Journal of Internal Medicine 2005; 258: 250256

Metformin improves endothelial function in patients with

metabolic syndrome
C. VITALE1, G. MERCURO2, A. CORNOLDI1, M. FINI1, M. VOLTERRANI1
& G. M. C. ROSANO1
From the 1Department of Medical Sciences, Cardiovascular Research Unit, IRCCS San RaffaeleRoma, Tosinvest Sanita, Rome; and 2Department of
Cardiology, University of Cagliari, Cagliari; Italy

Abstract. Vitale C, Mercuro G, Cornoldi A, Fini M,

Volterrani M, Rosano GMC (IRCCS San Raffaele
Roma, Rome; and University of Cagliari, Cagliari;
Italy). Metformin improves endothelial function in
patients with metabolic syndrome. J Intern Med
2005; 258: 250256.
Background. Metabolic Syndrome (MS) is associated
with impaired endothelial function and increased
cardiovascular risk. Insulin resistance is a key
feature of MS and plays an important role in the
pathogenesis of endothelial dysfunction. Aim of the
present study was to evaluate the effect of metformin
on endothelial function and insulin resistance,
assessed by the homeostasis model (HOMA-IR,
homeostasis model assessment-insulin resistance),
in patients with MS.
Methods. Sixty-five subjects (37 men and 28
women, mean age 54 6 years) with MS were
allocated to receive metformin 500 mg twice daily
(n 32) or placebo (n 33) for 3 months. Before
and after treatment we assessed endothelial
function, using flow-mediated dilatation of the
brachial artery, and HOMA-IR.

Introduction
Metabolic Syndrome (MS) is a highly prevalent and
complex clinical entity that associates abdominal
obesity, insulin resistance or glucose intolerance,
high blood pressure, hypertriglyceridaemia and low
HDL cholesterol and that is associated with an
increased cardiovascular risk [13].
Insulin resistance was suggested by Reaven as the
cause of metabolic Syndrome X and is now
considered an important component of the MS
250

Results. Patients
who
received
metformin
demonstrated statistically significant improvement
in endothelium-dependent vasodilation compared
with those treated with placebo (from 7.4 2.1% to
12.4 1.9% vs. 7.3 2.5% to 6.9 2.7%, P
0.0016, metformin vs. placebo respectively), without significant effect on endothelium-independent
response to sublingual glyceryl trinitrate (P
0.32). Metformin improved insulin resistance
compared with placebo group (HOMA-IR from
3.39 to 2.5 vs. 3.42 to 3.37; 26% reduction in
HOMA-IR, P 0.01). An association between
the improvement in insulin resistance and the
improvement in endothelial function (r )0.58,
P 0.0016) was found.
Conclusion. Metformin improves both endothelial
function and insulin resistance in patients with MS.
These findings support the central role of insulin
resistance in the development of endothelial
dysfunction and the role of metformin for the
treatment of patients with MS.
Keywords: endothelial function, insulin resistance,
metabolic syndrome, metformin.

linked to both visceral obesity and arterial hypertension [4]. Insulin resistance has also been suggested as an independent risk factor of coronary heart
disease as insulin-resistant subjects have a higher
incidence of cardiovascular events compared with
subjects with normal insulin sensitivity [3, 57].
Recent data suggest that patients with insulin
resistance and MS have an impaired endothelial
function and that this attenuation may represent an
initial step towards the development of atherosclerosis, and to the increased cardiovascular risk [811].

2005 Blackwell Publishing Ltd

METFORMIN IN METABOLIC SYNDROME

Hyperinsulinaemia and insulin resistance are

associated with an impaired NO release from endothelial cells and with reduced endothelial function.
Metformin has been consistently shown to lower
fasting insulin levels in type 2 diabetes [1214] and
in insulin-resistant states [15, 16]. Several studies
have suggested that metformin, an insulin-sensitizing biguanide, may improve some of the features of
the MS as it not only improves insulin sensitivity in
the liver and muscle, as its primary anti-hyperglycaemic mechanism of action, but also induces additional beneficial effects on several metabolic
abnormalities associated with the MS [16].
At the present it is not clear whether in patients
with MS the improvement of insulin resistance after
therapy with metformin may in turn improve
endothelial function. Aim of this study was to
evaluate the effect of metformin on insulin resistance and endothelial function in patients with MS.

Methods
Study population
The study population included 78 consecutive
newly diagnosed patients with the clinical features
of MS, defined according to the criteria proposed by
the World Health Organization [17]. Included in the
study were those 65 (37 men, 28 women, mean age
54 6 years) with insulin resistance, without any
change in dietary habits and physical activity, stable
blood pressure values and lipid and glycaemic profile
over the past 3 months, and who had not previously
received any therapy for glycaemic control or for
insulin resistance.
Patients with contraindications to metformin
therapy, including renal or hepatic impairment,
congestive heart failure, severe respiratory insufficiency, acute or chronic metabolic acidosis, alcoholism, dehydration, need of use of intravenous
radiographic contrast agents and those with overt
diabetes mellitus and known intolerance to metformin were excluded from the study.
Study design
The study design was randomized, parallel, placebo
controlled. After a baseline evaluation of all inclusion and exclusion criteria, all suitable patients
entered a run in phase, to ensure the stability of

251

clinical and laboratory parameters of MS for

4 weeks, at the end of which patients underwent a
baseline evaluation of flow-mediated dilatation
(FMD) of the brachial artery and of whole body
insulin resistance by the homeostasis model (HOMAIR, homeostasis model assessment-insulin resistance). All patients were given a low carbohydrate
normo-caloric diet and all were randomized to
receive, in blind, either metformin (500 mg, b.d.s.)
or matching placebo (b.d.s.) for 3 months, added to
background therapy. All patients underwent
re-evaluation of FMD of the brachial artery and
HOMA-IR at the end of the study. The study protocol
was approved by the San Raffaele Eur Ethical
Committee and all subjects gave informed consent
prior to participation.
Patients and controls were asked to refrain from
smoking and drinking alcohol or caffeine-containing
beverages and, also, to abstain from severe physical
exercise in the 24 h preceding the study. At each
visit, patients were weighed and measured to
calculate body mass index (BMI) and spent at least
a 20-min acclimatization period lying in a quiet
room at a controlled temperature of 20 1 C and
relative humidity of 65 10%.
Blood samples for fasting serum insulin, glucose,
haemoglobin A1c (HbA1c), cholesterol (total, HDL-c,
LDL-c), and triglycerides were obtained 20 min prior
the investigation of brachial artery endothelial function and chemical parameters were evaluated with
standard methods. Whole-body IR was calculated
using the HOMA-IR [18].
Brachial artery endothelial function
Endothelial function was assessed by measuring
changes from baseline in the calibre of the brachial
artery during reactive hyperaemia, a procedure that
increases blood flow and sheer stress through the
vessel. Brachial artery FMD was measured with
high-resolution ultrasound. The same investigator
studied each patient in order to avoid inter-observer
variability. Studies of brachial artery reactivity were
conducted according to a previously reported protocol [19]. In brief, all patients were studied in a quiet,
temperature-controlled room (2223 C). Participants were asked to avoid drinking beverages
containing caffeine and to refrain from smoking for
6 h preceding the study. After 15-min of rest in a
supine position, the right brachial artery was

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C . V I T A L E et al.

imaged using a Hewlett-Packard 2500 high-resolution ultrasound machine (Hewlett-Packard, Palo

Alto, CA, USA) equipped with a 7.512.5 MHz
linear array transducer. The artery was scanned
over a longitudinal section 35 cm above the elbow,
the site where the clearest image can be obtained.
The focus zone was set to the depth of the anterior
vessel wall. Depth and gain settings were optimized
to identify the lumen vessel wall interface. The
diameter of the right brachial artery was measured
continuously four times: at rest, during reactive
hyperaemia, after a 10-min recovery period, and
5 min following sublingual nitroglycerin. A pneumatic tourniquet was placed around the forearm
distal to the target artery and has been inflated to a
pressure of 50 mmHg above patients systolic blood
pressure for 5 min. Reactive hyperaemia was
induced by sudden cuff deflation. The brachial
artery was continuously imaged for 30 s prior to
and 180 s after cuff release. Ten minutes following
cuff deflation, a third scan was recorded to confirm
that basal conditions had been re-established. To
assess endothelium-independent vasodilation, sublingual nitroglycerin (0.4 mg) was administered,
and a fourth scan was recorded for 5 min. The
ultrasound images were recorded directly onto the
hard disk of the ultrasound machine, and transferred to a floppy disk. Image analysis was performed
using a validated program. The diameter of the
brachial artery was measured from the anterior to
the posterior interface. For each condition, the mean
arterial diameter was calculated from four cardiac
cycles synchronized with the R-wave peak on the
electrocardiogram. All measurements were made at
end diastole. The diameter change was expressed as
the percentage change compared with baseline
diameter. In our group the intra-observer variability
in diameter measurements is 0.38 0.26% (range
0.11.2), the coefficient of variation is 1.26% and
the coefficient of repeatability is 0.5%, as previously
reported.
Biochemical parameters
Blood samples were obtained at baseline and after
3 months. Venous blood samples were taken after at
least 10 h fasting, in a supine position after 20 min
of rest with a Vacutainer system (Becton Dickinson,
Meylan, France). Baseline blood samples were collected in tubes containing serum to evaluate with

standard methodologies insulin, glucose, cholesterol (total, HDL-c, LDL-c), and triglycerides levels
and tubes with ethylenediaminetetraacetic acid for
HbA1c.
The HOMA-IR was used as a measure of insulin
resistance where HOMA-IR is calculated as fasting serum insulin (uU mL)1) fasting glucose
(mmol L)1)/22.5.
Statistical analysis
Values are given as mean SD or as percentages
where appropriate. Analysis of covariance was performed in order to test statistical differences (treatment effect) between groups. ancova for repeated
measurements using baseline values as constant
covariates was used to test statistical differences
between baseline and follow-up measurements
between groups. Correlation between variables was
calculated using the Spearmans correlation coefficient. A stepwise multivariate analysis was performed
in order to detect the variables associated with
improvement in endothelial function. In the analysis
plasma levels of glucose, insulin, cholesterol, LDL
cholesterol, cigarette smoking, hypertension, new use
of any cardio-active or antiplatelet or lipid-lowering
drug, were entered as independent variables.

Results
Clinical features of study patients are shown in
Table 1, patients assigned to metformin and placebo
had similar male/female distribution and clinical
features.
Medication compliance was 97% in the metformin
group where one patient withdrew from the study
for gastrointestinal side-effects and 91% in the
placebo group where three patients withdrew
because of the complaint of weight gain (one
patient), nausea (one patient) and unwillingness to
continue the study (one patient).
At baseline all subjects had similar values of
endothelial function (FMD 7.4 2.1% vs.
7.3 2.5%) and value of HOMA-IR (3.39 1.2
vs. 3.42 1.5). After 3 months no significant
differences in blood pressure or BMI were detected
between groups. A significant improvement in
insulin resistance was noted in patients receiving
metformin compared with those allocated to placebo
(HOMA-IR from 3.39 to 2.5 vs. form 3.42 to 3.37;

2005 Blackwell Publishing Ltd Journal of Internal Medicine 258: 250256

METFORMIN IN METABOLIC SYNDROME

Table 1 Clinical characteristics of study patients

Patients Metformin Placebo
(65)
(32)
(33)
Mean age (years)
Men/women
BMI
Risk factors for CAD (%)
Cigarette smoking
Dyslipidaemia
Hypertension
Grade 12
IR/IGT/diabetes
Family history for CAD
Aspirin/ticlopidine/clopidogrel
Anticoagulants
Diuretics
b-Blockers
Ca-antagonists
ACE-I
ARB
Statins

54 6
37/28
32 3

55 4
18/14
31 5

54 7
19/14
32 4

14
100
100
76
100
36
47
3
43
36
19
28
33
43

16
100
100
72
100
31
22
2
23
20
9
14
15
20

12
100
100
79
100
39
25
1
20
16
10
14
18
23

Controls were more frequently smokers and had family history of

CAD but had less frequently hyperlipidaemia or arterial hypertension. Use of drugs at randomization in patients allocated to
metformin and placebo. No significant difference in the use of any
class of drug was found. BMI, body mass index; IR, insulin
resistance; IGT, impaired glucose tolerance; CAD, coronary artery
disease; ACE, angiotensin converting enzyme; ARB, angiotensin
receptor blockers.

26% reduction in HOMA-IR, P < 0.001). Also a

decrease in plasma fasting glucose levels was
detected in patients taking metformin but not in
those on placebo (from 123 5 to 108
3 mg dL)1 vs. 121 6 to 122 7 mg dL)1;
Table 2). Compared with baseline and placebo
patients who received metformin had significant
improvement of endothelial function (FMD
12.4 1.9% vs. 6.9 2.7%; metformin vs. placebo,
P 0.0016; Fig. 1), whereas no significant effect
Table 2 Baseline clinical characteristics of study patients and
controls

was seen on endothelium-independent response to

sublingual glyceryl trinitrate (P 0.32).
A significant positive correlation was found
between the improvement in insulin resistance and
that in endothelial function (r )0.58, P
0.0016; Fig. 2). No correlation was found between
the improvement in fasting plasma glucose and
endothelial function. The multivariate analysis
showed the improvement in insulin resistance as
the only parameter significantly associated with the
improvement in endothelial function.

Discussion
The present study shows that 3 months of treatment
with metformin improves both insulin resistance,
measured by HOMA-IR, and endothelial function in
patients with MS. Our data are in agreement with a
previous study of Mather et al. in which metformin
improved endothelium-dependent vascular response
and insulin sensitivity in patients with type 2
diabetes without other metabolic abnormalities.
More recently De Jager et al. [20] have shown that
in patients with type 2 diabetes treated with insulin,
metformin treatment was associated with improvement of endothelial function, which was not related
to changes in glycaemic control.
In addition our results show that the improvement of endothelial function observed with metformin is directly linked to the improvement of insulin
resistance and not related to the improvement in
fasting plasma glucose suggesting the prominent
role of insulin resistance in the pathogenesis of
endothelial dysfunction in patients with MS [21].
Metabolic syndrome is a clustering of metabolic
risk factors whose importance is increasing as one of
the major issue in the management of cardiovascular
Metformin

HOMA-IR
Glucose (mg dL)1)
HbA1c (%)
Cholesterol (mg dL)1)
LDL-c (mg dL)1)
HDL-c (mg dL)1)
Triglycerides (mg dL)1)

253

Placebo

Baseline

Follow-up

Baseline

Follow-up

P value

3.39
123 5
5.4 0.7
231 27
168 11
31 7
243 21

2.5
108 3
5.1 0.9
218 31
146 14
37 9
219 18

3.42
121 6
5.6 0.8
247 33
174 16
30 8
236 15

3.37
122 7
5.6 1.3
240 29
165 12
32 12
247 26

<0.001
<0.005
NS
NS
NS
NS
NS

Baseline and follow-up biochemical characteristics of patients allocated to metformin and placebo.
HbA1c, haemoglobin A1c; HDL-c, HDL cholesterol; HOMA-IR, homeostasis model assessment
insulin resistance; LDL-c, HDL cholesterol.

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C . V I T A L E et al.

FMD
16
14
12
10

P = 0.0016

8
6
4
2
0
Baseline

After therapy
Placebo

Metformin

Fig. 1 Effect of metformin on endothelial function (flow-mediated

dilatation, FMD) in patients with metabolic syndrome. Metformin
treatment significantly improved brachial FMD in patients with
metabolic syndrome.

% FMD
100
90
80
70
60
50
40
30
20
10
0

** * * * * ** * *
*
*
********* *** *
*
* *
*
* **
* * * * **** *** ******
* * **
* * ** * *
*
*
*
*
0

10

20

30

40

50

% HOMA-IR
Fig. 2 Correlation between improvement in insulin resistance
and endothelial function. A significant positive correlation was
found.

disease because of its epidemic proportion (prevalence of 40% of the population >40 years) and its
impact on the risk of developing both cardiovascular
disease and type 2 diabetes [2224].
As suggested by Reaven insulin resistance, both
genetically determined and environmentally induced,
may lead to the development of the MS and also plays
an important role in the pathogenesis of endothelial
dysfunction in patients with the syndrome [25].
Insulin resistance may be linked to endothelial
dysfunction through several different mechanisms,
such as the disturbances of subcellular signalling
pathways, the PI-3-kinase/Akt pathway, common to
both insulin action and nitric oxide production [26].
Metformin improves insulin sensitivity, decreases
insulin resistance and has beneficial effects on
several metabolic anomalies associated with MS.

The link between improvement in insulin resistance

and endothelial function with metformin has been
suggested by experimental studies showing that the
beneficial effect of metformin on insulin resistance
may be related to several mechanisms, including the
increased binding of insulin to its receptors, phosphorylation, and tyrosine kinase activity of insulin
receptors, the increased glycogen synthesis, the
increase in the recruitment and/or activity of GLUT
4 glucose transporters and, by re-esterification of
free fatty acid (FFA) and the promotion of lipolysis,
the reduction of FFA lipotoxicity [2732].
Consistent with the hypothesis that insulin resistance mediates endothelial dysfunction and in agreement with previous studies in animals and in
humans with type 2 diabetes [33, 34], we found
that the reduction of insulin resistance with metformin treatment is associated with a significant
improvement of endothelial-dependent function in
patients with MS.
Our findings suggest the central role of insulin
resistance in the development of endothelial dysfunction in patients with MS and the role of
metformin for the treatment of these patients.
Although a large body of evidence suggest that
metformin has important effects on cardiovascular
risk factors known to affect endothelial function,
such as plasma glucose levels, weight loss, plasma
lipid profiles [3538] in the present study no
correlation between improvement of endothelial
function and changes in metabolic parameters
except from insulin resistance was found. Indeed,
although we found an improvement in fasting
plasma glucose with metformin, the multivariate
analysis showed that the improvement of endothelial function observed in our study is not directly
related to the amelioration of glycaemic control.
A large body of evidence suggests that metformin
improves cardiovascular outcomes in patients with
abnormal glucose metabolism [3941]. The effect of
metformin in patients with MS may be of relevant
importance as MS is associated with a significant
increase in cardiovascular risk and mortality [22]
and predicts cardiovascular disease and total mortality more strongly than the individual risk factors
included in the syndrome.
As endothelial dysfunction is not only an early
marker of atherosclerosis but also a potential tool for
predicting CHD risk it seems reasonable to suggest
that one of the effects through which metformin

2005 Blackwell Publishing Ltd Journal of Internal Medicine 258: 250256

METFORMIN IN METABOLIC SYNDROME

may positively affect cardiovascular outcome is the

improvement of endothelial function.
Furthermore, insulin resistance leads to excess
liberation of FFA from adipose tissue, which may
impair endothelial function through several mechanisms. In the present study, we did not measure
neither vascular inflammation markers nor oxidative stress nor FFAs; however, seen the primary
effect of metformin on insulin sensitisation and the
strong correlation between improvement in insulin
resistance and improvement in endothelial function
it seems unlikely that these factors may play a
relevant role in explaining our results.
One limitation of our study may be the use of
HOMA index instead of either the euglycaemic or
the hyperinsulinaemic clamp to evaluate insulin
resistance. Although the euglycaemic and the
hyperinsulinaemic clamp are believed to be the gold
standard for evaluating insulin resistance several
studies have shown that the HOMA index is a simple
and economic method closely correlated with the
insulin resistance index measured by the clamp
technique [42, 43].
In conclusion, our data show that metformin
improves both insulin resistance and endothelial
function in patients with MS, suggesting a central
role of insulin resistance in vascular pathophysiology. Although longer-term trials are necessary to
determine whether metformin will be effective in
reducing outcomes in patients with insulin resistance or MS our findings suggest a rational for the
choice of metformin for the treatment of patients
with MS.

Conflict of interest statement

There is not any conflict of interest for any of the
authors.

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Correspondence: Giuseppe M.C. Rosano MD, PhD, FACC, Cardiovascular Research Unit, Department of Medical Sciences, IRCCS
San RaffaeleRoma, Tosinvest Sanita, via della Pisana 235,
00163 Rome, Italy.
(fax: +39 06 52244512; e-mail: giuseppe.rosano@sanraffaele.it).

2005 Blackwell Publishing Ltd Journal of Internal Medicine 258: 250256