The relationship between diabetes and cardiovascular disease: what do cardiologists prioritize?

Abstract

Cardiovascular evaluation must go beyond the diagnosis of diabetes and incorporate a dynamic and multidimensional stratification that allows for the individualization of therapeutic goals and treatment intensity.

Initial Identification of the Very High-Risk Patient

This category includes patients with: established atherosclerotic cardiovascular disease (ASCVD), whether clinical or documented by imaging; relevant chronic kidney disease; or microvascular disease in at least three different territories (e.g., microalbuminuria, retinopathy, and neuropathy). In these cases, the clinical priority shifts from estimating risk to the intensive implementation of preventive strategies.

Risk Quantification via SCORE2-Diabetes

In the absence of established ASCVD or advanced organ damage, quantitative risk estimation is the next step. Currently, SCORE2-Diabetes is the most specific tool for evaluating atherosclerotic cardiovascular risk in people with diabetes. Based on national cardiovascular mortality rates, Argentina can be interpreted as an intermediate-high risk country.

Refinement of Stratification

A high cardiovascular risk phenotype is defined by factors such as: diabetes duration ≥10 years; insulin therapy; retinopathy; neuropathy; or diabetic nephropathy. Furthermore, early nephropathy (UACR >30 mg/g), retinopathy, or neuropathy serve as potent amplifiers of global cardiovascular risk.

Directly quantifying the atherosclerotic burden is one of the most useful tools for reclassifying risk. Among the most valuable instruments are the coronary calcium score and the identification of plaques via ultrasound.

Biomarkers and Residual Risk

• Cardiac Biomarkers: Tools like NT-proBNP (≥125 pg/mL), BNP (≥35 pg/mL), and high-sensitivity troponin allow for the early detection of diabetic cardiomyopathy and left ventricular dysfunction.
• Inflammation: A high-sensitivity C-reactive protein (hs-CRP) >2 mg/L identifies a persistent inflammatory state associated with a higher risk of cardiovascular events.
• Lipid Biomarkers: Modern lipid evaluation must go beyond LDL cholesterol, paying particular attention to: triglycerides >175 mg/dL; lipoprotein(a) [Lp(a)] >50 mg/dL; and apolipoprotein B (apoB) >130 mg/dL.

Comorbidities and Risk Amplifiers

Additional clinical conditions influencing cardiovascular risk include chronic inflammatory diseases, HIV infection, and cancer. Furthermore, a family history of premature cardiovascular disease, high-risk genetic variants, and clonal hematopoiesis of indeterminate potential (CHIP) are emerging elements of great prognostic relevance.

Non-traditional factors that should be incorporated into modern stratification include:

• Visceral obesity, ectopic fat, and obstructive apnea.
• Frailty, periodontal disease, low birth weight, and psychosocial factors.
• Environmental pollution and socioeconomic vulnerability.

Specific conditions for women must also be considered: early menopause, polycystic ovary syndrome, preeclampsia, gestational hypertension, and gestational diabetes.

Cardiovascular risk stratification in patients with diabetes must evolve from an approach based exclusively on diagnosis toward a comprehensive model centered on the magnitude of individual risk.