Mitochondrial-Endothelial Crosstalk in Cardiometabolic Disease: Mechanisms and Translational Opportunities in the Multi-omics Era.

Mitochondria and endothelial cells engage in bidirectional crosstalk to maintain vascular tone, barrier integrity, and inflammatory quiescence. In cardiometabolic diseases (CMDs), metabolic overload and chronic inflammatory cues disrupt endothelial mitochondrial bioenergetics, dynamics, and quality-control mechanisms. As protective systems weaken, redox imbalance and impaired nitric oxide signaling-further exacerbated by barrier dysfunction-trigger endothelial activation and loss of homeostasis. Clinical translation has lagged largely because endothelial responses vary across vascular beds and microenvironments, and most clinical trials fail to align patient selection or endpoints with mitochondrial mechanisms. This review addresses a major translational gap: how mitochondrial stress programs map onto context-specific endothelial phenotypes in human CMDs, and how this mapping can inform the selection of actionable therapeutic strategies. Indeed, this review integrates single-cell and spatial multi-omics data to link mitochondrial stress and metabolic remodeling to specific anatomical niches, transforming the broad notion of "endothelial dysfunction" into defined biological programs for biomarker selection and target discovery. Moreover, this review categorizes translational opportunities by the strength of human evidence. Near-term priorities include repurposed cardiometabolic drugs (e.g., sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1(GLP-1) receptor agonists) and circulating biomarkers for patient stratification or pharmacodynamic monitoring (e.g., growth differentiation factor 15 (GDF15), cell-free mitochondrial DNA (cf-mtDNA), endothelium-derived extracellular vesicles). In contrast, gene and cell therapies, as well as advanced delivery and regenerative platforms, remain at the preclinical stage and require stronger mechanistic validation, improved safety profiles, and scalable delivery systems before clinical evaluation. Thus, a key unmet need is for multicenter, mechanism-informed trials that integrate endothelial functional endpoints (e.g., flow-mediated dilation (FMD)/peripheral arterial tonometry (PAT) with mitochondrial-associated molecular readouts under harmonized protocols and standardized reference criteria to enhance reproducibility and cross-study comparability. Collectively, these insights establish mitochondrial-endothelial biology as an evidence-based entry point for precision vascular medicine in CMDs.