Evidence-Based Cardiovascular Risk Management in Diabetes

Multipronged risk management in diabetes has contributed to the recent decline in cardiovascular mortality. Few antihyperglycemic drugs have been conclusively shown to have cardioprotective effects. These include metformin, liraglutide, semaglutide, dulaglutide, and sodium-glucose cotransporter-2 inhibitors. Statins are the cornerstone of treatment for people with established coronary artery disease (CAD) or at risk of CAD. In patients with persistent low-density lipoprotein cholesterol (LDL-C) levels > 70 mg/dL, the addition of ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors is recommended. In general, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers should be included in the treatment regimen. The goal is to have blood pressure < 140/90 mmHg, whereas a lower goal of < 130/80 mmHg is recommended in patients with CAD or proteinuria (> 1 g/day). Aspirin antiplatelet therapy should be restricted for people with established CAD or those with multiple CAD risk factors. While antiobesity medications have a modest role in managing obesity, bariatric surgery in people with body mass index (BMI) >= 40 or >= 35 with comorbidities can substantially affect quality of life and may reduce cardiovascular risks. Prescribing therapeutic agents should take into consideration a variety of factors, including the patient's preferences and the drug's affordability, side effect profile, and proven cardiovascular benefit.