Theranostics 2021; 11(19):9376-9396. doi:10.7150/thno.64706

Review

Metformin in cardiovascular diabetology: a focused review of its impact on endothelial function

Yu Ding1, Yongwen Zhou1,3, Ping Ling1,3, Xiaojun Feng2, Sihui Luo1, Xueying Zheng1, Peter J. Little4,5, Suowen Xu1✉, Jianping Weng1,3✉

1. Institute of Endocrine and Metabolic Diseases, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
2. Department of Pharmacy, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
3. Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
4. Sunshine Coast Health Institute, University of the Sunshine Coast, Birtinya, QLD 4575, Australia.
5. School of Pharmacy, Pharmacy Australia Centre of Excellence, the University of Queensland, Woolloongabba, Queensland 4102, Australia.

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Citation:
Ding Y, Zhou Y, Ling P, Feng X, Luo S, Zheng X, Little PJ, Xu S, Weng J. Metformin in cardiovascular diabetology: a focused review of its impact on endothelial function. Theranostics 2021; 11(19):9376-9396. doi:10.7150/thno.64706. Available from https://www.thno.org/v11p9376.htm

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Abstract

As a first-line treatment for diabetes, the insulin-sensitizing biguanide, metformin, regulates glucose levels and positively affects cardiovascular function in patients with diabetes and cardiovascular complications. Endothelial dysfunction (ED) represents the primary pathological change of multiple vascular diseases, because it causes decreased arterial plasticity, increased vascular resistance, reduced tissue perfusion and atherosclerosis. Caused by “biochemical injury”, ED is also an independent predictor of cardiovascular events. Accumulating evidence shows that metformin improves ED through liver kinase B1 (LKB1)/5'-adenosine monophosphat-activated protein kinase (AMPK) and AMPK-independent targets, including nuclear factor-kappa B (NF-κB), phosphatidylinositol 3 kinase-protein kinase B (PI3K-Akt), endothelial nitric oxide synthase (eNOS), sirtuin 1 (SIRT1), forkhead box O1 (FOXO1), krüppel-like factor 4 (KLF4) and krüppel-like factor 2 (KLF2). Evaluating the effects of metformin on endothelial cell functions would facilitate our understanding of the therapeutic potential of metformin in cardiovascular diabetology (including diabetes and its cardiovascular complications). This article reviews the physiological and pathological functions of endothelial cells and the intact endothelium, reviews the latest research of metformin in the treatment of diabetes and related cardiovascular complications, and focuses on the mechanism of action of metformin in regulating endothelial cell functions.

Keywords: Metformin, cardiovascular diabetology, endothelial function, diabetes, panvascular disease