A person with T2DM dies more often from the heart than from dialysis. This is not a reason to forget the kidney. It is a reason not to treat cardiology as "the next chapter of the textbook".
ADA 2026, Section 10, holds hypertension, lipids, heart and kidney together, because the benefit of SGLT2 inhibitors and GLP-1 agonists overlaps these fields. Recommendation 10.4: if safely attainable, the on-treatment BP target is <130/80 mmHg; a systolic target <120 should be encouraged in people at high cardiovascular or renal risk (level A — the 2026 wording, which sharpened the emphasis on <120 for high risk). The MoH RK 2022 protocol gives age windows: 18–65 years systolic ≥120 and <130, diastolic ≥70 and <80; over 65 years systolic ≥130 and <140. The discrepancy with ADA 2026 regarding the lower bound and the age split must be named: a student in the RK works within protocol No. 158, but must know that the 2026 international standard has shifted to a lower systolic target in high risk.
Starting antihypertensive therapy. ADA 2026 Recommendation 10.6: with confirmed office BP ≥130/80 — pharmacotherapy with titration to the individual target (level A). At ≥150/90 — two drugs straight away, or a fixed-dose combination of classes shown to reduce events in people with diabetes (10.7). First line with albuminuria or CAD — an ACE inhibitor or ARB (10.8).
Lipids. MoH RK 2022 protocol: target low-density lipoprotein (LDL) cholesterol <2.6 mmol/L at moderate risk, <1.8 at high risk, <1.4 or a 50% reduction at very high risk. In Section 10, ADA 2026 stratifies statin intensity by age and the presence of atherosclerotic cardiovascular disease (ASCVD): with established ASCVD — a high-intensity statin aiming for an LDL reduction of ≥50% and an absolute target that in the 2023 abridged version (for comparison of logic) was worded as <55 mg/dL; the exact 2026 numerical targets for each subgroup the student checks against the Table in Section 10 of the primary source, not from memory of previous years. The course does not substitute the outdated "<100 mg/dL for everyone". Recommendation 10.32 of the 2026 edition: do not add a fibrate, niacin or dietary supplements with n-3 fatty acids to a statin for additional cardiovascular risk reduction — they do not provide it.
Heart failure. ADA 2026 separately addresses heart failure with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). An SGLT2 inhibitor is recommended in T2DM and HF of any ejection fraction regardless of HbA1c (9.8, level A). For symptomatic HFpEF plus obesity, the 2026 edition adds a dual GIP/GLP-1 agonist with proven benefit on symptoms and HF events (9.9a) and a GLP-1 agonist with proven benefit on symptoms (9.9b). This is already the pharmacology of Module 4, but the logic of the complication is here: HF is not "late decompensation of a diabetic", but an outcome in its own right that changes the first line on the day it is recognised.
EMPA-REG OUTCOME as the anchor of macrovascular effect. Zinman et al., N Engl J Med. 2015;373:2117–2128. PMID 26378978. Population: 7020 people with T2DM and established cardiovascular disease, median follow-up 3.1 years, empagliflozin 10 or 25 mg vs placebo on top of standard therapy. Primary three-point endpoint (cardiovascular death, non-fatal MI, non-fatal stroke): 10.5% vs 12.1%, HR 0.86 (0.74–0.99). The driver was cardiovascular death, 3.7% vs 5.9% (relative reduction 38%; HR 0.62). Hospitalisation for HF: 2.7% vs 4.1% (35% reduction). All-cause mortality: 5.7% vs 8.3% (32% reduction). There was no significant reduction in MI or stroke individually. The population is not primary care without ASCVD. Transferring "minus 38% cardiovascular death" to a 42-year-old with new T2DM and no ASCVD is a population error.
The conclusion of the module. Small vessels require a calendar and glycaemic control. Large vessels require BP, a statin and classes with organ protection — often on the same day the diagnosis is made, not "when angina appears".