Professor Merlin Thomas Professor and program leader, department of diabetes, Monash University, Melbourne, Victoria.

Copyright © 2025 Australian Doctor All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means without the prior written permission of the publisher. For permission requests, email: howtotreat @ adg. com. au.

This information was correct at the time of publication: 31 October 2025

BACKGROUND

TYPE 2 diabetes is associated with

an increased risk of cardiovascular

disease, contributing to a higher incidence of heart attack, stroke, heart failure, arrhythmia and cardiovascular mortality. 1, 2

Indeed, cardiovascular disease( CVD) is the leading cause of years of life lost due to type 2 diabetes( T2DM). 3, 4 Evaluating and managing cardiovascular risks in patients with T2DM is a central pillar of management. 5, 6 At least a third of all patients with T2DM in Australian primary care will already have CVD. 7, 8 The majority of the remainder are at high risk of CVD now, or will be in the near future. In some cases, the first major adverse cardiovascular event( MACE) is also their last, as patients with T2DM have reduced survival following a heart attack or stroke, as well as an increased risk of sudden cardiovascular death. Consequently, the primary prevention of CVD with education, lifestyle changes and appropriate pharmacotherapy is key to the holistic management of patients with T2DM. 5, 6

The risk of having a heart attack

or stroke can be significantly reduced by early multifactorial risk factor management. This How to Treat describes how to approach the primary prevention of CVD in patients with T2DM( ie, in patients with T2DM but without established CVD), including cardiovascular risk assessment, investigations, treatment and prognosis. It aims to ensure GPs can screen for the risk of CVD in all their patients with T2DM, and when increased risk is identified, can initiate appropriate investigations and mitigation strategies.

Primordial prevention of CVD( ie, prevention of diabetes and other risk factors for developing CVD through healthy behaviours) and the secondary prevention of CVD( ie, in patients with symptomatic CVD) are beyond the scope of this article.

EPIDEMIOLOGY

GLOBALLY, at least one in three people with T2DM has CVD. 9 However, in many Western countries where

older patients with T2DM predominate, almost two in three adults with T2DM may self-report as having CVD. 10 Three to four per cent of

individuals with T2DM experience a MACE every year. 1, 2 In Australia, at least a third to a half of all patients admitted to hospital with an MI and one-quarter of all referrals for coronary revascularisation are associated with T2DM. 11, 12 In observational studies, patients with T2DM experience higher rates of coronary heart disease( CHD), including angina pectoris, non-fatal and fatal MI and silent myocardial ischaemia; approximately twice that of non-diabetic adults. 1, 2, 13 Although all patients with T2DM have an increased risk of CVD, the relative increase in risk is most pronounced in cohorts that usually have lower absolute cardiovascular risk, such as younger people, women and non-smokers( ie, any increase appears relatively greater from a lower baseline). 14 But the superimposition of T2DM still imparts an additional burden in high-risk patients( eg, those with established CVD).

Overall, the life expectancy of adults with T2DM is reduced by 8-9 years on average, compared with non-diabetic individuals. CVD is the single leading cause for this foreshortened life span and accounts for at least a third to a

half of all deaths in people with T2DM. 3, 4 The presence and severity of CVD is one of the strongest risk factors for reduced survival in adults with T2DM. 15, 16 For example, in the contemporary Reduction of Atherothrombosis for Continued Health cohort, more than one in six participants with T2DM and CVD experienced MI or stroke, or died from CVD during four years of follow-up. 17

Higher cardiac mortality in adults with diabetes is partly due to the increased frequency of CVD events experienced by those with T2DM( detailed earlier), as well as worse functional outcomes and survival from them, when compared with non-diabetic individuals. 18 Sudden cardiac death( SCD) is also a common cause of death in patients with T2DM. 19 Overall, SCD is twice as common in adults with T2DM. 20 In most cases, these events are triggered by acute cardiac decompensation and / or arrhythmia in the setting of structural heart disease. However, many people with T2DM and no prior clinical history of heart disease also die suddenly for reasons that remain to