24 HOW TO TREAT: PRIMARY PREVENTION OF CVD IN TYPE 2 DIABETES
24 HOW TO TREAT: PRIMARY PREVENTION OF CVD IN TYPE 2 DIABETES
31 OCTOBER 2025 ausdoc. com. au treatment with GLP-1 RAs was associated with a 12-14 % reduction in MACE, a 12-13 % reduction in all-cause and cardiovascular mortality, and 10-13 % lower rates of fatal or non-fatal MI in participants with T2DM and established or high risk for CVD. 54 Based on this evidence, the American Diabetes Association guidelines now recommend the use of GLP-1 RAs as adjunctive therapy in all people with T2DM and indicators of high CVD risk, independent of their HbA1c or body weight. 55 Real-world data have also identified cardiovascular benefits in patients with T2DM at moderate CVD risk. 56 A PBS subsidy is available for GLP-1 RAs for glucose lowering management of T2DM on a streamlined authority prescription, regardless of CVD risk. GLP-1 RAs are not subsidised for weight loss or CVD risk reduction.
Antiplatelet therapy
Low-dose aspirin( 75-162mg / day) reduces the risk of MACE in patients with established CVD( ie, secondary prevention). However, its potential to prevent cardiovascular events in patients with T2DM without CVD remains controversial. There has been about a 10 % reduction in the risk of MACE across several trials in participants without CVD, but at the same time a 2-3-fold relative increase in the risk of major bleeding with low-dose daily aspirin. 57 At present, guidelines suggest low-dose aspirin should be considered for the primary prevention of cardiovascular events in patients with T2DM assessed to be at high risk and who are not at increased risk of bleeding. 5 Aspirin is not recommended for those with T2DM at moderate or low risk of CVD, as the small absolute benefit from aspirin therapy is likely to be outweighed by the increased risk of bleeding. 58
Regular review and re-evaluation
Regular review and continuity of care from the same GP increases the likelihood of achieving risk factor control. 59 Once treatment targets have been achieved, regular repeated measurement of risk factors is appropriate in all
How to Treat Quiz. people with increased CVD risk; this should be performed routinely, at least every 3-6 months. Once it is established that someone is deemed high risk for CVD, further risk scoring is not usually required, unless it is being used to discuss the potential value of more aggressive treatment targets. Ongoing strategies to improve treatment adherence( eg, fixeddose combinations, pre-packaging, improved education, communication, co-ordination and continuity of care) are also particularly valuable in high-risk patients.
PROGNOSIS OF A TYPICAL PATIENT WITH T2DM BUT WITHOUT CVD
THE natural history of T2DM is well understood. In patients with T2DM but without CVD, over the next five years, on average, one in five will develop CVD. This is in part due to a prolonged legacy of exposure to elevated glucose, lipids, body fat and blood pressure that predated their diagnosis of diabetes(‘ metabolic karma’). As a result, at least half to two-thirds of
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1. Which ONE is the leading cause of years of life lost due to type 2 diabetes( T2DM)? a Diabetic ketoacidosis. b Kidney failure. c Diabetic eye disease. d CVD.
2. Which THREE statements regarding the epidemiology of CVD in T2DM are incorrect? a Patients with T2DM experience about twice the rate of CHD as non-diabetic adults. b The higher incidence of CVD in people with T2DM is most pronounced in cohorts with the highest absolute CVD risk. c Life expectancy of adults with T2DM is reduced by 8-9 years on average, compared with non-diabetic individuals. d Sudden cardiac death is approximately twice as common in adults with T2DM.
3. Which ONE is NOT associated with increased rates of CVD pathology in T2DM? a Greater plaque burden. b Less coronary calcification. c Reduced coronary collateral recruitment. d Greater extent of coronary ischaemia.
4. Which THREE statements regarding assessing the risk of a cardiovascular event are correct? a Having high-risk chronic kidney disease identifies patients as having a high CVD risk. b Estimate the absolute risk of having a cardiovascular event in all people with T2DM at the time of their diabetes diagnosis. c The result of the risk calculated using the Australian CVD Risk Calculator incorporates all the risks found in any individual patient. d Use the Australian CVD Risk Calculator to categorise a patient’ s risk.
5. Which THREE statements regarding assessing the risk of a cardiovascular event are correct? a Only a minority of patients with T2DM will be assessed to have a low or moderate risk of CVD. b Screen all people with T2DM without any cardiac symptoms for subclinical CVD with exercise stress testing or a stress echo. c In some patients with a low or moderate risk score, a coronary artery calcium CT can be used to support consideration of a more intensive management strategy. d Perform an ECG as a baseline in all patients with T2DM and increased risk of CVD.
6. Which THREE statements regarding patients with T2DM but without CVD are correct? a About 14 % develop symptomatic CVD every year. b In men, the most frequent first CVD presentation is CHD or peripheral arterial disease. c In women, the most common first presentation is heart failure or stroke. d In those older than 65, the most frequent first presentation of CVD is heart failure.
7. Which TWO statements regarding the non-pharmacological management of the risk of CVD in T2DM are correct? a Lifestyle changes may be less likely to work or be sustained if many changes are made all at once. b After five years of not smoking, the excess risk for CHD falls to half that of current smokers. c Recommend that patients using SGLT2 inhibitors consume a low-carbohydrate diet. d A simple first goal is to aim for at least 30 minutes of moderate-intensity aerobic physical activity on most, if not all, days of the week.
8. Which THREE statements regarding optimal glucose control are correct? a Intensive glucose lowering can improve cardiovascular outcomes in people with T2DM, proportional to the degree and duration of glucose control. b Normalisation of glucose control, on its own, significantly reduces cardiovascular risk beyond standard of care. c Intensive glucose lowering has been associated with a 14 % reduction in major adverse cardiovascular events( MACE). d An HbA1c of less than 7 % is appropriate and achievable in
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PRIMARY PREVENTION OF CVD IN TYPE 2 DIABETES
all people with T2DM without CVD have identifiable plaque in their coronary arteries. 60 This potentially blurs the lines between primary and secondary prevention.
CASE STUDY
MARK, 65, is an engineer who was diagnosed with T2DM three years ago. His glucose is well controlled on metformin and a dipeptidyl peptidase-4 inhibitor( HbA1c 6.8 %). After his GP puts his details in the CVD risk calculator, he is found to be at high risk of having a heart attack. After communicating this to Mark, he agrees to add an SGLT2 inhibitor and a high-intensity statin to his care.
As he has previously had a stomach ulcer, the GP decides not to put him on aspirin. Although his systolic blood pressure is 136mmHg on an ACEI and a CCB, the GP discusses the need for optimal blood pressure control and the value of home monitoring to achieve optimal risk reduction.
CONCLUSION
IN Australian general practice, most patients with T2DM also have a high risk of CVD. This
most patients with T2DM.
9. Which THREE statements regarding the pharmacological management of the risk of CVD in T2DM are correct? a Statins unequivocally remain the single most powerful strategy to lower CVD risk in patients with T2DM. b Use moderate-intensity statin therapy, in addition to lifestyle modifications, in all adults with T2DM but without CVD. c Most individuals with T2DM at high CVD risk achieve and maintain adequate blood pressure control on the maximum dose of a single antihypertensive agent. d As those with T2DM often experience a non-dipping pattern of high blood pressure, it has been suggested that evening dosing with antihypertensive agents could be beneficial.
10. Which THREE statements regarding the pharmacological management of the risk of CVD in T2DM are correct? a Treatment with GLP-1 receptor agonists is independently associated with a reduction in cardiovascular events, including benefits in individuals without CVD. b Treatment with SGLT2 inhibitors lowers the risk of MACE, cardiovascular mortality and heart failure in people with T2DM at high CVD risk. c Aspirin is recommended for all patients with T2DM as primary prevention. d Weight loss greater than 10 % is associated with improved cardiovascular outcomes in participants with T2DM. means a central pillar of their management is assessing and mitigating their CVD risk through education, diet and lifestyle change and appropriate medications, beyond simply better glucose control. There are unequivocal data that treatment with statins, SGLT2 inhibitors, RAAS inhibitors and GLP-1 RAs can reduce the risk of MACE. Although most of these data have been obtained in patients with T2DM and established CVD, waiting for a heart attack or stroke to occur before intensifying therapy is like closing the stable door after the horse has bolted. CVD risk can be readily calculated in routine care, identifying highrisk patients most likely to benefit from additional education and monitoring as well as early initiation of appropriate medications.
RESOURCES
• Australian Chronic Disease Prevention Alliance— Australian Guideline for assessing and managing CVD risk bit. ly / 46h4Jp3
• RACGP— Management of type 2 diabetes: A handbook for general practice bit. ly / 42zRn53
• International Diabetes Federation Diabetes Atlas 2025 bit. ly / 463Bq8q
• American Diabetes Association Professional Practice Committee. Cardiovascular disease and risk management: Standards of care in diabetes— 2025. Diabetes Care 2025; 48( 1 Suppl 1): S207-S238. bit. ly / 45WKj3w
• Marx N, et al. 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. European Heart Journal 2023; 44:4043-4140. bit. ly / 42w5UhX
• UK National Institute for Health and Care Excellence— Type 2 diabetes in adults: management bit. ly / 45Tbkx2
• Arnett DK, et al. 2019 ACC / AHA guideline on the primary prevention of cardiovascular disease. Journal of the American College of Cardiology 2019; 74: e177-e232. bit. ly / 47jWV7h
• Nguyen M, et al. Risk treatment thresholds for initiating cardiovascular disease pharmacotherapy: Synthesis of international evidence to support guideline recommendations. Australian Journal of General Practice 2024; 53:( Suppl) December Supplement. bit. ly / 42VYCnS
• Heart Foundation— Clinical guidelines and position statements bit. ly / 3JwsKA5
• Australian CVD Risk Calculator cvdcheck. org. au / calculator
References Available on request from howtotreat @ adg. com. au