Type 2 diabetes and obesity: integrated strategies for managing atherosclerotic cardiovascular risk

Abstract Background Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality among individuals with type 2 diabetes (T2D). Despite effective low-density lipoprotein cholesterol (LDL-C) reduction and optimal management of conventional risk factors, individuals with T2D continue to have significant residual ASCVD risk. Elevated lipoprotein(a) [Lp(a)] and triglyceride-rich lipoprotein remnants are increasingly recognised as key drivers of this residual risk. Moreover, the interplay between T2D and obesity accelerates atherosclerosis through multiple interconnected mechanisms. This review highlights the evolving landscape of ASCVD management in individuals with T2D, with and without obesity, focusing on advances in cardiovascular risk prediction, emerging biomarkers, novel pharmacological therapies and non-pharmacological strategies. Main Text Advances in cardiovascular risk prediction have improved risk stratification among individuals with T2D. Diabetes-specific risk models, together with artificial intelligence (AI)-driven approaches, enable the integration of multimodal data beyond traditional risk factors, providing more robust cardiovascular risk assessment. Pharmacological developments have facilitated a shift towards precision-based management through targeting specific atherogenic pathways. Emerging treatments targeting Lp(a), triglyceride regulation, and gene-editing technologies have expanded the therapeutic landscape in ASCVD management. In parallel, organ-protective therapies have transformed the management of T2D and its complications. Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RA)-based therapies have demonstrated significant cardiovascular-kidney benefits, together with clinically meaningful weight reduction, independent of glycaemic control. Beyond pharmacological interventions, effective public health strategies remain essential for reducing cardiovascular burden. Sustained lifestyle modification, environmental interventions, and policy-driven initiatives play important roles in promoting cardiovascular health at both individual and community levels. Conclusions ASCVD prevention in individuals with T2D and obesity is evolving toward a precision-based approach through advanced risk prediction, novel biomarkers, targeted pharmacotherapies, and population-level interventions. These combined strategies are essential to reduce residual cardiovascular risk and improve long-term cardiovascular outcomes.