Arterial stiffness and endothelial dysfunction in diabetes mellitus

Table 3 Comparison of pulse wave velocity, cardio-ankle vascular index, flow-mediated dilation, and reactive hyperemia-peripheral arterial tonometry

	Physiological target	Vascular territory assessed	Most informative stage of diabetic vascular dysfunction	Prognostic evidence in diabetes	Advantages	Limitations
PWV	Arterial stiffness (mainly structural arterial changes)	Large elastic and muscular arteries (cfPWV: Aorta; baPWV: Central and peripheral arteries)	Intermediate to advanced stage (arterial stiffening and vascular remodeling)	Strong; multiple prospective studies demonstrate associations with CVD events, CVD mortality, and all-cause mortality	Well validated; extensive prognostic evidence; cfPWV regarded as gold standard for arterial stiffness assessment	Influenced by blood pressure at measurement; reflects relatively late vascular changes
CAVI	Arterial stiffness corrected for blood pressure effects; ventricular-arterial coupling	Arterial tree from the aortic root to the ankle	Intermediate stage; potentially sensitive to both functional and structural vascular alterations	Moderate to strong; several prospective cohort studies report associations with CVD events and mortality	Less influenced by blood pressure; highly reproducible; may reflect therapeutic responses and overall cardiovascular phenotype	Evidence base smaller than for PWV; most data derived from Japanese and Asian populations
FMD	Endothelium-dependent vasodilation (nitric oxide bioavailability)	Conduit arteries (typically brachial artery)	Early stage (endothelial dysfunction preceding structural vascular damage)	Limited in diabetes-specific cohorts; evidence mainly from high-risk or mixed populations	Detects early vascular abnormalities; extensively studied endothelial function test	Operator-dependent; requires technical expertise and standardization; limited clinical applicability
RH-PAT	Microvascular endothelial responsiveness	Digital microcirculation (fingertip)	Very early stage (microvascular endothelial dysfunction)	Limited; few studies specifically targeting diabetic populations	Automated measurement; good reproducibility; low operator dependence; suitable for screening	Limited prospective evidence in diabetes; biological mechanisms less well established than in FMD

PWV: Pulse wave velocity; cf-PWV: Carotid-femoral pulse wave velocity; baPWV: Brachial-ankle pulse wave velocity; CVD: Cardiovascular disease; CAVI: Cardio-ankle vascular index; FMD: Flow-mediated dilation; RH-PAT: Reactive hyperemia-peripheral arterial tonometry.