients with AS.	60% AS males vs. 60% male controls

Note: AS: Ankylosing spondylitis, Interquartile range, Quality Assessment by the Newcastle‐Ottawa scale.