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Highb Moderateb Established ASCVD or severe TODa Patients with type 2 diabetes mellitus AND Stop smoking and lifestyle recommendations (Class I) HbA1c: <53 mmol/mol (<7.0%) (Class I) STEP 1 Risk Residual 10-year CVD risk Lifetime CVD risk and treatment benefitd Comorbidities, frailty Patient preferences Intensified treatment based on: SBP <130 mmHg if tolerated (Class I) SGLT2-i or GLP-1RA if not already on itc (Class I) LDL-C <1.4 mmol/L (<55 mg/dL) (Class I) DAPT, DPI, novel upcoming interventions (e.g. colchicine, EPA) (Class IIb) 10-year CVD risk Lifetime CVD risk and treatment benefitd Comorbidities, frailty Patient preferences Intensified treatment based on: SBP <130 mmHg if tolerated (Class I) SGLT2-i or GLP-1RA if not already on it (Class IIb) LDL-C <1.8 mmol/L (<70 mg/dL) (Class I) SBP <140 to 130 mmHg if tolerated (Class I) LDL-C ≥50% reduction and <1.8 mmol/L (<70 mg/dL) (Class I) Antithrombotic therapy (Class I) SGLT2-i or GLP-1RA...c ... for TOD: Class IIb ... for CVD: Class I SBP <140 to 130 mmHg if tolerated (Class I) LDL-C <2.6 mmol/ (<100 mg/dL) (Class I) Additional prevention goals generally not recommended (Class III) STEP 2 Without With Figure 8 Flow chart of cardiovascular risk and risk factor treatment in patients with type 2 diabetes mellitus. Ultimate treatment goals for SBP (<130 mmHg) and LDL-C (according to level of risk) according to the respective ESC Guidelines3,4 are to be pursued as indicated. The stepwise approach has to be applied as a whole: after STEP 1, considering proceeding to the intensified goals of STEP 2 is mandatory. Risk scores are available in the ESC CVD Risk Calculator app for mobile devices (https://www.escardio.org/Education/ESC-Prevention-of-CVD-Programme/Risk-assessment/esc-cvd-risk-calculationapp) and at websites such as https://www.u-prevent.com. ACR = albumin-to-creatinine ratio; ASCVD = atherosclerotic cardiovascular disease; CKD = chronic kidney disease; CVD = cardiovascular disease; DAPT = dual antiplatelet therapy; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; ESC = European Society of Cardiology; GLP-1RA = glucagon-like peptide-1 receptor agonist; HbA1c = glycated haemoglobin; HF = heart failure; LDL-C = low-density lipoprotein cholesterol; SBP = systolic blood pressure; SGLT2 = sodium-glucose cotransporter 2; TOD = target organ damage (retinopathy, nephropathy, neuropathy). aSevere TOD is defined as at least one of: eGFR <45 mL/min/1.73 m2 irrespective of the presence or absence of albuminuria; eGFR 4659 mL/min/1.73 m2 and microalbuminuria (ACR 30300 mg/g or 330 mg/mmol); proteinuria (ACR >300 mg/g or >30 mg/mmol); presence of microvascular disease in at least three different sites (e.g. microalbuminuria plus retinopathy plus neuropathy). bSee Table 4 for CVD risk groups. cPatients with prevalent HF or CKD are recommended for SGLT2 inhibitor, and patients post stroke are recommended for GLP-1RA treatment. dLifetime treatment benefit is expressed as extra CVD-free life gained from a certain intervention or treatment intensification. See Box 1. Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026