Cardiovascular disease in diabetes mellitus: beyond atherosclerosis and heart failure

The global burden of diabetes mellitus continues to grow, now affecting one in nine adults. In people with diabetes mellitus, cardiovascular disease is a leading cause of morbidity and mortality, and considerable focus has been placed on reducing the incidence of atherosclerotic cardiovascular disease and heart failure over the past few decades. Due to reductions in the prevalence of some major risk factors, improved control of other risk factors and improved therapeutic agents, mortality attributed to atherosclerotic cardiovascular disease has declined. Meanwhile, the decline in mortality attributed to heart failure has stalled. However, beyond atherosclerotic cardiovascular disease and heart failure, many other cardiovascular diseases are responsible for morbidity and mortality. We provide a comprehensive narrative summary of the association between diabetes mellitus and the most common cardiovascular diseases as reported by the 2023 Global Burden of Disease study. The evidence indicates that diabetes mellitus is a risk factor for atrial fibrillation, infective endocarditis, hypertensive heart disease, intracerebral haemorrhage and aortic stenosis. We also discuss the available evidence for the effects of incretin hormone mimetics, such as glucagon-like peptide 1 receptor agonists, and of sodium/glucose cotransporter 2 inhibitors for each of these cardiovascular diseases. This Review underscores the multifaceted link between cardiovascular disease and diabetes mellitus, highlighting that integrated strategies are required to effectively reduce the global burden of both conditions.