Early autonomic neuropathy in prediabetes: an overlooked driver of cardiometabolic risk

INTRODUCTION: Prediabetic neuropathy is increasingly recognized as an early consequence of glucose dysregulation that may precede type 2 diabetes and contribute to cardiovascular risk. AREAS COVERED: This narrative review summarizes current evidence on autonomic dysfunction in prediabetes, including its epidemiology, pathophysiology, clinical significance, and therapeutic implications. A literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science for studies published between 2010 and 2026. Evidence indicates that alterations in heart rate variability, impaired baroreflex sensitivity, endothelial dysfunction, and chronic low-grade inflammation contribute to autonomic imbalance and increased cardiovascular risk in individuals with impaired fasting glucose or impaired glucose tolerance. EXPERT OPINION: Autonomic dysfunction should be considered an early manifestation of cardiometabolic disease rather than a late complication of diabetes. Although accumulating evidence supports its prognostic relevance, routine screening remains limited by the absence of standardized diagnostic criteria and clear guideline recommendations. Incorporating autonomic assessment into risk stratification may facilitate earlier identification of high-risk individuals and support targeted preventive strategies. Future studies should focus on validating diagnostic thresholds and determining whether early intervention improves long-term cardiovascular outcomes.