Complications

Type 2 diabetes and cardiovascular risk

Management of type 2 diabetes: A handbook for general practice

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Table of contents

Supplementary material

Last revised: 01 Aug 2025

Complications| Type 2 diabetes and cardiovascular risk

Table of recommendations

Recommendation	Grade	References	Recommended as of:
Calculate cardiovascular disease (CVD) risk level using the Australian absolute cardiovascular disease risk calculator (Aus CVD Risk Calculator). Age ranges for assessing CVD risk in people without known CVD are as follows: All people aged 45–79 years People with diabetes aged 35–79 years Aboriginal and Torres Strait Islander people aged 30–79 years. Assess individual CVD risk factors in Aboriginal and Torres Strait Islander people aged 18–29 years* The updated Aus CVD Risk Calculator can be accessed here. When using the calculator within electronic medical records, verify the version to ensure it is not outdated. Refer to the National Aboriginal Community Controlled Health Organisation (NACCHO)–Royal Australian College of General Practitioners (RACGP) National guide to preventive healthcare for Aboriginal and Torres Strait Islander people*.	Conditional Conditional Consensus	¹	14/11/2024
For Aboriginal and Torres Strait Islander people, consider reclassifying estimated CVD risk to a higher risk category after assessing the person’s clinical, psychological and socioeconomic circumstances, and community CVD prevalence.* Refer to the NACCHO-RACGP National guide to preventive healthcare for Aboriginal and Torres Strait Islander people.	Conditional, moderate	¹	14/11/2024
In people whose estimated CVD risk is close to the threshold for a higher risk category, consider reclassifying estimated CVD risk to a higher risk category for the following groups: Māori people Pacific Islander people people of South Asian ethnicity (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese, or Maldivian ethnicities)	Conditional, moderate	¹	14/11/2024
People with pre-existing CVD are at high risk of another CVD event.	Consensus	²	14/11/2024
Managing CVD risk
For people at high risk of CVD* (estimated 5-year risk ≥10% determined using the Australian cardiovascular disease risk calculator), prescribe lipid-modifying medicines to reduce CVD risk, unless contraindicated or clinically inappropriate. Explain the potential benefits and harms of treatment to the person and encourage shared decision-making. Encourage, support and advise a healthy lifestyle. * For people at intermediate or low risk of CVD, refer to the Australian guideline for assessing and managing CVD risk.	Strong	¹	14/11/2024
For people at high risk of CVD* (estimated 5-year risk ≥10% determined using the Australian CVD risk calculator), prescribe blood pressure-lowering medicines to reduce CVD risk, unless contraindicated or clinically inappropriate. Explain the potential benefits and harms of treatment to the person and encourage shared decision-making. Encourage, support and advise a healthy lifestyle. * For people at intermediate or low risk of CVD, refer to the Australian guideline for assessing and managing CVD risk.	Strong	¹	14/11/2024
We recommend the addition of an sodium–glucose cotransporter 2 inhibitor (SGLT2i) to other glucose-lowering medication(s) in adults with type 2 diabetes who also have CVD, multiple cardiovascular risk factors* and/or kidney disease. *We define multiple cardiovascular risk factors as men 55 years of age or older or women 60 years of age or older with type 2 diabetes who have one or more additional traditional risk factors, including hypertension, dyslipidaemia or smoking.	Strong	³	14/11/2024
We recommend the addition of a glucagon-like peptide-1 receptor agonist (GLP-1RA) to other glucose-lowering medication(s) in adults with type 2 diabetes who have CVD, multiple cardiovascular risk factors* and/or kidney disease, and are unable to be prescribed an SGLT2i due to either intolerance or contraindication. *We define multiple cardiovascular risk factors as men 55 years of age or older or women 60 years of age or older with type 2 diabetes who have one or more additional traditional risk factors, including hypertension, dyslipidaemia or smoking.	Strong	³	14/11/2024
Antihypertensive medication
Antihypertensive therapy is strongly recommended in patients with diabetes and systolic blood pressure ≥140 mmHg.	Strong; Level I evidence	⁴	14/11/2024
For people with diabetes and hypertension, blood pressure targets should be individualised through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications and individual preferences	B	⁵	14/11/2024
In patients with diabetes and hypertension, any of the first-line* antihypertensive drugs that effectively lower blood pressure are recommended. *Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ARB) agents.⁵	Strong; Level I evidence	⁴	14/11/2024
In patients with diabetes and hypertension, chronic kidney disease or comorbidities of heart disease, a blood pressure target of <140/90 mmHg is recommended.	Strong; Level I evidence	⁴	14/11/2024
For individuals with hypertension and a history of transient ischemic attack (TIA) or stroke, a blood pressure target of <140/90 mmHg is recommended.	Strong; Level I evidence	⁴	14/11/2024
Lipid-lowering medications
All adults with type 2 diabetes and known prior CVD (except haemorrhagic stroke) should receive the maximum tolerated dose of a statin, irrespective of their lipid levels. Note: The maximum tolerated dose should not exceed the maximum available dose (eg 80 mg atorvastatin, 40 mg rosuvastatin).	A	²	14/11/2024
In people with type 2 diabetes and known prior CVD, fibrates should be commenced in addition to a statin or on their own (for those intolerant to statin) when fasting triglycerides are greater than or equal to 2.3 mmol/L, or high-density lipoprotein (HDL) cholesterol is low†. Note: When used in combination with statins, fenofibrate presents a lower risk of adverse events than other fibrates combined with statins. †HDL <1.0 mmol/L (based on the cut-offs reported in the ACCORD and FIELD studies).	B	²	14/11/2024
In individuals with atherosclerotic CVD (ASCVD) or other cardiovascular risk factors on a statin with controlled low-density lipoprotein (LDL) cholesterol but elevated triglycerides (135–499 mg/dL [1.5–5.6 mmol/L]), the addition of icosapent ethyl can be considered to reduce cardiovascular risk.	A	⁵	14/11/2024
For people with diabetes and ASCVD, treatment with high-intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL (<1.4 mmol/L). Addition of ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor/PCSK9 targeted therapies with proven benefit in this population is recommended if this goal is not achieved on maximum tolerated statin therapy.	B	⁵	14/11/2024
Antithrombotic medication
All adults with type 2 diabetes and known prior CVD should receive long-term antiplatelet therapy unless there is a clear contraindication.	A	²	14/11/2024
Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of ASCVD. Based on a clinical history of atherosclerotic disease not imaging retinopathy risk reduction.	A	⁵	14/11/2024
For individuals with ASCVD and documented aspirin allergy, clopidogrel (75 mg/day) should be used. Based on a clinical history of atherosclerotic disease not imaging retinopathy risk reduction.	B	⁵	14/11/2024

Clinical context

CVD is the leading cause of death in people with diabetes, making the assessment, prevention and management of CVD risk a vital part of diabetes care.

It is important to note that although myocardial infarction and stroke are commonly used as primary outcomes in type 2 diabetes trials, other common manifestations of CVD in people with type 2 diabetes are, in fact, peripheral arterial disease and heart failure.⁶ General practitioners (GPs) therefore need to consider these risks when addressing CVD risk in people with type 2 diabetes.

Assessment of CVD risk

Assessment of combined multiple risk factors (absolute CVD risk) is more accurate than the use of individual risk factors.¹

All people with type 2 diabetes should be assessed for absolute CVD risk, using a validated tool, at diagnosis. Note that all patients with type 2 diabetes and existing CVD are considered to be at high risk of another event.²

Depending on the level of risk, people should be reassessed at the following intervals:

low absolute risk (<5%): every two years
moderate risk (5–10%): every 6–12 months
high risk (>10%): as clinically indicated.¹

Calculate CVD risk level using the Australian CVD Risk Calculator.

Coronary artery calcium (CAC) scoring: the clinical utility of CAC scoring may be utilised to re-evaluate the calculated risk scores. A level of zero may allow downgrading of calculated risk, whereas higher levels (>100) may necessitate upgrading calculated risk.^5,7

People with type 2 diabetes have double the risk of developing CVD and risk is higher for people with a longer-term duration of diabetes and in the presence of microvascular disease and persistently elevated glycaemic levels.⁸ Thus, it is important to identify and manage CVD risk in people with type 2 diabetes.

Aboriginal and Torres Strait Islander people aged from 30 to 79 years should have specific CVD risk screening annually. Individuals aged 18–29 years should be assessed for diabetes. If diabetes is present in this group, screening for chronic kidney disease and serum lipids should be assessed. Refer to NACCHO-RACGP National guide to preventive healthcare for Aboriginal and Torres Strait Islander people Cardiovascular disease, Type 2 diabetes and Chronic kidney disease.⁹

Prevention and management of CVD

Interventions to manage CVD risk include:

lifestyle modification
antihypertensive medication
lipid-lowering medication
antithrombotic therapy
glucose-lowering medications that show novel non-glycaemic effects.

In addition to lifestyle modification, all people at high absolute CVD risk should be treated with both antihypertensive medication and lipid-lowering medication (see below), unless contraindicated or clinically inappropriate.¹

GPs should set individual treatment targets for patients, balancing the benefits and risks of interventions. For example, the CVD risk associated with lipid and blood pressure levels is continuous; hence, specific targets are somewhat arbitrary and should be used as a guide to treatment, not as mandatory goals. It is important to understand that there might be small absolute benefits required to reach suggested goals. However, any reduction in risk factor values will be associated with some benefit.¹

When developing a management plan for people, refer to the 2023 guideline for assessing and managing CVD risk and the Australian CVD Risk Calculator.

Lifestyle modification

Lifestyle changes in nutrition, physical activity and smoking status underpin a general practice approach to CVD risk minimisation. Lifestyle changes show excellent cost-effectiveness in lowering the burden of disease and remain the basis for the management of all CVD risk levels.^10,11

In people with type 2 diabetes and obesity (mean body mass index 36 kg/m2), the Look AHEAD study found that a lifestyle intervention that focused on weight loss improved glycated haemoglobin (HbA1c) and quality of life, but did not significantly reduce the risk of cardiovascular morbidity or mortality.¹²

For further information, refer to the section ‘Lifestyle interventions for management of type 2 diabetes’.

Antihypertensive medication

Lowering blood pressure reduces cardiovascular events and all-cause mortality in people with type 2 diabetes. Although no difference is noted between different classes of blood pressure-lowering therapy for CVD outcomes, there is clear evidence that in people with type 2 diabetes, antihypertensive therapy with an ARB or angiotensin-converting enzyme inhibitor (ACEi) decreases the rate of progression of albuminuria and retinopathy, promotes regression to normoalbuminuria and may reduce the risk of decline in renal function. Combining an ARB and an ACEi is not recommended.^1,13

Blood pressure targets

The target level for optimum blood pressure is controversial. Some international guidelines have changed their blood pressure targets to <140/90 mmHg^4,14whereas others remain at <130/80 mmHg.¹⁵ Some suggest that low targets such as <130/80 mmHg could be appropriate for people at high risk of CVD, if achievable without undue treatment burden.¹⁴

Considering these guidelines, the RACGP recommends a blood pressure target of <140/90 mmHg for people with diabetes, with lower targets considered for younger people and those at high risk of stroke, as long as the treatment burden is not high.

For secondary prevention of CVD, the target blood pressure for people with diabetes and microalbuminuria or proteinuria (emergent chronic kidney disease) remains <130/80 mmHg. As always, treatment targets should be individualised and people with diabetes monitored for side effects from the use of medications to achieve lower targets.

Lipid-lowering medication

GPs should consider treatable secondary causes of raised blood lipids before commencing pharmacotherapy.

As part of patient centred care, develop a shared decision-making process to decide on optimal therapy including individuals’ preferences and CVD risk calculation. Statins are an appropriate first line lipid-modifying therapy.¹ The results from several systematic reviews are consistent, and suggest that people with diabetes gain at least similar benefits as people without diabetes. The data clearly demonstrate that statin therapy results in a significant decrease in coronary artery disease morbidity and mortality in type 2 diabetes for those at high CVD risk.^1,16,17 This benefit is in contrast to the contentious effects of improved glycaemic control in CVD risk management.

Statin use for primary prevention of CVD

Statins are indicated for people with diabetes at high absolute risk of CVD, at any cholesterol level.¹

Statin use for secondary prevention

Statin therapy is recommended for all people with CVD (unless exceptional circumstances apply).

Other lipid-lowering medications

The evidence for using lipid-lowering medications other than statins to decrease the risk of coronary artery disease is still accumulating. Recent evidence suggests CVD benefit in select subpopulations (see below).

Ezetimibe

Ezetimibe has been studied in the IMPROVE-IT trial in people with diabetes and existing acute coronary syndrome. Compared with a statin alone, ezetimibe combined with a statin showed an absolute risk reduction of 5.5% (40% versus 45.5%) for the composite primary end point of cardiovascular death, major coronary events or non-fatal stroke over seven years.¹⁸

Thus, in adults with diabetes with acute coronary syndrome, ezetimibe combined with a statin may provide additional LDL-C lowering (if >1.8 mmol/L on statin therapy and requiring CVD risk reduction).

Nicotinic acid, bile acid resins and fibrates

These agents have been suggested as alternatives for people who cannot tolerate statins.

Nicotinic acid (niacin) was shown in one trial to reduce CVD outcomes, although the study was performed in a cohort of people without diabetes.¹⁹ More recent trials have not confirmed this initial result.²¹ The use of nicotinic acid, in particular, as well as gemfibrozil and cholestyramine, is limited by a high rate of adverse effects.

The role of fibrates (fenofibrate, gemfibrozil) to decrease the risk of CVD is contentious. Fibrates, preferably fenofibrate, should be commenced in addition to a statin or on their own (for those intolerant to statin) when fasting triglycerides are ≥2.3 mmol/L, or HDL-C is low.²

Eicosapentaenoic acid-derived ethyl ester

The Reduce-IT trial of 4 g daily of eicosapentaenoic acid (EPA)-derived icosapent ethyl demonstrated a 25% risk reduction in high-risk people with diabetes on statin therapies who had elevated triglycerides.²¹ There was an excess of hospitalisation for atrial fibrillation but no associated elevated risk of stroke. The clinical availability of this intervention is still being evaluated in Australia.

PCSK9 inhibitors

PCSK9 inhibitors are injectable lipid-lowering agents that have restricted Therapeutic Goods Administration (TGA) and Pharmaceutical Benefits Scheme (PBS) approval for use in select high-risk patients. They provide potent lowering of LDL-C in addition to other approved lipid-lowering therapies such as statins, ezetimibe and PCSK9-targeted therapies, including monoclonal antibodies and small interfering RNA. Long-term outcome studies on safety for both in class agents are needed. For more information, refer to the TGA and the PBS websites.

Antithrombotic therapy

It is not usually recommended that antiplatelet therapy (eg aspirin, clopidogrel) be used in the primary prevention of CVD. For secondary prevention, the strong positive effects in the conditions outlined in the ‘Table of recommendations’ need to be weighed against individual risks.

Glucose-lowering medications (novel non-glycaemic effects)

In populations with existing CVD, cardiovascular outcome trials have been conducted for newly developed diabetes drugs to demonstrate, primarily, cardiovascular safety and various secondary non-glycaemic endpoints.²² Some trials did include people with multiple risk factors for CVD. The trials were not glycaemic efficacy trials.

Summary of outcomes

Refer below to the individual trial designs and outcomes for specific drug effects.

Sodium glucose co-transporter 2 inhibitors

A 2019 meta-analysis of cardiovascular outcomes trials showed that the use of SGLT2i led to:²³

an 11% reduction in major adverse cardiovascular events, seen only in those with established CVD and not those without CVD
a 23% reduction in CVD death or hospitalisation for heart failure in those with or without atherosclerotic disease or heart failure.

An updated 2022 meta-analysis evaluating the use of SGLT2i in people with diabetes, with or without other diseases, reported that the use of an SGLT2i over a period of 3.5 years by 1000 people with diabetes and an elevated CVD risk would result in a reduce the number of deaths by nine, major cardiovascular events by nine, hospitalisations for heart failure by 11 and cases of end stage kidney disease by two, but potentially create two cases of ketoacidosis and 36 cases of genital infection.²⁴

The exact mechanism of action of SGLT2i on CVD, chronic kidney disease and heart failure has not been fully elucidated.

Glucagon-like peptide-1 receptor agonists

A 2022 meta-analysis of six RCTs showed that GLP-1RAs reduced the risk of:

death from cardiovascular causes by 10%
fatal and non-fatal stroke by 15%.²⁵

A 2023 meta-analysis showed that the use of GLP-1RAs led to:

a 17% reduction in primary end points for major adverse cerebrovascular outcomes
a 15% reduction in non-fatal stroke and a 27% reduction in ischaemic stroke, but no reduction in haemorrhagic stroke.²⁶

The exact mechanism of action of GLP-1RAs has not been fully elucidated.

CVD outcomes of combined GLP-1RA/glucose-dependent insulinotropic polypeptide (GIP) agents are yet to be reported.

Dipeptidyl peptidase-4 inhibitors

Recent meta-analyses for dipeptidyl peptidase-4 inhibitors showed that:^27–29

safety, but non-significant benefits for cardiovascular outcomes in those at high risk of cardiovascular events or with established CVD
a statistically non-significant 5% increased risk of hospitalisation for heart failure with saxagliptin.

Sulfonylureas

Meta-analyses of randomised clinical trials for sulfonylureas have shown:

no excess cardiovascular risks associated with this class^30,31
lower all-cause and cardiovascular mortality associated with gliclazide and glimepiride compared with glibenclamide.³²

References

National Heart Foundation of Australia. Australian guideline and calculator for assessing and managing cardiovascular disease risk. 2023 [Accessed 4 September 2024].
Baker IDI Heart and Diabetes Institute. National evidence-based guideline on secondary prevention of cardiovascular disease in type 2 diabetes. Baker IDI Heart and Diabetes Institute, 2015.
Living Evidence for Diabetes Consortium. Australian evidence-based clinical guidelines for diabetes. Living Evidence for Diabetes Consortium, 2024 [Accessed 4 September 2024].
National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults – 2016. National Heart Foundation of Australia, 2016.
American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes – 2024. Diabetes Care 2024;47(Suppl 1):S179–218. doi: 10.2337/dc24-S010.
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