Cardiovascular risk in patients with diabetes: how can we better stratify risk and take timely action?

Abstract

Type 2 diabetes mellitus (T2DM) has prevalence rates of up to 13–14% in certain countries. It is estimated that up to 50% of people with diabetes remain undiagnosed, which delays risk stratification and timely treatment. Patients with T2DM face a 2- to 4-fold higher risk of developing cardiovascular disease (CVD), which occurs up to 12 years earlier compared to the general population. The use of validated tools from the time of diagnosis helps quantify the risk of life-threatening events, optimizing therapeutic decisions to reduce morbidity and mortality. Notable among these are:

• SCORE2-Diabetes (ESC): Estimates the 10-year risk of CVD in the European population, incorporating both traditional and specific risk factors (age at diagnosis, HbA1c, and estimated glomerular filtration rate [eGFR]).
• PREVENT (AHA): Estimates 10- and 30-year risk, incorporating contemporary factors to guide targeted intervention.

Comprehensive evaluation at diagnosis

A formal evaluation should be conducted at the time of T2DM diagnosis, regardless of age, including screening for kidney disease, retinopathy, liver disease (MASLD), heart failure, and atrial fibrillation. The essential parameters are:

• Clinical and demographic: Age, sex, duration of disease, BMI, waist-to-hip ratio, smoking status, and blood pressure.
• Laboratory: HbA1c, fasting blood glucose, lipid profile, creatinine, and liver function tests.
• Organ damage and biomarkers: Urinary albumin-to-creatinine ratio (UACR), ECG, fundus examination, and tests to detect subclinical atherosclerosis (NT-proBNP, ankle-brachial index, carotid/femoral Doppler, or calcium score).

Correlation and agreement of scores

When comparing the performance of multiple scoring systems for the same patient (Framingham, ACC/AHA 2018, PREVENT, SCORE2-Diabetes, and the UKPDS equations), the estimated risk was considerable for most of them. Adequate correlation and very good discriminative ability for the detection of carotid atherosclerotic plaque (CAP) were observed; however, agreement among the different scores was fair, indicating that risk estimation may vary depending on the tool used.