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  • Review Article
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Cardiovascular risk in diabetes mellitus: epidemiology, assessment and prevention

Nature Reviews Cardiology volume 20, pages 685–695 (2023)Cite this article

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Abstract

Cardiovascular diseases (CVDs) are the leading causes of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). Secular changes in CVD outcomes have occurred over the past few decades, mainly due to a decline in the incidence of ischaemic heart disease. The onset of T2DM at a young age (<40 years), leading to a greater number of life-years lost, has also become increasingly common. Researchers are now looking beyond established risk factors in patients with T2DM towards the role of ectopic fat and, potentially, haemodynamic abnormalities in mediating important outcomes (such as heart failure). T2DM confers a wide spectrum of risk and is not necessarily a CVD risk equivalent, indicating the importance of risk assessment strategies (such as global risk scoring, consideration of risk-enhancing factors and assessment of subclinical atherosclerosis) to inform treatment. Data from epidemiological studies and clinical trials demonstrate that successful control of multiple risk factors can reduce the risk of CVD events by ≥50%; however, only ≤20% of patients achieve targets for risk factor reduction (plasma lipid levels, blood pressure, glycaemic control, body weight and non-smoking status). Improvements in composite risk factor control with lifestyle management (including a greater emphasis on weight loss interventions) and evidence-based generic and novel pharmacological therapies are therefore needed when the risk of CVD is high.

Key points

  • Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM).

  • Beyond glycaemia, evidence exists for the ‘upstream’ role of excess ectopic fat in mediating important CVD outcomes in individuals with T2DM.

  • Individuals with T2DM have a wide spectrum of risks that warrant assessment, including global risk scoring, consideration of risk-enhancing factors and, in subgroups, assessment of subclinical atherosclerosis to inform treatment.

  • Strategies to reduce the risk of CVD in individuals with T2DM include lifestyle management as the foundation, followed by pharmacological management to optimize plasma lipid levels, blood pressure and glycaemic control.

  • Epidemiological and clinical trial data show that the control of multiple risk factors is associated with ≥50% reductions in CVD events, but only ≤20% of individuals with T2DM achieve risk factor targets.

  • Improvements are needed to achieve composite risk factor control by comprehensive lifestyle and pharmacological approaches, including new evidence-based therapies for T2DM that reduce CVD outcomes by mechanisms not yet fully understood.

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Fig. 1: Number of individuals aged 20–79 years predicted to have type 1 or type 2 diabetes mellitus worldwide in 2021–2045.
Fig. 2: Association between central adiposity and T2DM.
Fig. 3: CHD event rates according to CAC score.
Fig. 4: Cardiovascular risk factor control in adults from the USA with type 2 diabetes mellitus.
Fig. 5: CVD and CHD event rates in patients with diabetes according to the number of risk factors for CVD controlled.

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Authors and Affiliations

  1. Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, CA, USA

    Nathan D. Wong

  2. Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK

    Naveed Sattar

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  1. Nathan D. Wong
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The authors contributed substantially to all aspects of the article.

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Correspondence to Nathan D. Wong or Naveed Sattar.

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Competing interests

N.D.W. receives research support through his institution from Eli Lilly, Novartis and Novo Nordisk. N.S. has consulted for or received speaker honoraria from Abbott Laboratories, Afimmune, Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Hanmi Pharmaceuticals, Janssen, Merck Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, Roche Diagnostics and Sanofi. N.S. has also received grants funding, paid to his University, from AstraZeneca, Boehringer Ingelheim, Novartis and Roche Diagnostics.

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Wong, N.D., Sattar, N. Cardiovascular risk in diabetes mellitus: epidemiology, assessment and prevention. Nat Rev Cardiol 20, 685–695 (2023). https://doi.org/10.1038/s41569-023-00877-z

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