Section 10:

Cardiovascular Disease and

Risk Management
Atherosclerotic cardiovascular disease (ASCVD), encompassing coronary heart disease, cerebrovascular disease, and peripheral
artery disease (PAD) presumed to be of atherosclerotic origin, is the primary cause of morbidity and mortality in individuals with
diabetes, leading to significant health care costs. Managing multiple risk factors simultaneously can prevent or slow the progression
of ASCVD. Heart failure is another major cause of morbidity and mortality from cardiovascular disease.

Recommendations for the Treatment of Confirmed Hypertension in Nonpregnant People With Diabetes

Initial BP ≥130/80 & <150/90 mmHg Initial BP ≥150/90 mmHg

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Start one agent Lifestyle management Start two agents

Albuminuria or CAD* Albuminuria or CAD*

No Yes No Yes

Start one drug from the Start one drug: Start drug from Start:
following options: • ACEi or ARB 2 of 3 options: • ACEi or ARB
• ACEi or ARB • ACEi or ARB and
• CCB† • CCB† • CCB† or Diuretic‡
• Diuretic‡ • Diuretic‡

Assess BP Control and Adverse Effects

Treatment tolerated Not meeting target Adverse effects

and target achieved

Add agent from complementary drug Consider change to

Continue therapy class: alternative medication:
• ACEi or ARB • ACEi or ARB
• CCB† • CCB†
• Diuretic‡ • Diuretic‡
Not meeting target
on two agents
Adverse effects

Assess BP Control and Adverse Effects

Treatment tolerated Not meeting target or adverse effects

and target achieved using a drug from each of three classes

Consider Addition of Mineralocorticoid Receptor Antagonist;

Continue therapy Refer to Specialist With Expertise in BP Management

*An ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) is suggested to treat hypertension for people with coronary artery disease (CAD) or urine albumin-to-creatinine ratio (UACR)
30–299 mg/g creatinine and strongly recommended for individuals with UACR ≥300 mg/g creatinine. †Dihydropyridine calcium channel blocker (CCB). ‡Thiazide-like diuretic; long-acting
agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. BP, blood pressure. Adapted from de Boer IH, Bangalore S, Benetos A, et al. Diabetes and
hypertension: a position statement by the American Diabetes Association. Diabetes Care 2017;40:1273–1284.

Suggested citation: American Diabetes Association Primary Care Advisory Group. 10. Cardiovascular disease and risk management: Standards of Care in
Diabetes—2024 abridged for primary care professionals. Clin Diabetes 2024;42:209–211 (doi: 10.2337/cd24-a010). ©2024 by the American Diabetes Association.

VOLUME 42, NUMBER 2, SPRING 2024 209

ABRIDGED STANDARDS OF CARE 2024 Section 10: Cardiovascular Disease and Risk Management

Screening for Asymptomatic Cardiovascular Disease (CVD)

Peripheral Artery
Coronary Artery Disease Heart Failure (HF)
Disease (PAD)

Screen individuals with

Routine screening is
not recommended for
asymptomatic individuals.
Who to Screen?
diabetes and age ≥50 years,
Screen all adults with
any microvascular disease,
diabetes, which increases
foot complications, or end-
risks for asymptomatic (stage
stage organ damage from
B) and symptomatic (stage
diabetes. Consider screening
C) HF.
anyone with a diabetes
duration ≥10 years.

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If atypical cardiac symptoms,
Measure B-type natriuretic
signs or symptoms of
peptide (BNP) or N-terminal
associated vascular disease, Screen with ankle-brachial
pro-BNP. Echocardiography
or electrocardiogram index testing.
is recommended for those
abnormalities are present,
with abnormal BNP levels.
screen using routine methods.

Treatment of Stage B HF in People With Diabetes

To reduce the risk

Treatment with and ACEi or ARB and a
for progression to
β-blocker is recommended.
stage C HF

If high risk for or established CVD If diabetic kidney disease

SGLTi* Finerenone

To reduce the
risk of HF
hospitalization
SGLT2i (canagliflozin, dapagliflozin,or
OR SGLT1/2i (sotagliflozin)*
empagliflozin)*

*People with type 1 diabetes, ketosis-prone type 2 diabetes, or on a ketogenic diet require education on the signs and
symptoms of ketoacidosis, risk management strategies, and ketone monitoring while taking an SGLTi. SGLTi, sodium–glucose
cotransporter inhibitor; drugs in this class include the SGLT2 inhibitors canagliflozin, dapagliflozin, and empagliflozin and the
SGLT1/2 inhibitor sotagliflozin.

210 DIABETESJOURNALS.ORG/CLINICAL
 AMERICAN DIABETES ASSOCIATION

How often should you check lipids? Statin Therapy Potency Chart
• For people with prediabetes or diabetes
not on lipid-lowering therapy, check High-intensity statin therapy Moderate-intensity statin therapy
at diagnosis and at least annually (lowers LDL cholesterol by ≥50%) (lowers LDL cholesterol by 30-49%)
thereafter.
Atorvastatin (40–80 mg) Atorvastatin (10–20 mg)
• Check lipids at initiation of lipid-
Rosuvastatin (20–40 mg) Rosuvastatin (5–10 mg)
lowering therapy, 4–12 weeks after
initiation or dose changes, and annually Simvastatin (20–0 mg)
thereafter.
Pravastatin (40–80 mg)

Lovastatin (40 mg)

Fluvastatin XL (80 mg)

Pitavastatin (1–4 mg)

Once-daily dosing. XL, extended release.

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Lipid Management for Primary Prevention of Atherosclerotic Cardiovascular Disease (ASCVD)
Events in People with Diabetes

Consider statin therapy if

In people 20–39 years
Lifestyle therapy there are additional ASCVD
of age
risk factors.

Use bempedoic acid

Use a moderate-intensity
for those who are statin
statin in those without
intolerant.
ASCVD.
In people 40–75
Lifestyle therapy
years of age
Use a high-intensity statin
It may be reasonable to
in those with ≥1 ASCVD
add ezetimibe or a PCSK9
risk factor, targeting an LDL
inhibitor to maximum
cholesterol <70 mg/dL (<1.8
tolerated statin therapy.
mmol/L).

In people >75
Lifestyle therapy Continue current statin
years of age
therapy or consider initiating
a moderate-intensity stain
after weighing benefits and
risks.

Lipid Management for Secondary Prevention of ASCVD Events in People With Diabetes of All Ages

Use an alternative lipid-lowering treatment for those

Add ezetimibe or a
Use high-intensity statin who are statin intolerant:
PCSK9 inhibitor
therapy to reduce LDL
Lifestyle if LDL cholesterol • PCSK9 inhibitor with monoclonal antibody
cholesterol by ≥50% from
therapy goals are not met on treatment
baseline to a target of <55
maximum tolerated
mg/dL (<1.4 mmol/L). • Bempedoic acid
statin therapy.
• PCSK9 inhibitor with siRNA inclisiran

PCSK9, proprotein convertase subtilisin/kexin type 9.

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