September 4, 2019
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.
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.