The particularities of cardiovascular risk in people with type 2 diabetes

The cardiovascular risk of someone with type 2 diabetes isn't just “one more risk factor” — it has its own distinct characteristics that call for a specific approach to care, different from the one applied to the general population.

Numbers that put the issue in perspective

Diabetes affects a growing share of the population. In France, more than 4 million people are treated for diabetes, type 2 in more than nine cases out of ten. In the United States, the CDC estimates that 38.4 million people live with diabetes, or 11.6% of the population. Worldwide, the International Diabetes Federation's (IDF) 2025 Atlas counts 589 million adults with diabetes, more than four in ten of whom don't know it.

The link with the heart is strong. An analysis of more than a hundred studies covering nearly 700,000 people, published in 2010 in The Lancet (Emerging Risk Factors Collaboration), showed that diabetes roughly doubled the risk of coronary heart disease and stroke, independent of other risk factors. This excess risk is proportionally more pronounced in women, who lose, with diabetes, some of the protection they otherwise have before menopause.

A risk that affects several vascular territories at once

In someone with diabetes, prolonged excess sugar damages both large arteries (risk of heart attack, stroke — known as macrovascular complications) and the smallest blood vessels (eyes, kidneys, nerves — microvascular complications). This simultaneous impact on several territories explains why cardiovascular follow-up for someone with diabetes usually comes together with ophthalmological, kidney, and neurological follow-up — cardiovascular complications and other diabetes complications share a common origin, linked to the harmful impact of chronic high blood sugar on the body's entire vascular network, regardless of vessel size.

A risk that frequently stacks with other factors

Type 2 diabetes is very often combined with other cardiovascular risk factors in the same person: being overweight, high blood pressure, dyslipidemia (cholesterol abnormalities). This frequent combination — sometimes called metabolic syndrome — means that the actual risk for someone with diabetes often exceeds the sum of the risks taken in isolation, which is why an overall calculation integrating the whole profile matters more than assessing each factor separately. This clinical reality justifies the integrated approach SCORE2-Diabetes offers, which doesn't simply add a “diabetes” factor to a calculation otherwise identical to the rest of the population.

Care that is now better personalized

European cardiology guidelines (ESC 2023) have updated the treatment strategy for type 2 diabetes to specifically account for this individualized cardiovascular risk level — the decision to intensify treatment or not (statins, certain diabetes medications with their own proven cardiovascular benefit) now takes the risk score obtained into account, rather than applying the same strategy to everyone with diabetes regardless of their profile. This growing personalization reflects a broader shift in cardiovascular medicine, moving away from one-size-fits-all approaches toward strategies adjusted to each person's actual risk profile.

Treatments that also protect the heart

For a long time, diabetes treatments had one goal only: lowering blood sugar. Over the past decade or so, two families of medication have shown that they also protect the heart and kidneys, beyond their effect on sugar.

SGLT2 inhibitors, or gliflozins, cause glucose to be eliminated through urine. In the EMPA-REG OUTCOME trial, published in 2015 in the New England Journal of Medicine, empagliflozin reduced cardiovascular mortality by 38% in people with diabetes who already had cardiovascular disease. This drug family also reduces hospitalizations for heart failure and slows kidney disease.

GLP-1 analogs, most often given by weekly injection, reduce the risk of heart attack and stroke. In the LEADER trial, published in 2016, liraglutide reduced major cardiovascular events by 13%.

This is why the 2023 guidelines recommend these treatments as a priority for people with diabetes who have high cardiovascular risk or who already have heart or kidney disease, regardless of their HbA1c level. They add to the other measures that remain just as important: statins, blood pressure control, quitting smoking, physical activity. The Danish Steno-2 study showed that acting on all these factors at once cut cardiovascular events roughly in half in high-risk people with diabetes.

What this means in practice

Two people with type 2 diabetes, the same age, can have very different cardiovascular risk levels depending on how long they've had diabetes, their blood sugar control, and their kidney function. This is exactly what SCORE2-Diabetes makes it possible to distinguish, where a uniform approach (“every person with diabetes = the same risk”) would miss this individual variability that is nonetheless decisive for tailoring care. This distinction has concrete implications for treatment choices: two people with the same diagnosis can legitimately receive different recommendations, without this reflecting any inconsistency in care, but rather an adaptation to genuinely different risk profiles.

The role of how long diabetes has been present, an often underestimated factor

Beyond simply having diabetes, how long the disease has been present plays a decisive role in accumulated cardiovascular risk. Someone who has had well-controlled diabetes for 3 years generally has a very different risk profile from someone who has had it for 20 years, even with comparable blood sugar control at the time of assessment — the cumulative exposure of blood vessels to high blood sugar over a longer period leaves traces that don't disappear immediately, even after blood sugar control improves.

The link with weight and sedentary behavior, two factors not to overlook

In someone with type 2 diabetes, being overweight and sedentary behavior aren't just side issues — they are often at the very heart of the mechanism of diabetes itself, with excess abdominal fat in particular promoting the insulin resistance that characterizes this form of diabetes. This is why managing cardiovascular risk in someone with type 2 diabetes almost always comes with recommendations on weight and physical activity, two levers that act both on blood sugar control and directly on cardiovascular risk, through partly independent pathways.

Why a single assessment isn't always enough

Unlike other risk factors that are more stable over time, the cardiovascular risk profile of someone with type 2 diabetes can change relatively quickly — particularly with a notable change in blood sugar control, kidney function, or the appearance of a new associated risk factor. This is why cardiovascular follow-up for someone with diabetes generally isn't limited to a single assessment, but is part of an ongoing cycle of periodic reassessment, coordinated with the overall diabetes care already in place.

A public health issue at the scale of diabetes populations

At the population level, cardiovascular disease remains the leading cause of death in people with type 2 diabetes, which justifies the particular attention given to this dimension in overall diabetes follow-up, alongside the prevention of microvascular complications more traditionally associated with this disease. This priority given to cardiovascular risk in recent guidelines reflects a better understanding of the real scale of this issue, long underestimated compared with eye or kidney complications, which are more clinically visible but statistically less deadly.

Why this integrated approach benefits the whole care pathway

By integrating cardiovascular risk into the overall assessment of someone with diabetes, rather than treating it as a separate question only addressed during specific cardiology appointments, this approach makes for smoother coordination between the different professionals involved in follow-up. The primary care doctor or endocrinologist can thus anticipate certain cardiology follow-up needs right from the risk assessment, rather than waiting for suggestive clinical signs to refer to a specialist — a proactive rather than reactive approach, consistent with the overall prevention philosophy behind every tool offered on this site.

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