An implementation meeting devoted to the European Society of Cardiology (ESC) and European Association of Diabetes (EASD) on diabetes, prediabetes and cardiovascular disease was held at the European Heart House on 29-30 June. This was also the occasion for the launch of the pocket version of these guidelines. Professors Rydén and Standl report back for the ESC Corporate Newsletter.
Diabetes and cardiovascular diseases are two fields of medicine that have tight connections. Diabetes is a major risk factor and cause of cardiovascular disease and many patients with cardiovascular disorders, not the least coronary heart disease, have glucometabolic perturbations although not detected without special attention.
Offer patients a comprehensive management
Type 2 diabetes, about 90% of all diabetes, and its prestates, impaired glucose tolerance, may indeed remain undetected during many years and a first manifestation may be a cardiovascular event that triggers further evaluation including blood glucose. Moreover the prevalence of type 2 diabetes increases rapidly world wide and its importance for cardiovascular diseases will therefore become even more pronounced by time. Although there are European guidelines on cardiovascular disease (issued by ESC) and on diabetes (issued by IDF Europe) and also US guidelines (issued by ACC and AHA and ADA) they represent the opinion of either the cardiology and diabetology professions. New and important is the crossing of the borders between these two specialities. One of the most important messages that can be derived from the new guidelines is how important it is to offer the patients a comprehensive management based on skills and good therapy for both conditions.
Unique as representing leading specialists' opinions from two major professional organisations
The full text version of the guidelines were put on the ESC and EASD web pages in January 2007 and at the same time an executive summary of the this document was published in the European Heart Journal. These guidelines are unique in the sense they represent the opinion of leading specialists appointed jointly by two major professional organisations. Accordingly it was felt important to invite people with an influence on further distribution of knowledge based on the guidelines to a presentation of the contents and a demonstration of the available educational material for activities focused on the complex management of patients with diabetes and prediabetes and cardiovascular disease.
As emphasised already the guidelines were created by a group of experts representing cardiology and diabetology and likewise the implementation meeting welcomed people from both medical professions as well as industrial representation in consideration of the great contributions to postgraduate medical education that is made by industry.
Risk factor management and glucose control far from guidelines' recommendations
A large part of the meeting was devoted to the proper management of patients with diabetes and various cardiovascular disease manifestations. The need for counselled life style advices and strict treatment targets for blood glucose, HbA1c, blood pressure, blood lipids and dietary recommendations were reviewed. The care for diabetic patients with acute coronary syndromes and those in need for revascularisation was discussed and some aspects on health economy and diabetes summarised. The need for further improvement of all day practice in these respects was underlined considering data from the recent European Heart Survey on Diabetes and the Heart. From this survey it is clear that risk factor management and glucose control among European patients with diabetes and cardiovascular disease frequently is far from what the guidelines prescribes. Thus education and other efforts to improve clinical practice are of crucial importance during the nearest time period.
Don't wait for the patient to be struck by disease
An important message at the meeting was the need to underline that the vascular engagement related to glucose perturbations starts at a lower range of blood glucose than that presently defined as diabetes. Glucose should, like cholesterol, be considered as a continuously increasing risk factor starting already at levels presently considered as normal and that post-load (oral glucose tolerance test) values are more predictive than fasting values. Diabetes and prediabetes are painless and remains undetected if not looked for. A majority of patients with gluco-metabolic perturbations are indeed not discovered until the patient is struck by a cardiovascular disease manifestation. Thus screening for elevated glucose (prediabetes) becomes important by prognostic reasons. The methods, as outlined in the guidelines, vary. At a population level simple, web based questionnaires may inform people on their actual risk and alert those in need of an improved life-style to take measure to avoid future development of the disease. Persons at a particular high risk, for example those with a strong family history, established cardiovascular disease, adiposity or previous gestational diabetes, should be screened with oral glucose tolerance tests at defined intervals. If a prediabetic state is detected a modest weight reduction in the order of 10% combined with a more physically active life style may prevent or retard the development of established diabetes. An alternative is to use drugs, like metformin or acarbose, if life style advices fail.
How to best disseminate these findings
By the end of the meeting the audience and the faculty members, joined in a discussion on how to further distribute knowledge from the guidelines. A number of activities and measures were emphasised and agreed upon. Suited educational activities should be directed towards the public and patients. More specific information has to reach general practitioners including nurses and specialists in cardiology and diabetology. A successful implementation also necessitates information to decision makers in the medical field. Distribution of knowledge may start with translation of the guidelines to domestic languages and adaptation of the contents to local practice. The responsibility for this should preferably originate from joint efforts of professional organisations for cardiology, diabetology, general practice and nursing. Alerted patient organisations may also contribute. It was also emphasised that a successful implementation of the knowledge necessitates some way of following the impact on all day practice for example via registries.
Clear and simple messages
It was also underlined that the messages should be clear and simple. It was felt that the pocket guidelines, soon available also in an electronic format, and the set of slides produced from the presentations at this meeting on the promotion of the joint ESC, EASD guidelines on Diabetes, Prediabetes and Cardiovascular Diseases may serve in this respect.
Read the Top Ten Recommendations list devised by Professors Rydén and Standl here...