Table 1. Suggested treatment prioritization to reduce ASCVD risk in type 2 diabetes.

Author-recommended approach to cardiovascular risk reduction in type 2 diabetes. Recommendations for aggressive blood pressure control and limitation of aspirin to patients with established coronary artery disease do not necessarily agree with guideline recommendations but do reflect the authors’ assessment of the current literature.

	Primary prevention		Secondary prevention (Coronary/carotid diseaseb)
	Moderate ASCVD riska	High ASCVD risk
	Provide or reinforce lifestyle interventions:c diet, exercise, weight loss, and smoking cessation		Continue emphasis on lifestyle interventionsc
Vascular territory
Macrovascular and microvascular	Moderate intensity statin Guidelines recommend BP <140/90 mmHg but consider targeting <120/80 mmHg if tolerated, especially in renal disease or increased stroke risk.e Use caution with multiple agents to avoid hypotension Low dose aspirin or no aspirinf Early glycemic control may reduce later ASCVD riskg	High intensity statin Consider additional lipid lowering therapiesd Guidelines recommend BP <140/90 mmHg but consider targeting <120/80 mmHg if tolerated, especially in renal disease or increased stroke risk.e Use caution with multiple agents to avoid hypotension Low dose aspirin or no aspirinf	High intensity statin Consider additional lipid lowering therapiesd Guidelines recommend BP <140/90 mmHg but consider targeting <120/80 mmHg if tolerated, especially in renal disease or increased stroke risk.e Use caution with multiple agents to avoid hypotension Low dose aspirin
Microvascular	HbA1c ≤ 6.5% if able to achieve with minimal hypoglycemia	HbA1c ≤ 7.0% if able to achieve with minimal hypoglycemia	HbA1c ≤ 7.0% if multiple diabetes drugs are tolerated and polypharmacy does not diminish intensity of CV risk management; HbA1c ≤7.5% if not

^aDiabetes per se confers an increased risk of ASCVD, so the vast majority of diabetes patients without ASCVD fall into the moderate or high ASCVD risk category; treatment should be individualized and a few patients may fall into a lower risk category, but all patients should undergo lifestyle intervention. Special caution should be used in the elderly.

^bCoronary or carotid disease refers to a clinical history of an acute ischemic event (acute coronary syndrome or ischemic stroke) or coronary revascularization.

^cRandomized trials of lifestyle interventions of diet, exercise and weight loss in diabetes have not shown a reduction in CV events.²⁶⁵ However lifestyle modification and weight loss help improve CV risk factors and result in other positive health outcomes.

^dAdditional lipid-lowering therapies could include fibrates in persons with diabetes and elevated triglyceride and low HDL cholesterol levels.

^eThe AHA/ADA Guidelines^132,219 recommend BP <140/90 mmHg but consider targeting <120/80 mmHg if tolerated,²⁵⁸ especially in renal disease or increased stroke risk. Cardiorenal disease includes elevated urine albumin excretion or chronic kidney disease.

^fThe AHA/ADA Guidelines^132,219 recommend low-dose aspirin for those with 10-year CVD risk of ≥10% without increased risk of bleeding as well as those at intermediate risk (10-year CVD risk 5–10%) but the evidence is Level B and C, and data to support this are controversial.

^gA period of good glycemic control (HbA_1c of 7% vs 7.9%) in patients with newly-diagnosed type 2 diabetes led to a reduction in MI and all-cause mortality after 20 years⁴¹

ASCVD = atherosclerotic cardiovascular disease, BP = blood pressure, CV = cardiovascular, CVD = cardiovascular disease, HbA1c = hemoglobin A_1c