The 2023 update reflects expanded evidence on glucose-lowering medications, heart failure management, and chronic kidney disease in diabetes:
Key Updates vs. 2019
SGLT2i and GLP-1 RA Class I recommendations: For reduction of CV events in patients with T2DM and ASCVD, independent of glucose control and HbA1c targets
Heart failure emphasis: SGLT2i now recommended for all HF phenotypes (HFrEF, HFmrEF, HFpEF) in patients with T2DM
CKD-specific therapy: Finerenone added as novel non-steroidal MRA for patients with T2DM and CKD
Blood pressure targets: Individualized approach (<130/80 mmHg in most; <120/70 in selected high-risk patients)
Lipid targets by risk: Very high risk: LDL <55 mg/dL; High risk: <70 mg/dL; Moderate: <100 mg/dL
AF screening: Opportunistic screening for asymptomatic AF (pulse palpation, ECG) in patients ≥65 years
Weight reduction: GLP-1 RA or structured exercise programs for weight loss and CV benefit
Cardiovascular Risk Categories in Type 2 Diabetes
Patients with T2DM should be stratified into CV risk groups based on ASCVD/severe target-organ damage (TOD) and 10-year CV risk using SCORE2-Diabetes:
Very High Risk
Clinically established ASCVD or
Severe TOD or
10-year CV risk ≥20% using SCORE2-Diabetes
High Risk
No ASCVD but meets high-risk criteria and
10-year CV risk 10–<20% using SCORE2-Diabetes
Moderate Risk
No ASCVD, no very high-risk criteria and
10-year CV risk 5–<10% using SCORE2-Diabetes
Low Risk
No ASCVD, no very high-risk criteria and
10-year CV risk <5% using SCORE2-Diabetes
Cardiovascular Risk Assessment
SCORE2-Diabetes: 10-Year CV Risk Estimation
1In patients aged ≥40 years with T2DM without ASCVD or severe TOD, estimate 10-year CV risk using SCORE2-Diabetes algorithm. Risk factors integrated: age, smoking, systolic BP, total/HDL cholesterol ratio, diabetes duration, and HbA1c.
Organ Damage Assessment
Evaluate for presence of severe TOD defined as:
eGFR <30 mL/min/1.73 m² (or CKD stage ≥4)
UACR ≥300 mg/g (stage A3 albuminuria)
Proteinuria >300 mg/day or UACR >300 mg/g
Microalbuminuria plus neuropathy: Stage A2 plus ≥2 different sites with microvascular disease
Screening Recommendations
All patients with T2DM should be evaluated for presence of ASCVD and severe TOD
History and clinical examination for symptoms of ASCVD
ECG for asymptomatic ischemia in high-risk patients
Biomarkers (BNP, troponin) in symptomatic or high-risk populations
Glycemic Management for Cardiovascular Benefit
Glycemic Targets
1For reducing CAD in long term, preferably use agents with proven CV benefit (HbA1c <7%)
2aIndividualize HbA1c targets according to comorbidities, duration, and life expectancy (6.5–8.0% in most)
1Avoid hypoglycemia, particularly in patients with CVD
SGLT2 Inhibitors (Proven Class I Recommendation)
1SGLT2 inhibitors with proven CV benefit are recommended in patients with T2DM and ASCVD to reduce CV events, independent of HbA1c and independent of concomitant glucose-lowering medication.
1GLP-1 RAs with proven CV benefit are recommended in patients with T2DM and ASCVD to reduce CV events, independent of HbA1c and independent of concomitant glucose-lowering medication.
Agents with demonstrated CV benefit: liraglutide, semaglutide, dulaglutide, exenatide ER
2aIf additional glucose control is needed, metformin should be considered in patients with T2DM and ASCVD
2bIf additional glucose control is needed, pioglitazone may be considered in patients with T2DM and ASCVD without HF
3DPP-4 inhibitors (sitagliptin, alogliptin, linagliptin) have neutral effect on HF hospitalization; not recommended if HF present
3Saxagliptin and pioglitazone increase HF hospitalization risk; not recommended in patients at risk of HF
Lipid Management in Diabetes
LDL-Cholesterol Targets by CV Risk Category
1Statin-based therapy is recommended for all patients with T2DM at above-target LDL-C levels.
Risk Category
LDL-C Target
Recommended Approach
Very high CV risk
<55 mg/dL (<1.4 mmol/L)
High-intensity statin ± ezetimibe ± PCSK9i
High CV risk
<70 mg/dL (<1.8 mmol/L)
High-intensity statin ± ezetimibe
Moderate CV risk
<100 mg/dL (<2.6 mmol/L)
Moderate-intensity statin
Statin Therapy
1High-intensity statins (rosuvastatin 20–40 mg, atorvastatin 40–80 mg daily) are recommended for LDL-C reduction in patients with T2DM.
Additional Lipid-Lowering Agents
1Ezetimibe 10 mg daily: Add to statin if LDL-C target not achieved with statin monotherapy. Reduces LDL-C by additional 15–20%.
1PCSK9 inhibitors (alirocumab, evolocumab): Recommended in very high CV risk patients with persistently high LDL-C despite maximum tolerated statin + ezetimibe. Reduces LDL-C by additional 50%.
2bInclisiran (PCSK9 antisense): Emerging therapy for LDL-C reduction with potential long-term benefit; dosing every 6 months after loading.
2bBempedoic acid: For patients intolerant to statins; modest LDL-C reduction (~10%).
2bFibrates (fenofibrate, bezafibrate): For elevated triglycerides and low HDL-C despite statin; modest CV benefit; monitor for renal function.
Triglyceride Management
Fasting TG <150 mg/dL optimal; 150–199 high; ≥200 very high
Consider adding aldosterone antagonist (spironolactone) in resistant hypertension with preserved eGFR
Screening and Monitoring
1Regular BP measurements (at every clinic visit and at home/ABPM) recommended to detect and treat hypertension
Home BP monitoring or 24-hour ABPM to rule out masked hypertension and confirm office diagnosis
Antiplatelet Therapy in Diabetes
Primary Prevention (No Prior ASCVD)
2bLow-dose aspirin (75–100 mg o.d.) may be considered in patients with T2DM without symptomatic ASCVD or documented ASCVD to prevent the first major CV event if absence of clear contraindications.
Evidence for primary prevention is limited; decision should be individualized
Secondary Prevention (Prior ASCVD or Revascularization)
1Aspirin at a dose of 75–100 mg o.d. is recommended in patients with T2DM and prior MI or revascularization (CABG or stenting).
Dual antiplatelet therapy (DAPT): Aspirin + P2Y12 inhibitor for 12 months post-ACS or stent implantation
After 12 months, continue aspirin monotherapy indefinitely unless high bleeding risk
Acute Coronary Syndrome (ACS)
1Clopidogrel 75 mg o.d. following appropriate loading dose (600 mg or at least 5 days already on maintenance therapy) is recommended in addition to aspirin for 6 months in patients with ACS in patients with diabetes without indication for long-term oral anticoagulation.
Chronic Coronary Syndrome (CCS)
2bVery low-dose rivaroxaban (2.5 mg b.i.d.) with aspirin may be considered in patients with diabetes with CCS without high bleeding risk.
Heart Failure in Patients with Diabetes
Epidemiology & Diagnosis
Diabetes increases HF risk 2–5-fold. HF prevalence in T2DM patients: ~20% with HFrEF, ~40% with HFpEF. Screening and early diagnosis recommended in symptomatic patients or those at high risk.
SGLT2 Inhibitors: Class I for All HF Phenotypes
1SGLT2 inhibitors (dapagliflozin or empagliflozin) are recommended in all patients with T2DM and HF (HFrEF, HFmrEF, HFpEF) to reduce the risk of HF hospitalization and CV death.
Dapagliflozin 10 mg daily: DAPA-HF trial: 26% reduction in CV death/HF hospitalization in HFrEF
Empagliflozin 10 mg daily: EMPEROR-Reduced and EMPEROR-Preserved: 21–27% reduction in HF hospitalization across EF spectrum
1SGLT2 inhibitors (Class 1) recommended for HF hospitalization reduction across all EF categories in T2DM.
ARNi/ACEi/ARB and beta-blockers use recommended per CCS guidelines
Diuretics for symptom control and congestion relief
Additional Therapies for Selected Populations
2bHydralazine and isosorbide dinitrate should be considered in self-identified Black patients with HFrEF ≤35% or with LVEF <45% combined with structural LV abnormalities and diuretics
2bDigoxin may be considered in symptomatic HFrEF in sinus rhythm despite treatment with ACEi, beta-blocker, and MRA
2bIvabradine should be considered to reduce HF hospitalization and CV death in HFrEF in sinus rhythm with heart rate ≥70 b.p.m., with remain symptomatic despite evidence-based therapy
Device Therapy
1ICD, CRT-P, and CRT-D recommended in patients with T2DM and HFrEF as in general population (per HF guidelines).
Coronary Artery Disease in Diabetes
Chronic Coronary Syndrome
1Myocardial revascularization in CCS is recommended when angina persists despite treatment with anti-anginal drugs or in patients with a documented large area of ischemia (>10% LV).
Revascularization Strategy: CABG vs. PCI
1Similar revascularization techniques are implemented (e.g., use of DES and radial approach for PCI, use of LIMA for CABG) in patients with and without diabetes.
Multivessel disease: CABG preferred over complex PCI; lower surgical risk with newer operative techniques
Single/two-vessel disease: PCI with drug-eluting stents (DES) acceptable; comparable outcomes to CABG
Assessment of CAD complexity: SYNTAX Score for risk stratification; scores >23 favor CABG
Acute Coronary Syndrome (ACS)
1Complete revascularization is recommended in patients with STEMI without cardiogenic shock and with multivessel CAD.
1Myocardial revascularization in CCS is recommended when angina persists despite treatment
2aComplete revascularization should be considered in patients with NSTE-ACS without cardiogenic shock and with multivessel CAD
Glucose-lowering therapy (SGLT2i, GLP-1 RA) continued during hospitalization for improved outcomes
Statins, ACEi/ARBs, beta-blockers, and aspirin per standard ACS guidelines
Arrhythmias: Atrial Fibrillation & Sudden Cardiac Death
Atrial Fibrillation & Diabetes
Diabetes increases AF risk 1.3–2.5 fold. AF and diabetes coexist in >25% of AF patients and >10% of T2DM patients. Elevated AF risk driven by hypertension, obesity, CKD, CAD.
AF Screening
1Opportunistic screening for AF by pulse taking or ECG is recommended in patients ≥65 years of age.
1Opportunistic screening for AF by pulse taking or ECG is recommended in patients with diabetes <65 years of age (particularly when other risk factors are present) because patients with diabetes exhibit a higher AF frequency at a younger age.
Anticoagulation for AF & Diabetes
1Oral anticoagulation is recommended for preventing stroke in patients with AF and with at least one additional (CHA₂DS₂-VASc) risk factor for stroke.
ICD indicated for primary prevention of SCD in HFrEF (LVEF <35%) per standard HF guidelines
Glucose control and avoidance of hypoglycemia important for SCD prevention
Peripheral Arterial Disease in Diabetes
Epidemiology & Screening
Lower-extremity arterial disease (LEAD) affects ~25% of T2DM patients. Includes claudication, critical limb ischemia (CLI), diabetic foot ulcers. Early screening and intervention essential for limb salvage.
Clinical Evaluation & Diagnosis
1In patients with diabetes and symptomatic LEAD, antiplatelet therapy is recommended
1In patients with diabetes and CLI, it is recommended to assess risk of amputation
1Duplex ultrasound is recommended as the first-line imaging method to assess anatomy and haemodynamic status of lower-extremity arteries
Ankle-brachial index (ABI) <0.90 diagnostic of LEAD; <0.40 indicates severe disease
Duplex sonography, CTA, MRA for anatomic assessment and intervention planning
Revascularization & Wound Management
1In patients with diabetes and chronic symptomatic LEAD without high bleeding risk, combination of low-dose rivaroxaban (2.5 mg b.i.d.) and aspirin (100 mg o.d.) should be considered.
1In case of CLTI, revascularization is recommended whenever feasible for limb salvage
1Patient education about foot care, importance of skin inspection, early recognition of foot tissue loss and/or infection, referral to multidisciplinary team is mandatory
1In patients with diabetes and aortic aneurysm, it is recommended to implement the same diagnostic work-up and therapeutic strategies as in patients without diabetes.
Chronic Kidney Disease in Diabetes
CKD Staging & Screening
CKD defined as abnormalities of kidney structure/function for ≥3 months. Staged by eGFR and albuminuria. All patients with T2DM and CKD should be offered screening and management of CV disease.
CV Risk Reduction in CKD
1Intensive LDL-C lowering with statins or statin/ezetimibe combination is recommended.
1A BP target of ≤130/80 mmHg is recommended to reduce CV risk and albuminuria in patients with T2DM and CKD.
SGLT2 Inhibitors: Kidney Protection
1A SGLT2 inhibitor (canagliflozin, empagliflozin, or dapagliflozin) is recommended in patients with T2DM and CKD with an eGFR ≥20 mL/min/1.73 m² to reduce CV and kidney failure risk.
DAPA-CKD trial: Dapagliflozin 10 mg daily reduced composite of CV death, nonfatal MI/stroke, HF hospitalization by 71% in CKD (eGFR 22–90)
EMPA-KIDNEY trial: Empagliflozin 10 mg daily reduced CV death/HF hospitalization by 25% and kidney composite by 39% in CKD stages 3–5
Benefit independent of: Glucose control, baseline eGFR, diabetes status
ACE Inhibitors/ARBs & Finerenone
1ACE-I or ARB is recommended to reduce CV risk in patients with T2DM and eGFR <60 mL/min/1.73 m² or urinary albumin–creatinine ratio >30 mg/g.
1Finerenone is recommended in addition to an ACE-I or ARB in patients with T2DM and eGFR >60 mL/min/1.73 m² with a UACR ≥30 mg/mmol (≥300 mg/g) or eGFR 25–60 mL/min/1.73 m² and UACR ≥3 mg/mmol (≥30 mg/g) to reduce CV events and kidney failure.
FIDELITY-DKD and FIGARO-DKD trials: Finerenone reduced CV death/nonfatal MI/HF hospitalization and kidney composite outcomes
Mechanism: Non-steroidal MRA; blocks aldosterone effects on fibrosis and inflammation
Glycemic & BP Control in CKD
1Personalized HbA1c targets 6.5–8.0% (48–64 mmol/mol) recommended, with a target <7% (<53 mmol/mol) to reduce microvascular complications
Avoid hypoglycemia; use agents with proven benefit (SGLT2i, GLP-1 RA)
Regular monitoring: eGFR, UACR, electrolytes
Key Clinical Messages
DO:
Use SGLT2 inhibitors in ALL patients with T2DM and ASCVD (Class I, independent of HbA1c)
Use GLP-1 RAs in patients with T2DM and ASCVD for MACE reduction (Class I)
Implement SGLT2i for all HF phenotypes (HFrEF, HFmrEF, HFpEF) in T2DM (Class I)
Treat to LDL targets: <55 very high risk, <70 high risk, <100 moderate risk
Target BP <130/80 mmHg in most patients with T2DM (individualize in frail/elderly)
Use ACE-I/ARB as first-line BP management; add CCB or diuretic for dual/triple therapy
Add finerenone to ACE-I/ARB in CKD patients with albuminuria (Class I)
Screen for AF in patients ≥65 years and those <65 with risk factors (Class I)