High cardiovascular risk and diabetes: what are the options?

Getting a high cardiovascular risk result while living with diabetes is neither a surprise to dramatize nor a foregone conclusion — it's information that opens up concrete care options, to discuss with a doctor, with multiple, complementary levers for action.

Glycemic control, a direct lever

Better blood sugar control, reflected in a better-managed HbA1c, directly reduces the risk of long-term cardiovascular complications. It isn't the only lever, but it's the one that acts most specifically on the mechanism unique to diabetes — every lasting improvement in blood sugar control translates, over several years, into a measurable reduction in the risk of complications, both cardiovascular and microvascular (eyes, kidneys, nerves).

Some diabetes medications have a proven cardiovascular benefit

Beyond simply controlling blood sugar, certain newer classes of diabetes medication (such as SGLT2 inhibitors or GLP-1 agonists) have shown, in large randomized clinical trials, a cardiovascular benefit of their own — beyond their effect on blood sugar itself. These drugs notably reduce the risk of hospitalization for heart failure and, for some, the risk of major cardiovascular events, through mechanisms that remain only partly understood but that appear to involve direct effects on the heart and blood vessels, independent of blood sugar lowering alone. Current European guidelines suggest favoring these options in cases of high cardiovascular risk in primary prevention, rather than older treatments that are neutral on this front.

Two trials in particular shifted practice. In 2015, the EMPA-REG OUTCOME trial, involving more than 7,000 people with diabetes who already had cardiovascular disease, showed that empagliflozin, an SGLT2 inhibitor, reduced cardiovascular deaths by about 38% and hospitalizations for heart failure by about 35%. In 2016, the LEADER trial showed that liraglutide, a GLP-1 agonist, reduced major cardiovascular events by about 13%. Other drugs in these two families have since confirmed benefits of a similar magnitude. SGLT2 inhibitors also protect the kidneys, and GLP-1 agonists promote significant weight loss.

Like any treatment, they have their own side effects and precautions: genital infections for the former, digestive issues early in treatment for the latter. Their prescription is therefore discussed case by case, taking the person's full profile into account.

Managing other risk factors remains essential

Controlling blood pressure (often with a stricter target for people with diabetes than for the general population), cholesterol (with an LDL target generally lower than for the general population), quitting smoking where applicable, and regular physical activity (at least 150 minutes a week of moderate activity) remain pillars of care, just as much as glycemic control itself. This multifactorial approach reflects a reality already discussed in a previous article on this blog: cardiovascular risk in someone with diabetes rarely results from a single isolated factor, but from a combination of several elements that reinforce each other.

The recommended targets are stricter than for the general population, and they depend on the level of risk. According to European Society of Cardiology guidelines, the target blood pressure is generally below 130/80 mmHg when well tolerated. For “bad” cholesterol (LDL), the goal is usually below 0.70 g/L (about 70 mg/dL) for people with diabetes at high risk, and below 0.55 g/L (about 55 mg/dL) for those at very high risk, for example after a heart attack or with significant kidney impairment. These figures explain why statin treatment is very often prescribed, even when cholesterol appears “normal” on a standard panel. Conversely, aspirin is no longer prescribed systematically in primary prevention: its value is discussed case by case, since the benefit must be weighed against the risk of bleeding.

If you monitor your own blood pressure, the Do I have high blood pressure? tool lets you take a three-day self-measurement following recommended guidelines. For quitting smoking, the Am I addicted to nicotine? test helps assess your level of dependence before talking to a professional.

The role of nephrology follow-up

When kidney impairment is also present (reduced eGFR), specialized nephrology follow-up is usually added alongside diabetes care — kidney function and cardiovascular risk being closely linked in people with diabetes, as discussed in a previous article on this blog. This joint follow-up makes it possible to adjust certain treatments (some medications requiring a dose adjustment based on kidney function) and to monitor how that function changes over time, a factor that directly influences overall cardiovascular prognosis.

The importance of coordination between healthcare professionals

Managing cardiovascular risk in someone with diabetes often involves several healthcare professionals — primary care doctor, endocrinologist, cardiologist, sometimes a nephrologist — whose coordination is essential to avoid fragmented or contradictory approaches. The primary care doctor generally plays a central coordinating role, making sure the various specialist opinions fit together coherently within an overall strategy, rather than treating each aspect in isolation without a comprehensive view.

Taking an active role in your care

Diabetes is managed day to day, largely by the person themselves. That's why patient therapeutic education plays a significant role in the Haute Autorité de santé's recommendations. Offered in hospitals, community health centers, or by patient associations, these programs help people better understand their treatments, learn to read their results, adapt their diet and activity, and recognize signs that call for a doctor's visit. Patient associations, such as the Fédération française des diabétiques, also offer information, support groups, and peer support.

Diet and physical activity, dual-effect levers

A lifestyle change centered on diet and physical activity is particularly valuable for someone with type 2 diabetes: it acts simultaneously on blood sugar control and on cardiovascular risk, through partly shared mechanisms (improved insulin sensitivity, weight loss, improved lipid profile). This dual effect makes it a particularly worthwhile lever in terms of overall benefit, even though its effectiveness depends heavily on the ability to sustain these changes over time — a challenge well documented elsewhere in the behavior-change literature.

The importance of setting realistic, gradual goals

Faced with a high-risk result potentially involving several areas for action (blood sugar control, blood pressure, cholesterol, weight), it can be tempting to want to improve everything at once. Clinical experience shows, however, that a step-by-step approach, prioritizing one or two levers at a time with the help of the primary care doctor, generally produces better lasting results than an attempt at immediate, wholesale transformation — an observation that echoes what is documented for managing cardiovascular risk in the general, non-diabetic population.

What to remember

Managing cardiovascular risk in a person with type 2 diabetes is now comprehensive and personalized: it is no longer limited to blood sugar control alone, but takes the whole cardiovascular risk profile into account to guide increasingly targeted treatment choices. A high-risk result from this tool is, above all, an invitation to this broader discussion with a doctor — not a verdict to face alone — and the options available today are considerably more numerous and better suited than they were just a decade ago.

To get your own estimate, take the “What is my cardiovascular risk with diabetes?” test.