Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among people with diabetes mellitus. Individuals with diabetes have a 2–4-fold higher risk of developing cardiovascular disease than the general population, primarily due to accelerated atherosclerosis, endothelial dysfunction, chronic inflammation, hypertension, dyslipidaemia, and other metabolic abnormalities. Cardiovascular complications may involve the coronary, cerebral, and peripheral arterial circulation and often remain asymptomatic until advanced stages. Comprehensive cardiovascular risk assessment and aggressive management of modifiable risk factors are essential components of diabetes care.

Risk Factors

Non-modifiable risk factors

• Increasing age

• Male sex

• Family history of premature cardiovascular disease

• Long duration of diabetes

Modifiable risk factors

• Poor glycaemic control

• Hypertension

• Dyslipidaemia

• Smoking

• Obesity (especially central obesity)

• Physical inactivity

• Chronic kidney disease or albuminuria

• Diabetic nephropathy or retinopathy

Clinical Manifestations

Coronary artery disease

• Angina pectoris (may be silent)

• Acute coronary syndrome

• Myocardial infarction

• Sudden cardiac death

Heart failure

• Shortness of breath

• Orthopnoea

• Peripheral oedema

• Fatigue

Cerebrovascular disease

• Stroke

• Transient ischaemic attack (TIA)

• Vascular dementia

Peripheral arterial disease

• Intermittent claudication

• Cold extremities

• Non-healing foot ulcers

• Gangrene

Investigations

Annual cardiovascular assessment

• Blood pressure measurement

• Lipid profile

• HbA1c

• Renal function tests

• Urine albumin assessment

Additional investigations when indicated

• Electrocardiogram (ECG)

• Chest X-ray (if symptoms or signs of heart failure are present)

• Echocardiography where indicated

• Cardiac biomarkers (e.g., troponin) in suspected acute coronary syndrome

Peripheral vascular disease assessment

• Ankle-brachial index (ABI), where available

• Doppler ultrasound of lower limbs

• Lower limb angiography when clinically indicated

Management

Treatment Goals

• Prevent cardiovascular events

• Reduce cardiovascular mortality

• Achieve optimal glycaemic control

• Control blood pressure and lipid levels

• Reduce overall cardiovascular risk

Non-Pharmacological Management

• Smoking cessation

• Weight reduction for overweight or obese patients

• Regular physical activity (at least 150 minutes of moderate exercise weekly)

• Healthy balanced diet low in saturated fats and refined sugars

• Salt restriction in patients with hypertension

• Optimal glycaemic control

• Regular foot examination and vascular assessment

• Management of other cardiovascular risk factors

Pharmacological Management

Acute Coronary Syndrome (ACS)

All adults with type 2 diabetes mellitus who have experienced a recent acute coronary syndrome or undergone coronary stent placement should receive dual antiplatelet therapy for 12 months, unless contraindicated.

A: Acetylsalicylic acid (Aspirin) 75–100 mg orally once daily

AND

D: Clopidogrel 75 mg orally once daily

Aspirin for Primary Prevention

Low-dose aspirin may be considered for primary prevention in adults with type 2 diabetes aged over 40 years who have one or more major cardiovascular risk factors, including:

• Family history of ischaemic heart disease

• Cigarette smoking

• Obesity

• Proteinuria

• Dyslipidaemia

Contraindications to Aspirin

• Active peptic or duodenal ulcer

• Severe dyspepsia or heartburn

• Malignant (severe uncontrolled) hypertension

• Previous haemorrhagic stroke

Lipid-Lowering Therapy

Statin therapy should be considered for diabetic patients at high cardiovascular risk according to national guidelines.

Examples include:

• Simvastatin

• Atorvastatin

Blood Pressure Control

ACE inhibitors or angiotensin receptor blockers (ARBs) are preferred first-line antihypertensive agents in diabetic patients, particularly those with albuminuria or chronic kidney disease.

Additional antihypertensive agents may be added if blood pressure targets are not achieved.

Monitoring

Patients with diabetes should undergo annual cardiovascular assessment, including:

• Blood pressure measurement

• Lipid profile

• HbA1c

• Renal function assessment

• Urine albumin testing

• ECG when clinically indicated

• Chest X-ray in suspected heart failure

• Doppler ultrasound or angiography for suspected peripheral arterial disease

Prevention

Cardiovascular disease prevention should begin at the time of diabetes diagnosis and include:

• Early detection and treatment of hypertension

• Early management of dyslipidaemia

• Optimal glycaemic control

• Smoking cessation

• Healthy diet and regular physical activity

• Weight management

• Regular cardiovascular risk assessment

• Appropriate use of statins and antiplatelet therapy in eligible patients

• Early detection and management of chronic kidney disease

Prognosis

Good glycaemic control combined with aggressive management of hypertension, dyslipidaemia, and other cardiovascular risk factors substantially reduces the incidence of myocardial infarction, stroke, heart failure, peripheral arterial disease, and cardiovascular mortality. Regular screening and early intervention improve long-term cardiovascular outcomes and quality of life in people living with diabetes.