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Increasingly, international guidelines are recommending treatment decisions be based on an individual patient’s overall cardiovascular risk rather than solely targeting particular risk factor levels [27, 28]. There is also a growing focus on tailoring treatment targets, including glycaemic targets, for individuals according to a personalised risk-benefit assessment. Therefore, clinicians need to be equipped with strategies to interpret and apply epidemiological evidence in their provision of care to individual patients. Such strategies should be rigorously investigated in interventional trials. Determining an individual’s absolute risk of cardiovascular disease and knowing at what threshold of risk to intervene and with what therapy are not straightforward. Hence, existing guidelines have varying suggested approaches.

Intensive pharmacological risk factor modification for patients with established cardiovascular disease (i.e., “secondary prevention”) is an accepted standard of care with a robust evidence base. Clinical risk assessment and management for patients with diabetes but without known cardiovascular disease is more complicated, with guidelines suggesting various potential approaches. Essentially, the goal is to translate available evidence into day-to-day clinical care, to maximise benefits to individuals, while minimising treatment-related harm and economic costs. Individual patients and healthcare settings will have unique factors that influence treatment decisions that may not always align with published guidelines. Nevertheless, guidelines provide a valuable framework for standardisation of care.

Figure 6 provides a conceptual overview of different approaches to considering cardiovascular risk in patients with diabetes. One potential approach in primary prevention is to treat specific risk factors in all patients when they are outside of the normal range. For example, to commence an antihypertensive agent if the systolic blood pressure remains above 140 mm Hg or a statin if the LDL level is 3.5 mmol/L (135 mg/dL) or higher.

Fig. 6. Various approaches used to assess the need for pharmacological therapy to modify cardiovascular risk factors in patients with diabetes.

An alternate approach is to determine initiation of pharmacotherapy on the basis of an individual’s overall cardiovascular risk. Some guidelines essentially recommend treating all patients with diabetes as being at high risk. For example, the 2013 European Society of Cardiology and European Association for the Study of Diabetes guidelines consider all patients with type 2 diabetes at “high risk” and recommend statin therapy with a target LDL of <2.5 mmol/L (97 mg/dL) [27]. Patients with type 2 diabetes and an additional risk factor are recommended statin therapy with a target LDL of less than 1.8 mmol/L (80 mg/dL). Similarly, the 2018 American Diabetes Association guidelines recommend moderate intensity statin therapy to all patients with diabetes aged 40 years and above [28].

A more nuanced risk assessment option is to calculate an estimated absolute cardiovascular risk for a patient using a validated risk score and then initiate treatment in patients who score above a specified threshold. For example, the 2014 National Institute for Health and Care Excellence guidelines recommend commencement of statin therapy in patients with type 2 diabetes and a 10% or greater 10-year risk of developing cardiovascular disease on the QRISK2 assessment tool [29].