Cardiovascular prevention in diabetes mellitus. Is it appropriate to speak of moderate or intermediate risk?

Diabetes, especially type 2 (DM2), is considered a risk situation for atherosclerotic cardiovascular disease (ASCVD). Subjects with DM2 have a mortality rate due to ASCVD three times higher than that found in the general population, attributed to hyperglycemia and the frequent association of other cardiovascular risk factors, such as atherogenic dyslipidemia.

Numerous scientific societies have established a risk classification for ASCVD in diabetes based on 3 degrees (moderate, high and very high). The objectives of dyslipidemia control are clearly defined and accepted, and vary depending on the previously established cardiovascular risk.

In moderate or intermediate risk, the guidelines propose a less aggressive intervention, maintaining LDL-C levels <100 mg/dL and NO-HDL-C levels <130 mg/dL, and waiting 10 years until reaching the high-risk category to initiate more aggressive treatment. However, during the decade of follow-up recommended in the guidelines, cholesterol deposition in the arterial wall increases, facilitating the development of an unstable and inflammatory atheromatous plaque, and the development of ASCVD. Alternatively, diabetes could be considered from the outset to be a high-risk situation and the goal should be LDL-C <70 mg/dL. Furthermore, maintaining LDL-C levels <70 mg/dL contributes to reducing and stabilizing atheromatous plaque, avoiding or reducing mortality episodes due to ASCVD during those years of diabetes evolution.

Should we maintain the proposed objectives in subjects with diabetes and moderate risk for a decade until reaching the high cardiovascular risk phase or, on the contrary, should we adopt a more aggressive stance from the beginning seeking to reduce cardiovascular risk in the majority of patients with diabetes? Is it better to wait or prevent with effective therapeutic measures from the first moment?