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New guidelines for the management and prevention of cardiovascular disease (CVD) in patients with diabetes or prediabetes were released this week.  Francesco Cosentino, MD, PhD, Karolinska Institute and Karolinska University Hospital in Stockholm, Sweden, and Peter J. Grant, MD, University of Leeds, United Kingdom, respective European Society of Cardiology (ESC) and European Association for the Study of Diabetes (EASD) co-chairs of the writing task force, presented the guidelines at the ESC Congress 2019. The guidelines were simultaneously published online on August 31 in the European Heart Journal and on the ESC website.

The guidelines are developed by the ESC in collaboration with EASD. They are designed to provide guidance on the management and prevention of CVD in people with or at risk of developing diabetes. The last Guidelines were launched in 2013.

What’s New

Key headlines related to the new Guidelines include advice about sodium-glucose co-transporter-2 (SGLT2) inhibitors based on positive data from cardiovascular outcome trials (CVOTS), thereby removing metformin as best first-line therapy for all. Additionally, CVD risk has been restratified into medium-, high- and very high- versus traditional values of primary prevention and secondary prevention.

Reclassifying CVD risk

The guidelines reclassify patients with diabetes as follows:

  • Medium CVD risk If they are young, lack other CVD risk factors, and have had diabetes for less than 10 years.
  • High CVD risk if they have had diabetes for more than 10 years and have at least one other risk factor, but no target-organ damage.
  • Very high CVD risk if they have CVD or target-organ damage or have had type 1 diabetes for more than 20 years.

Metformin is no longer considered the best first-line strategy.  For drug-naive patients with type 2 diabetes and established CVD and very-high-risk patients, the new guidelines advise prescribing SGLT-2 inhibitors or GLP-1 receptor agonists. This can be added to metformin or initiated alone.

CVD risk

Blood Pressure and Lipids

Optimal BP control reduces the risk of micro- and macrovascular complications, therefore, guidance on lifestyle changes must be provided for people with diabetes and hypertension.

The revised BP goal is to target systolic BP (SBP) to 130 mmHg in patients with diabetes and <130 mmHg if tolerated, but not <120 mmHg. In older people (aged >65 years), the SBP goal is to a range of 130 – 139 mmHg. The diastolic BP (DBP) target is <80 mmHg, but not <70 mmHg.

The guidelines recommend lipid targets as:

  • In patients with T2DM at moderate CVD risk, an LDL-C target of <2.5 mmol/L (<100 mg/dL) is recommended
  • In patients with T2DM at high CVD risk, an LDL-C target of <1.8 mmol/L (<70 mg/dL) is recommended
  • In patients with T2DM at very high CVD risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) is recommended

The guidelines suggest that for people at very high risk, with persistent high LDL-C despite treatment with maximum tolerated statin dose in combination with ezetimibe, or in patients with intolerance to statins, a PCSK9 inhibitor is recommended. Additionally, Statins may be considered in asymptomatic patients with T1DM aged >30 years.

Glucose management and lifestyle modifications can’t be forgotten 

Glucose management and lifestyle modifications cannot be forgotten stress the guideline authors. They advise that people with diabetes should be achieving HBA1c levels below 7% in order to prevent microvascular complications that can damage eyesight, kidney function and nerves. Continuous glucose monitoring (CGM) is suggested to help achieve more optimal results, but individualized targets are key for success.

Lifestyle changes are key to prevent diabetes and its CVD complications. Smoking cessation, reduced calorie intake, moderate to rigorous weekly activity (>150 minutes per week) and a Mediterranean diet should be considered for all patients with diabetes and prediabetes.

Patient-centred care

The guidelines end with a short discussion on the importance of patient-centred care.  There are many challenges associated with sustaining lifestyle changes and meeting therapeutic goals. Almost half of people with diabetes  fail to meet HbA1c, BP and cholesterol targets. However, the guidelines recommend the best approach to deliver educational or self-management interventions is a patient-centred approach to strengthen self-management capabilities for optimal health and longer life.

For more information and to read the entire set of new guidelines, see:  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), European Heart Journal, Published: 31 August 2019.

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