Moving from the stratification of primary and secondary prevention of cardiovascular risk in diabetes towards a continuum of risk: need for a new paradigm

Traditionally, patients with type 2 diabetes have been stratified according to cardiovascular (CV) risk to requiring either primary prevention (those without atherosclerotic CV disease) or secondary prevention (those with atherosclerotic CV disease in any of the vascular beds). However, this classification is misleading and arbitrary, as not all patients requiring secondary prevention have the same risk for such events, which also holds true for those requiring primary prevention (i.e. CV risk ranges from moderate to very high). In addition, in some cases, the definitions of primary and secondary prevention do not rely on symptoms but rather on the results of supplementary tests. Furthermore, patients with type 2 diabetes may also develop heart failure or chronic kidney disease. Importantly, reducing CV risk stratification to primary and secondary prevention does not provide a comprehensive approach for the management of patients with diabetes, leading to an underuse of drugs with proven CV benefit regardless of the presence of atherosclerotic CV disease. Therefore, patients with diabetes should be treated according to their CV risk considered as a continuum and not simply as falling within primary or secondary prevention.