Biomarkers and therapies to target endothelial dysfunction in type 2 diabetes: moving a step forward

PURPOSE OF REVIEW: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality in people with type 2 diabetes mellitus (T2DM). Endothelial dysfunction is a precursor of atherosclerosis. This is a silent process that occurs over years. Focus on primary prevention to identify and target endothelial dysfunction early can slow down the atherosclerotic process and prevent ASCVD. RECENT FINDINGS: Emerging blood-based methods include novel endothelial related biomarkers, such as endothelial specific extracellular vesicles, markers of endothelial regeneration and endothelial specific polygenic risk score. Physiology imaging-based method includes the flow-mediated dilation of the brachial artery, a noninvasive procedure that had gained attention for standardization in an international consensus guideline. Recognizing the role of endothelial function in ASCVD, studies are increasingly incorporating endothelial function biomarkers and FMD as surrogate markers of response. There is also emerging evidence on how nonpharmacological and pharmacological strategies improve endothelial function. SUMMARY: Blood and imaging-based assessment of endothelial function is a promising area that can enhance early preventive efforts. Future studies to assess the incremental value of endothelial function assessment in contemporary longitudinal cohorts across diverse populations is necessary to identify the high-risk asymptomatic individuals who will benefit from intensive primary prevention.