ESC Guidelines on Diabetes, Pre-Diabetes, and Cardiovascular Diseases

Cosentino F, Grant PJ, Aboyans V, et al.
2019 ESC Guidelines on Diabetes, Pre-Diabetes, and Cardiovascular Diseases Developed in Collaboration With the EASD: The Task Force for Diabetes, Pre-Diabetes, and Cardiovascular Diseases of the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD). Eur Heart J 2019;Aug 31:[Epub ahead of print].

The following are key points to remember from the 2019 European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases (CVDs):

  1. These guidelines provide information on the current state of the art in how to prevent and manage the effects of diabetes mellitus (DM) on the heart and vasculature.
  2. DM should be investigated using fasting plasma glucose (FPG) or hemoglobin A1c (HbA1c). An oral glucose tolerance test (OGTT) is necessary to diagnose impaired glucose tolerance (IGT). Individuals with established CVD should be screened using HbA1c and/or fasting glucose; an OGTT can be carried out if FPG and HbA1c are inconclusive.
  3. Routine assessment of microalbuminuria should be carried out to identify patients at risk of developing renal dysfunction and/or CVD. A resting electrocardiogram is indicated in patients with DM and hypertension, or if CVD is suspected. Other tests, such as transthoracic echocardiography, coronary artery calcium score, and ankle–brachial index (ABI), may be considered to test for structural heart disease or as risk modifiers in those at moderate or high risk of CVD. Routine assessment of novel biomarkers is not recommended for CV risk stratification.
  4. Lifestyle changes are key to prevent DM and its CV complications. Reduced calorie intake is recommended to lower excessive body weight in patients with DM. A Mediterranean diet supplemented with olive oil and/or nuts reduces the incidence of major CV events. Moderate-to-vigorous physical activity of ≥150 minutes/week is recommended for the prevention and control of DM.
  5. Glucose control to target a near-normal HbA1c (<7.0% or <53 mmol/mol) will decrease microvascular complications in patients with DM. Tighter glucose control initiated early in the course of DM in younger individuals leads to a reduction in CV outcomes over a 20-year timescale. Less-rigorous targets should be considered in elderly patients on a personalized basis and in those with severe comorbidities or advanced CVD.
  6. The blood pressure (BP) goal is to target systolic BP (SBP) to 130 mm Hg in patients with DM and <130 mm Hg if tolerated, but not <120 mm Hg. In older people (aged >65 years), the SBP goal is to a range of 130−139 mm Hg. The diastolic BP (DBP) target is <80 mm Hg, but not <70 mm Hg. Optimal BP control reduces the risk of micro- and macrovascular complications.
  7. Evidence strongly supports the inclusion of an angiotensin-converting enzyme inhibitor (ACEI), or an angiotensin-receptor blocker (ARB) in patients who are intolerant to ACEI. BP control often requires multiple drug therapy with a renin–angiotensin–aldosterone system (RAAS) blocker, and a calcium channel blocker or diuretic. Dual therapy is recommended as first-line treatment. The combination of an ACEI and an ARB is not recommended. In pre-DM, the risk of new-onset DM is lower with RAAS blockers than with beta-blockers or diuretics. Patients with DM on combined antihypertensive treatments should be encouraged to self-monitor BP.
  8. Statins effectively prevent CV events and reduce CV mortality, and their use is associated with a limited number of adverse events. Because of the high-risk profile of patients with DM, intensive statin treatment should be used on an individualized basis. Currently, statins remain state-of-the-art therapy in lipid-lowering treatment in patients with DM. Ezetimibe or a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor on top of a statin—or alone, in case of documented intolerance to statins—further contribute to low-density lipoprotein cholesterol reduction in patients with DM, thus improving CV outcomes and reducing CV mortality.
  9. Patients with DM and symptomatic CVD should be treated no differently than patients without DM. In patients with DM at moderate CV risk, aspirin for primary prevention is not recommended. In patients with DM at high/very high risk, aspirin may be considered in primary prevention.
  10. Combined reduction in HbA1c, SBP, and lipids decreases CV events by 75%, but multifactorial treatment is still underused.
  11. Type 2 DM and pre-DM are common in individuals with acute coronary syndrome and chronic coronary syndromes, and are associated with an impaired prognosis. Glycemic status should be systematically evaluated in all patients with coronary artery disease (CAD). Intensive glycemic control may have more favorable CV effects when initiated early in the course of DM.
  12. Empagliflozin, canagliflozin, and dapagliflozin reduce CV events in patients with DM and CVD, or in those who are at very high/high CV risk. Similarly, liraglutide, semaglutide, and dulaglutide reduce CV events in patients with DM and CVD, or who are at very high/high CV risk.
  13. Intensive secondary prevention is indicated in patients with DM and CAD. Antiplatelet drugs are the cornerstone of secondary CV prevention. In high-risk patients, the combination of low-dose rivaroxaban and aspirin may be beneficial for CAD. Aspirin plus reduced-dose ticagrelor may be considered for ≤3 years post-myocardial infarction.
  14. In patients with DM and multivessel CAD, suitable coronary anatomy for revascularization, and low predicted surgical mortality, coronary artery bypass grafting is superior to percutaneous coronary intervention.
  15. The coexistence of DM and heart failure (HF) imparts a higher risk of HF hospitalization, all-cause death, and CV death. Guideline-based medical and device therapies are equally effective in patients with and without DM; as renal dysfunction and hyperkalemia are more prevalent in patients with DM, dose adjustments of some HF drugs (e.g., RAAS blockers) are advised. First-line treatment of DM in HF should include metformin and SGLT2 inhibitors; conversely, saxagliptin, pioglitazone, and rosiglitazone are not recommended for patients with DM and HF.
  16. Patients with DM are at higher risk of chronic limb-threatening ischemia as the first clinical manifestation of lower extremity artery disease (LEAD), supporting regular screening with ABI measurement for early diagnosis. The management of, and indications for, different treatment strategies are similar in patients with LEAD with or without DM, although the options for revascularization may be poorer because of diffuse and distal lesions. The management of carotid artery disease is similar in DM and non-DM patients.
  17. Group-based structured education programs improve disease knowledge, glycemic control, disease management, and empowerment in patients with DM.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and Imaging, Echocardiography/Ultrasound, Diet, Exercise, Hypertension

Keywords: Angiotensin-Converting Enzyme Inhibitors, Aspirin, Blood Pressure, Cardiovascular Diseases, Coronary Artery Bypass, Diabetes Mellitus, Type 2, Diet, Electrocardiography, Echocardiography, Exercise, Glucose Intolerance, Heart Failure, Hypertension, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Lipids, Metabolic Syndrome X, Myocardial Ischemia, Prediabetic State, Primary Prevention, Risk Factors, Secondary Prevention

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