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The deficiency of the Cd38 gene have been implicated in the dedifferentiation or transdifferentiation of arterial smooth muscle cells when stimulated by atherosclerosis, although the precise mechanism remains unclear [31, 32]

It has been reported that cardio-tolerance to oxidative stress reduces with advancing age due to the antioxidant levels, particularly enzymatic antioxidants, contributing to the development of CMD [6]

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Subsequent studies have shown that daily oral intake of 1.8 g of NAC had similar [44] or superior [45] effects compared to daily oral intake of 1.5 g of metformin in improving BMI, fasting insulin, homeostasis model assessment of insulin resistance (HOMA-IR), and menstrual irregularities