Endothelial dysfunction in diabetes mellitus: role in cardiovascular disease

Diabetes mellitus is associated with an increased risk of cardiovascular disease (CVD), even in the presence of intensive glycemic control. Substantial clinical and experimental evidence suggests that both diabetes and insulin resistance cause a combination of endothelial dysfunctions, which may diminish the anti-atherogenic role of the vascular endothelium. Endothelial dysfunctions that have been described include decreased endothelium-dependent vasorelaxation, increased leukocyte-endothelial cell adhesion and vascular permeability, and the altered production of a variety of vasoactive substances, which affect coagulation, extracellular matrix homeostasis, and smooth muscle physiology. The primary mechanisms that contribute to these endothelial dysfunctions in diabetes appear to involve the activation of protein kinase C (PKC) pathways, increased non-enzymatic glycation, increased oxidant stress, and reduced endothelial insulin action. In addition, many of the adverse effects of these abnormalities associated with hyperglycemia and insulin resistance are mediated and amplified by potent vasoactive hormones including angiotensin II, transforming growth factor-beta, and vascular endothelial growth factor. Multiple interventions have been shown to improve endothelial dysfunction in diabetes, including PKC inhibition, infusion of soluble receptors for advanced glycation end-products, antioxidant and insulin supplementation, and angiotensin-converting enzyme inhibition. These findings are consistent with a model involving a combination of factors contributing to the etiology of the endothelial dysfunctions in diabetes. Further work is needed to determine whether endothelial function can be used as a therapeutic target to reduce CVD and improve clinical outcomes.