Screening
Cardiovascular (CV) risk factors should be assessed at least annually in people with diabetes.[30] This includes an assessment of:[30]
Diabetes duration
Weight
Blood pressure
Lipids
Smoking status
Family history of premature coronary disease
Presence of albuminuria (indicator of chronic kidney disease [CKD])
One large cohort study found that in those with type 2 diabetes without existing cardiovascular disease (CVD), increased albuminuria levels were associated with higher risk of incident ischaemic stroke, myocardial infarction, and all-cause mortality.[80]
Based on the results of this screening, aggressive medical therapy to reduce CV risk is universally recommended, which may include antihypertensive therapy, lipid-lowering therapy, and, for those with established or high risk of coronary artery disease (CAD), antiplatelet therapy.[30]
The 2013 American College of Cardiology/American Heart Association (AHA) atherosclerotic cardiovascular disease (ASCVD) risk calculator can be used to estimate overall ASCVD risk and the 10-year risk of a first cardiovascular event. AHA/ACC: ASCVD risk calculator Opens in new window The variables included are age, sex, race, blood pressure, total and high-density lipoprotein (HDL) cholesterol, and history of smoking, diabetes, and treatment for hypertension. A European equivalent, known as SCORE2-Diabetes, is recommended by the European Society of Cardiology for use in people aged 40-69 years with type 2 diabetes.[7] In 2023, the AHA launched the Predicting Risk of cardiovascular disease EVENTs™ (PREVENT™) tool - an online calculator which estimates the 10-year and 30-year risk for total CVD (a composite of ASCVD and heart failure [HF]), as well as risks for ASCVD and HF separately, in adults aged 30-79 years without established CVD.[46] AHA: the American Heart Association PREVENT™ online calculator Opens in new window This represents a major evolution from previous tools which primarily focused on ASCVD. PREVENT™ integrates traditional risk factors with a broader range of clinical and social determinants (e.g., obesity, CKD, and social vulnerability), and notably excludes race as a variable.[155] It is intended to support personalised recommendations for lifestyle modification, pharmacological therapies (including sodium-glucose cotransporter-2 inhibitors [SGLT2] and glucagon-like peptide-1 [GLP-1] receptor agonists), and management of blood pressure and lipids.[155]
Screening for CAD
While screening for CVD risk factors is important, the benefits of screening asymptomatic people with diabetes for CAD remain unclear, and as such it is not recommended by the American Diabetes Association (ADA).[30] One meta-analysis suggested that systematic detection of silent ischaemia in high-risk asymptomatic people with diabetes is unlikely to provide any major benefit to clinically important outcomes compared with optimised medical management of CV risk factors alone.[156] Another meta-analysis found that routine screening of asymptomatic patients with type 2 diabetes for CAD neither reduced mortality nor reduced a composite of non-fatal myocardial infarction and CV death.[157]
The ADA recommends that investigations for CAD should be considered in the presence of any of the following:[30]
Typical or atypical cardiac symptoms
Abnormal resting ECG (e.g., Q waves)
Signs and symptoms of associated vascular disease, including carotid bruits, transient ischaemic attack, stroke, claudication, or peripheral arterial disease
Screening for heart failure
The ADA recommends that screening for heart failure (HF) with B natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-proBNP) levels should be considered in people with diabetes.[30] If abnormal natriuretic peptide levels are detected, echocardiography is recommended. Identification, risk stratification, and early treatment of risk factors in people with diabetes and asymptomatic stages of HF have been shown to reduce the risk of progression to symptomatic HF.[30]
Screening for peripheral artery disease
The ADA recommends screening for peripheral artery disease (PAD) using ankle-brachial index (ABI) testing in asymptomatic individuals with diabetes who are ≥65 years, and in those with microvascular disease, foot complications, or other diabetes-related end-organ damage, if establishing a PAD diagnosis would alter management..[30] Screening should also be considered in individuals with diabetes of ≥10 years’ duration who are at high cardiovascular risk.[30]
Joint American Heart Association and American College of Cardiology guidelines recommend ABI testing in asymptomatic patients with diabetes and any of the following characteristics:[29]
Aged ≥50 years
Aged <50 years with one additional risk factor for atherosclerosis
Known atherosclerotic disease in another vascular bed (e.g., coronary, carotid, subclavian, renal, mesenteric artery stenosis, or abdominal aortic aneurysm)
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