Most Patients With T2D Classified as "High Risk" for Fatal Heart Attack, Stroke

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Half of patients with type 2 diabetes (T2D) exhibit very high cardiovascular risk while the majority are at a high risk of fatal heart attack or stroke, according to new research published in the European Journal of Preventive Cardiology.

Half of patients with type 2 diabetes (T2D) exhibit very high cardiovascular (CV) risk while the majority are at a high risk of fatal heart attack or stroke, according to new research published in European Journal of Preventive Cardiology.

In patients with T2D, cardiovascular disease (CVD) is the leading cause of illness and death, while T2D is also a major risk factor for developing heart failure. However, whether the risk of subsequent adverse CV events in those with diabetes equals that of those with previous CVD has long been debated, the authors explained.

Based on results from previous studies, CV “risk levels approach coronary artery disease (CAD) risk equivalence in T2D patients after a decade or in those with target organ damage (proteinuria, estimated glomerular filtration rate < 30 mL/min/1.73 m2, left ventricular hypertrophy or retinopathy) or 3 or more CV risk factors,” they wrote.

“These concepts are reflected in recent European guidelines on diabetes, pre-diabetes, and CVD from the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD) and allow the classification of patients with diabetes into 3 categories: very high, high, and moderate CV risk.” Very high risk was defined as above 10%, while high was defined as between 5% and 10%, and moderate was defined as below 5%.


To calculate the likelihood of patients having a fatal heart attack or stroke within 10 years, using these categories, the researchers conducted a retrospective cross-sectional study. Data were gleaned from the Information System for the Development of Research in Primary Care database in Catalonia, Spain. The database includes 74% of the total population in this Mediterranean region.

“In relation to the concept of ‘CAD equivalent’ and applying the recommendations of the latest European guidelines, we hypothesized…most of T2D patients might be at very high CV risk analyzing a large population in a region of a low-risk European country,” the researchers wrote.

The study population comprised patients aged 18 or older with a diagnosis of T2D (n = 373,185), their mean (SD) age was 70.1 (12.3) years, and around 45% were female. The researchers applied specific International Classification of Diseases, 10th Revision, codes to identify those with previous CVD or target organ damage. CVD classification included coronary heart disease, stroke, peripheral arteriopathy, and heart failure.

Of those who exhibited CV risk factors, 72% had hypertension, 45% had obesity, 60% had dyslipidemia, and 14% were current smokers.

Analyses revealed:

  • Most patients with T2D (53.4%; 95% CI, 53.1% -53.6%) were at very high risk of fatal CV events
  • 55.6% of men (95% CI, 55.3%-55.9%) were at very high risk of fatal CV events compared with 50.7% of women (95% CI, 50.3%-51.0%)
  • Globally, 50% of those with very high risk did not show prior established CVD
  • In women with T2D at very high risk, a greater proportion of them did not show established CVD (55.9%)
  • Approximately 1 in 4 patients with T2D showed prior CVD (26.7%; 95% CI, 26.4%-26.9%)
  • Most patients showed high or very high risk of fatal CV events (92.95%; 95% CI, 92.87%-93.04%)
  • Of those T2D patients without established CVD, more than a third (36.4%; 95% CI, 36.1%-36.7%) exhibited very high CV risk and should be considered as ‘CAD equivalent’ patients

“Half of patients in the very high–risk group had no history of heart disease, meaning they would not be receiving medications to prevent heart attacks and strokes," said study author Manel Mata-Cases, MD.

Overall, “These findings in a primary care setting should fuel the implementation of integrated care. Healthy behaviors are the cornerstone of preventing cardiovascular disease and need to be combined with control of blood glucose, serum cholesterol, and blood pressure,” Mata-Cases said. “[General practitioners] and nurses should agree [on] treatment objectives with patients considering their characteristics and preferences."

Small shifts in risk achieved from a population-based primary care strategy can lead to significant reductions in disease burden, authors concluded. Setting goals according to risk levels and prioritizing antidiabetic medications that have been shown to reduce CV events can also aid in CVD prevention in those with T2D.


Cebrián-Cuenca AM, Mata-Cases M, Franch-Nadal J, Mauricio D, Orozco-Beltrán D, Consuegra-Sánchez L. Half of patients with type 2 diabetes mellitus are at very high cardiovascular risk according to the ESC/EASD: data from a large Mediterranean population. Eur J Prev Cardiol. Published online November 13, 2020. doi:10.1093/eurjpc/zwaa073