Why a dedicated cardiovascular risk score for diabetes?

The standard cardiovascular risk calculation (SCORE2) deliberately does not apply to people with diabetes — not by oversight, but because their risk profile follows a different logic, one that requires a dedicated tool, developed and validated specifically for this population.

Why diabetes changes the picture

A person with type 2 diabetes, with the same classic risk factors otherwise (age, blood pressure, cholesterol, smoking), already carries a cardiovascular risk 2 to 4 times higher than someone without diabetes. Diabetes isn't just “one more risk factor” to fold into the general equation — it is a factor that fundamentally changes how the other factors interact with each other, through biological mechanisms specific to chronically elevated blood sugar. This is why the European Society of Cardiology developed a dedicated model, SCORE2-Diabetes, rather than simply adding a “diabetes yes/no” box to the standard calculation, which would have underestimated the real scale of risk for this population.

The story of a gap identified, then filled

For a long time, cardiovascular risk assessment in people with diabetes relied on an unsatisfying approximation: either applying the standard model with a simple adjustment, or automatically classifying everyone into a high-risk category with no fine distinction between profiles. This approach, while useful as a first approximation, couldn't distinguish someone recently diagnosed with diabetes, with good blood sugar control and normal kidney function, from someone who has had diabetes for twenty years with early complications — two profiles with very different risk levels, yet which could have been classified identically under too generic an approach. The development of SCORE2-Diabetes, published in 2023, addresses precisely this need for finer distinction.

What sets SCORE2-Diabetes apart from the general calculation

In addition to the usual variables (age, sex, blood pressure, cholesterol, smoking), SCORE2-Diabetes includes three elements specific to diabetes itself:

• Age at diabetes diagnosis — diabetes diagnosed earlier in life has generally had more time to affect the blood vessels, regardless of the person's current age
• HbA1c (glycated hemoglobin) — reflects average blood sugar control over the past 2-3 months, a more reliable marker than a single blood sugar reading, covered in more detail in another article on this blog
• eGFR (estimated glomerular filtration rate) — assesses kidney function, itself closely linked to cardiovascular risk in people with diabetes

A tool reserved for a specific profile

SCORE2-Diabetes is validated specifically for people with type 2 diabetes, aged 40 to 69, without already established cardiovascular disease or severe target-organ damage (advanced kidney, eye, or nerve complications). Outside this precise scope — type 1 diabetes, over 70, or complications already present — the tool does not apply, and a direct assessment with a doctor remains the best option, since these situations are generally already classified as high or very high risk without needing an additional calculation to establish that.

Why this precision matters in practice

A risk calculation poorly matched to a person's actual profile can underestimate or overestimate their true risk level, with direct consequences for care decisions (preventive treatment, closer monitoring). Using the tool validated specifically for the right profile — here, type 2 diabetes — provides a far more reliable estimate than a generic calculation, and allows for a more precise discussion with a healthcare professional about the options actually suited to the individual situation.

A development built on massive datasets

As with SCORE2, the robustness of SCORE2-Diabetes rests on its development using data from a very large number of people with diabetes followed over several years across Europe, making it possible to statistically identify the real weight of each variable in predicting cardiovascular risk. This massive dataset gives the tool a reliability that a simple empirical clinical estimate could never offer, however experienced the practitioner.

A tool designed for regional calibration

Like SCORE2, SCORE2-Diabetes has been calibrated across different European risk zones, with France falling into the low cardiovascular risk zone, like several other Western European countries. This regional calibration reflects real differences in cardiovascular mortality observed between European countries, linked to multiple factors (dietary habits, access to care, historical smoking prevalence). It prevents the same risk profile from being interpreted identically in countries with different epidemiological realities, a refinement that contributes to the tool's overall reliability.

Why seeing a doctor remains essential, even with a reassuring result

It's important to remember that a reassuring result from this tool doesn't remove the need for regular medical follow-up of diabetes itself. SCORE2-Diabetes specifically assesses cardiovascular risk, but the overall follow-up of someone with type 2 diabetes includes other essential dimensions — long-term blood sugar control, screening for eye and kidney complications, foot care — that remain the responsibility of structured medical follow-up, regardless of the result obtained on this cardiovascular dimension alone.

An example to better understand what this specificity adds

Take two fictional people of the same age (55), both with type 2 diabetes, with the same blood pressure and the same smoking status. The first was diagnosed at 45, with poorly controlled HbA1c at 9% and a slightly reduced eGFR. The second was diagnosed only at 53, with well-controlled HbA1c at 6.5% and normal kidney function. A generic calculation that doesn't distinguish between these two profiles would likely classify them at the same risk level, whereas SCORE2-Diabetes, by incorporating these three specific variables, will produce significantly different risk estimates — faithfully reflecting a clinical reality that is itself very different between these two situations.

What this specificity changes for everyday follow-up

Beyond the calculation itself, having a tool suited to one's actual profile also changes the nature of the dialogue with the care team. Someone with diabetes who understands why their cardiovascular risk is assessed differently from that of a relative without diabetes, or of another person with diabetes of a different duration, generally approaches follow-up recommendations with a better understanding of what's at stake — rather than perceiving certain measures (regular kidney panels, HbA1c monitoring) as arbitrary constraints, they can concretely connect them to their role in assessing and reducing their own cardiovascular risk.

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