Written and medically reviewed by: Dr. Manas Parikh, MD (Medicine), DrNB (Cardiology), Interventional Cardiologist, Apollo CVHF Hospital, Ahmedabad
Last reviewed: 7 October 2026 Published: 7 October 2026
Diabetes raises the risk of heart attack, heart failure, stroke and blocked leg arteries, and cardiovascular disease is the leading cause of death in people with diabetes. According to the European Society of Cardiology, people with type 2 diabetes have two to four times the risk of these conditions compared with people without diabetes. Much of this risk can be lowered by treating blood pressure, cholesterol, kidney health and blood sugar together, and by using diabetes medicines with proven heart benefit.
In India, an estimated 101 million adults have diabetes and a further 136 million have prediabetes, according to the national ICMR-INDIAB survey published in 2023.
In brief
- Diabetes damages the inner lining of arteries and speeds up the build-up of cholesterol plaque in the arteries that supply the heart.
- Heart disease in diabetes can be silent. Chest pain may be mild, unusual or absent, and breathlessness or tiredness may be the only sign.
- Every adult with diabetes should have their heart risk factors reviewed at least once a year.
- Stress tests and heart scans are not needed for everyone without symptoms. They are chosen based on symptoms and individual risk.
- Two groups of diabetes medicines, SGLT2 inhibitors and GLP-1 receptor agonists, protect the heart and kidneys in addition to lowering blood sugar.
- When several coronary arteries are severely narrowed in a person with diabetes, bypass surgery often gives better long-term results than angioplasty. The decision is made for each patient individually.
How does diabetes damage the heart and blood vessels?
High blood sugar over months and years injures the endothelium, the thin inner lining of blood vessels. A damaged lining lets cholesterol particles enter the artery wall more easily, where they form plaque. This process, called atherosclerosis, narrows the coronary arteries that supply the heart muscle, as well as arteries to the brain and legs.
Diabetes rarely acts alone. It commonly occurs with high blood pressure, high triglycerides with low HDL cholesterol, excess abdominal fat and kidney disease. Blood also clots more readily in people with diabetes. Each of these adds to the others, which is why controlling blood sugar on its own does not remove the risk.
Diabetes can also affect the heart muscle directly. Over time the muscle can stiffen or weaken, which raises the risk of heart failure even without major artery blockages. Long-standing diabetes can damage the nerves that carry pain signals from the heart (cardiac autonomic neuropathy). This is one reason a heart attack in a person with diabetes may cause little or no chest pain.
Which heart and blood vessel conditions are linked to diabetes?
Diabetes raises the risk of several cardiovascular conditions besides heart attack. The 2023 European Society of Cardiology guidelines list coronary artery disease, heart failure, atrial fibrillation, stroke, and aortic and peripheral artery disease, along with chronic kidney disease, which further raises heart risk.
Kidney and heart health are closely connected in diabetes. The European Society of Cardiology recommends checking kidney function (eGFR) and urine albumin at least once a year in everyone with diabetes.
Who with diabetes is at higher risk?
Heart risk varies widely between people with diabetes. A cardiologist estimates it from the whole clinical picture, not from blood sugar alone. Risk is higher when diabetes occurs with any of the following:- Existing heart disease, a previous stroke or blocked leg arteries
- Kidney disease, including albumin (protein) in the urine
- Diabetes-related damage to the eyes (retinopathy) or nerves (neuropathy)
- Diabetes present for many years
- High blood pressure, high LDL cholesterol or high triglycerides
- Smoking or any tobacco use, including chewing tobacco
- Excess weight, especially around the wais
- Physical inactivity
- A parent, brother or sister who developed heart disease at a young age
- Older age
Type 1 diabetes also raises cardiovascular risk, particularly after many years and when kidney disease develops. Prediabetes is linked with a smaller rise in risk and is an opportunity to act early.
The link works in both directions. The European Society of Cardiology recommends that everyone with known heart or blood vessel disease is tested for diabetes with fasting glucose or HbA1c, because undiagnosed diabetes is common in heart patients and changes treatment choices.
What are the symptoms of heart disease in people with diabetes?
Heart disease in people with diabetes often causes fewer or less typical warning signs. Reduced blood flow to the heart without chest pain is called silent ischaemia. Because nerve damage can dull the pain signal, the first sign may be breathlessness or tiredness rather than chest pain.
Symptoms to report to a doctor include:
- Chest pain, pressure, tightness or burning, at rest or on exertion
- Discomfort in the arm, shoulder, back, neck, jaw or upper abdomen
- Breathlessness on exertion that is new or getting worse
- Unexplained tiredness, or being able to walk a shorter distance than before
- Sweating, nausea or vomiting without a clear cause
- Light-headedness or fainting
- Palpitations
- Ankle swelling, or breathlessness when lying flat
Is it low blood sugar or the heart?
Sweating, shakiness and dizziness can also be caused by low blood sugar (hypoglycaemia). If a glucose meter is at hand, a quick check helps. If symptoms continue after the sugar is corrected, or if there is chest discomfort or breathlessness, treat it as a possible heart problem.
When to get emergency help
Call 108 or go to the nearest hospital emergency department immediately for any of the following:
- Chest discomfort lasting more than a few minutes, or coming and going
- Chest discomfort with sweating, breathlessness or nausea
- Sudden severe breathlessness
- Fainting
- Sudden facial droop, arm weakness or slurred speech
Do not drive yourself. In a heart attack, the sooner the blocked artery is opened, the more heart muscle can be saved.
Which heart tests do people with diabetes need, and when?
Every adult with diabetes needs a review of heart risk factors at least once a year, as recommended by the American Diabetes Association. Further heart tests are chosen according to symptoms and individual risk rather than ordered for everyone.
Should everyone with diabetes have a stress test or heart scan?
How can people with diabetes protect their heart?
Blood pressure
Cholesterol
Blood sugar
Diabetes medicines that also protect the heart
- SGLT2 inhibitors such as empagliflozin and dapagliflozin reduce hospital admissions for heart failure and slow the progression of kidney disease.
- GLP-1 receptor agonists such as liraglutide and semaglutide reduce heart attacks and strokes in people with established cardiovascular disease or high risk, and help with weight loss.
Aspirin
Daily habits
- Stop smoking and all forms of tobacco, including gutka and chewing tobacco.
- Be active on most days. Most adults are advised to build up to at least 150 minutes a week of moderate activity such as brisk walking, spread over at least three days, plus muscle-strengthening exercise twice a week. If you have heart symptoms, get checked before increasing effort.
- Build meals around vegetables, pulses, whole grains and nuts. Limit sweets, refined flour, fried snacks such as farsan, sugary drinks and added salt.
- Lose weight if you are overweight. Even modest weight loss improves blood sugar, blood pressure and cholesterol.
- Limit alcohol.
- Take medicines regularly, and bring your reports and medicine list to every follow-up visit.
How is coronary artery disease treated in people with diabetes?
Why diabetes affects the choice between angioplasty and bypass
In the FREEDOM trial, 1,900 people with diabetes and narrowing in more than one coronary artery were randomly assigned to angioplasty with drug-eluting stents or to bypass surgery. Over five years, bypass surgery led to fewer deaths and heart attacks. It also carried a higher risk of stroke, mostly within 30 days of the operation.The heart team approach
Recovery and follow-up
Recovery after a planned angioplasty is usually quick, and at Apollo CVHF most patients go home the next morning. Bypass surgery involves a longer hospital stay and several weeks of recovery.Diabetes and heart care at Apollo CVHF, Ahmedabad
- Diabetes and heart health assessment by the cardiology team
- Heart health check packages with ECG, echocardiography, treadmill test and, where appropriate, CT coronary angiograph with calcium score
- Coronary angiography and angioplasty, including complex angioplasty with rotablation or intravascular lithotripsy, and intravascular imaging (IVUS or OCT) and FFR where appropriate
- Bypass surgery, including minimally invasive (MICS) bypass
- Heart failure care
- Two catheterisation laboratories available 24 hours a day for heart attack treatment
About the author
Frequently asked questions
Can a person with diabetes have a heart attack without chest pain?
Yes. Long-standing diabetes can damage the nerves that carry pain signals from the heart, so a heart attack may cause only breathlessness, sweating, nausea or unusual tiredness. Any of these, especially if sudden or unexplained, needs urgent medical assessment.
I have diabetes and feel well. Do I need heart tests?
You need a yearly review of blood pressure, cholesterol, kidney function and other risk factors. Stress tests or heart scans are not routinely recommended for people without symptoms whose risk factors are treated, because a large trial showed that screening everyone did not reduce heart attacks. Your cardiologist may still advise tests if you have unusual symptoms, an abnormal ECG or disease in other arteries.
Should I take aspirin every day because I have diabetes?
Only if your doctor advises it. Aspirin is clearly beneficial after a heart attack, stent, bypass or stroke. For people with diabetes and no heart disease, the reduction in heart attacks and strokes is roughly matched by an increase in serious bleeding.
Is bypass surgery better than angioplasty for people with diabetes?
For people with diabetes and severe narrowing in several coronary arteries, bypass surgery has given better long-term survival and fewer heart attacks than angioplasty in randomised trials, with a higher early risk of stroke.
For a single blockage or during a heart attack, angioplasty is usually preferred. The choice depends on the pattern of disease and the person's overall health, and is best made by cardiologists and cardiac surgeons together.
Does diabetes increase the risk of heart failure?
Yes. People with diabetes have two to four times the risk of heart failure, and many are unaware they have it. Breathlessness, ankle swelling and tiredness should be checked with an echocardiogram. SGLT2 inhibitor medicines reduce hospital admissions for heart failure in people with diabetes.
Does prediabetes affect the heart?
Prediabetes is linked with a smaller rise in cardiovascular risk than diabetes. It is also the stage at which weight loss, regular activity and diet changes can delay or prevent diabetes, so it is a good time to have blood pressure and cholesterol checked as well.
Should people with heart disease be tested for diabetes?
Yes. The European Society of Cardiology recommends testing everyone with heart or blood vessel disease for diabetes, using fasting glucose or HbA1c. Finding diabetes changes which medicines are used and, in some cases, which procedure is recommended.
When should a person with diabetes see a cardiologist?
- Chest discomfort, breathlessness or tiredness on exertion, even if mild or unusual
- An abnormal ECG or echocardiogram report
- Kidney disease or albumin in the urine
- A previous stroke, mini-stroke or leg artery disease
- Blood pressure or cholesterol that remains high despite treatment
- A recommendation for angioplasty or bypass surgery, and you want to understand the options
References
- Marx N, Federici M, Schütt K, et al. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023;44(39):4043–4140.
- American Diabetes Association Professional Practice Committee. 110. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1).
- Anjana RM, et al; ICMR–INDIAB Collaborative Study Group. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023;11(7):474–489.
- Young LH, Wackers FJ, Chyun DA, et al. Cardiac outcomes after screening for asymptomatic coronary artery disease in patients with type 2 diabetes: the DIAD study. JAMA. 2009;301(15):1547–1555.
- ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus.. N Engl J Med. 2018;379:1529–1539.
- Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367(25):2375–2384.
