Heart failure (HF) is one of the most frequent and prognostically important cardiovascular complications of type 2 diabetes mellitus (T2DM), and it often develops alongside coronary, cerebrovascular, and peripheral atherosclerosis. Because effective preventive therapy now exists, identifying which patients with diabetes and atherosclerotic disease will develop HF has become a practical clinical priority. This narrative review summarises the epidemiological link between diabetes, atherosclerotic disease, and HF, and critically appraises the main prediction tools: clinical risk scores (WATCH DM and TRS-HFDM), biomarker-based scores using natriuretic peptides and cardiac troponins, and models developed after acute coronary syndrome. Clinical scores achieve moderate discrimination (C-indices of roughly 0.70–0.76) and use routinely available data, whereas adding NT-proBNP and high-sensitivity troponin raises discrimination to 0.84–0.87 for HF hospitalisation. Performance varies with baseline risk, and few models were derived specifically in patients with established atherosclerotic disease. We outline a stepwise approach that combines a clinical score with selective biomarker testing and link risk stratification to preventive therapy with sodium-glucose cotransporter 2 (SGLT2) inhibitors. Key gaps include harmonised outcome definitions, prospective impact studies, and validation in more diverse populations.

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