European Heart, Diabetes Associations Update CVD, Diabetes Guidelines
AUGUST 31, 2019
Francesco Cosentino, MD, PhD
The first update to the ESC guidelines for the conditions since 2013, the new guidelines update care practices to reflect more recent information on the treatment of diabetes and cardiovascular disease going forward.
With the prevalence of diabetes and cardiovascular disease continuing to plague all corners of the globe, the 69-page guideline — which was created by an international task force comprised of 2 dozen investigators — contains information on an array of topics including healthy lifestyle recommendations, dietary advice, and guidance on choosing when to prescribe therapies such as SGLT2 inhibitors or GLP-1 receptor agonists.
"The emphasis of these guidelines is to provide state of the art information on how to prevent and manage the effects of diabetes on the heart and vasculature, with a focus on new data that has emerged since the 2013 document,” said Francesco Cosentino, MD, PhD, ESC Chairperson of the guidelines Task Force and professor of cardiology at the Karolinska Institute and Karolinska University Hospital in Stockholm.
Contrary to the 2013 guidelines, blood pressure targets are no longer recommended to be lower than 140/85 mmHg for everyone and individualized blood pressure targets are now recommended. .
In regard to lipid targets, new recommendations for patients with type 2 diabetes mellitus (T2DM) at a moderate CV risk is an LDL-C target of less than 2.5 mmol/L. For patients with T2DM at a high CV risk the target LDL-c level is less than 1.8 mmol/L and the target LDL-C level for T2DM patients with a very high CV risk is now less than 1.4 mmol/L.
Guidelines no longer recommended aspirin for primary prevention in diabetes mellitus patients at a low or moderate CV risk. Additionally, moderate alcohol consumption should no longer be promoted as a means to protect against CVD.
Guidelines now recommend self-monitoring of blood pressure and blood glucose for patients with diabetes to achieve better control. Metformin use should be considered in overweight patients with T2DM without CVD and at moderate CV risk — unlike the 2013 guidelines which recommended it as a first-line therapy in patients with DM.
Multiple changes were made pertaining to revascularization, specifically when percutaneous coronary intervention (PCI) should be used as an alternative to coronary artery bypass graft (CABG) — with a notable shift away from PCI and in favor of CABG for many patient groups.
Use of direct oral anticoagulants dabigatran, rivaroxaban, apixaban, or edoxaban for management of arrhythmia in patients. Resting electrocardiogram is now recommend in patients with DM with hypertension or suspected CVD. Lifestyle intervention is recommended to delay and prevent conversion from pre-diabetes mellitus to T2DM.
SGLT2 inhibitors are mentioned multiple times in the updates guidelines, including recommendations for use to prevent development of chronic kidney disease and reducing the risk of heart failure.
"Recent trials have shown the cardiovascular safety and efficacy of SGLT2 inhibitors and GLP-1 receptor agonists for type 2 diabetes. We provide clear recommendations here,” said Peter Grant, MD, EASD Chairperson of the guidelines Task Force and professor of medicine at the University of Leeds.
The “2019 ESC Guidelines on diabetes, pre-diabetes and cardiovascular diseases developed in collaboration with the EASD,” was published online in the European Heart Journal.