Diabetic cardiovascular disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 17 Aug 2025

Last updated: 06 Mar 2025

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes.

People with diabetes have up to a fourfold increased risk of stroke and are twice as likely to die after myocardial infarction than people without diabetes.

Regular physical activity, medical nutrition therapy, and smoking cessation or non-initiation are important lifestyle changes for the primary prevention of CVD.

Selected glucose-lowering drugs reduce all-cause and cardiovascular (CV) mortality. Addition of a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist is strongly recommended in patients with established atherosclerotic CV and/or chronic kidney disease. SGLT2 inhibitors are also indicated in patients with heart failure. Evidence also supports the use of a GLP-1 receptor agonist for primary prevention of stroke in patients at high CV risk.

Aggressive treatment of hypertension, use of lipid-lowering therapy, preventive anticoagulation, and coronary revascularization (percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery during episodes of acute coronary syndrome) can lead to improved survival.

Definition

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia, resulting from defects in insulin secretion, insulin action, or both.[1] The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.[1] Diabetes is an established major risk factor for the development of cardiovascular disease, including coronary artery disease (CAD), cerebrovascular disease (stroke or transient ischemic attack), and peripheral arterial disease.[2] This topic will discuss CAD in greatest detail.

History and exam

Key diagnostic factors

chest pain
dyspnea on exertion
hypotension
rales
S3 gallop
hypertension
nausea
diaphoresis
tachycardia
indigestion

Full details

Other diagnostic factors

unilateral weakness, numbness, and/or tingling
headache
intermittent claudication
bruits
aphasia
hemisensory loss
cranial nerve palsies
seizures
vertigo
limb pain at rest
diminished/absent lower extremity pulses
ulcers or gangrene
peripheral edema
smooth shiny skin with hair loss
pallor

Full details

Risk factors

cigarette smoking
hypertension
dyslipidemia
poor glycemic control
physical inactivity
overweight and obesity
albuminuria
chronic kidney disease (CKD)
elevated C-reactive protein
family history of CVD
female sex
gestational diabetes
mental illness
metabolic dysfunction-associated steatotic liver disease (previously nonalcoholic fatty liver disease)
atrial fibrillation

Full details

Diagnostic tests

1st tests to order

HbA1c
lipid profile

Full details

Tests to consider

B natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-proBNP)
transthoracic doppler echocardiogram
exercise ECG
exercise (stress) imaging test
pharmacologic (stress) imaging test
cardiac MRI or stress cardiac MRI
ankle-brachial index (ABI)
CT coronary angiography
CT coronary calcium scan
invasive coronary angiography
noncontrast head CT
brain MRI
duplex ultrasonography of carotid arteries
C-reactive protein
chest x-ray

Full details

Treatment algorithm

INITIAL

acute myocardial infarction or unstable angina

ACUTE

highly significant coronary artery disease: without acute myocardial infarction or unstable angina

ONGOING

diabetic cardiovascular disease: stable and/or after intervention

Contributors

Authors

Mohamed Al-Kazaz, MD

Assistant Professor of Medicine (Cardiology)

Section Chief, General Cardiology

Division of Cardiology, Department of Medicine

Northwestern University Feinberg School of Medicine

Bluhm Cardiovascular Institute

Northwestern Memorial Hospital

Chicago

Disclosures

MA is a speaker for Kiniksa Pharmaceuticals in relation to pericarditis/rilonacept.

Acknowledgements

Dr Mohamed Al-Kazaz would like to gratefully acknowledge Dr Alexander Meyer, Dr Laura Davidson, Dr Charles Davidson, and Dr Leonard E. Egede, the previous contributors to this topic, and would like to gratefully acknowledge the review by Dr Shreenidhi Venuraju, MB BS, MRCP, Wellington Hospital South, UK.

Disclosures

AM, LD, CD, and LE declare that they have no competing interests. LEE is an author of a number of references cited in this topic. SV not disclosed.

Peer reviewers

Irfan Moinuddin, MD

Assistant Professor

Chicago Medical School

Rosalind Franklin University

Lombard

Disclosures

IM declares that he has no competing interests.

David Leehey, MD

Medical Director

Hines VA Hospital

Hines

Disclosures

DL declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Marx N, Federici M, Schütt K, et al. 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023 Oct 14;44(39):4043-140.Full text Abstract

American Diabetes Association. Standards of care in diabetes - 2024. Diabetes Care 2024 Jan 1;47(suppl 1):S1-321.Full text

Joseph JJ, Deedwania P, Acharya T, et al. Comprehensive management of cardiovascular risk factors for adults with type 2 diabetes: a scientific statement from the American Heart Association. Circulation. 2022 Mar;145(9):e722-59.Full text Abstract

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-248.Full text Abstract

Writing Committee Members; Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. J Am Coll Cardiol. 2022 Jan 18;79(2):e21-129.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Unstable angina
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI)
More Differentials
Guidelines
- 2024 guideline for the primary prevention of stroke
- Newer pharmacological treatments in adults with type 2 diabetes
More Guidelines
Patient information
Diabetes type 2: should I take insulin?
Diabetes type 2: what treatments work?
More Patient information
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Diabetic cardiovascular disease

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

acute myocardial infarction or unstable angina

highly significant coronary artery disease: without acute myocardial infarction or unstable angina

diabetic cardiovascular disease: stable and/or after intervention

Contributors

Authors

Mohamed Al-Kazaz, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Irfan Moinuddin, MD

Disclosures

David Leehey, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice