<p>Nonfunctioning adrenal incidentalomas (NFAIs) are typically considered benign and hormonally inactive, yet emerging evidence suggests a potential association with increased cardiovascular risk. This study aimed to evaluate whether NFAIs are independently associated with vascular damage, assessed through arterial stiffness and carotid Doppler ultrasound. In this observational study, we prospectively enrolled outpatients undergoing evaluation for suspected secondary hypertension at the Arterial Hypertension and Cardiovascular Endocrinology Laboratory of the University of Turin. Patients with NFAI were compared to individuals with essential hypertension and normal adrenal imaging. Cardiometabolic and hemodynamic parameters, including augmentation index (AIx), pulse wave velocity, carotid intima-media thickness, and plaque presence, were assessed. A total of 25 patients with NFAI and 165 controls were included. Univariate analysis revealed a worse cardiometabolic profile in NFAI patients. In multivariable models, NFAI was independently associated with increased arterial stiffness: AIx P2/P1 (EC 1.097, 95% CI 1.016–1.185; p = 0.019), AIx AP/PP (EC 1.133, 95% CI 1.043–1.232; p = 0.004), and AIx@HR75 (EC 1.073, 95% CI 1.004–1.147; p = 0.039). Pulse wave velocity was also significantly higher in the NFAI group (EC 2.144, 95% CI 1.021–4.502; p = 0.044). Furthermore, NFAI was associated with increased odds of having carotid intima-media thickness ≥0.9 mm (OR 3.312, 95% CI 1.011–10.855; p = 0.048), independent of other confounders. This is the first study to demonstrate that NFAI is independently associated with increased arterial stiffness and early vascular remodeling. These findings support the need for systematic cardiovascular risk assessment in patients with NFAI, even in the absence of overt hormonal activity.</p><p></p>