Synopsis
Integrate vascular risk assessment and evidence-based prevention for adults with diabetes without reducing care to a single score or medicine.
- Separate primary prevention from established cardiovascular disease because risk scoring, antithrombotic treatment and lipid intensity are not interchangeable between those settings.
- Address smoking, blood pressure, atherogenic lipids, albuminuria, glycaemia, weight, physical activity and medicines adherence as one longitudinal plan rather than isolated annual-review boxes.
- Use the current NICE risk-assessment method where it applies, but do not use a calculated score to downgrade people who already have cardiovascular disease or another high-risk condition.
- Offer statin treatment according to the current NICE prevention pathway after discussing benefit, pregnancy potential, adverse effects, interactions and the person’s priorities.
- Choose glucose-lowering treatment with heart failure, atherosclerotic disease and chronic kidney disease in view; cardiorenal benefit may matter independently of the glucose result.
- Do not prescribe aspirin solely because a person has diabetes; antiplatelet treatment follows a documented secondary-prevention or other specific indication.
- Confirm persistent albuminuria and optimise renal and blood-pressure protection while checking creatinine, estimated GFR and potassium after relevant renin–angiotensin system changes.
- Make the plan measurable: record baseline values, treatment targets, safety monitoring, sick-day advice and a named review point for incomplete response or intolerance.
Key red flags
Exertional breathlessness, unexplained falls, epigastric pressure or reduced exercise tolerance may be an anginal equivalent, especially with autonomic neuropathy; investigate symptoms clinically rather than arranging routine screening of every asymptomatic adult.
Orthopnoea, oedema, raised jugular venous pressure, crackles or a displaced apex should trigger diagnostic assessment because heart failure materially changes diabetes-drug selection and prognosis.
Exertional calf pain, rest pain, non-healing wounds, tissue loss or absent pulses require vascular assessment; a threatened limb needs same-day escalation and must not wait for a routine diabetes review.
Investigation priorities
Define secondary-prevention disease, current symptoms and modifiable exposures before calculating risk.
Management branches
An adult with diabetes attends cardiovascular or annual long-term-condition review.
- Search the record and history for coronary, cerebrovascular and peripheral arterial disease, heart failure, chronic kidney disease, albuminuria and previous revascularisation.
- If no established disease is present, use the current NICE primary-prevention framework, including the special recommendations for type 1 diabetes and conditions in which risk may be underestimated.
- Document the category and rationale so subsequent prescribers do not inadvertently substitute score-based primary prevention for a secondary-prevention plan.