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“Since the last ESC Guidelines on diabetes, pre-diabetes and cardiovascular diseases (CVDs) were published in 2013, a tremendous amount of information has been gained from several large cardiovascular outcome trials (CVOTs) of newer glucose-lowering treatments. By digesting all these new data, the 2019 ESC Guidelines, developed in collaboration with the European Association for the Study of Diabetes (EASD),1 aim to provide clarity for physicians,” says Professor Kåre Birkeland (University of Oslo, Oslo, Norway), Guideline Review Coordinator for the EASD.
Initially studied for their glucose-lowering abilities, evidence from CVOTs indicates that certain sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide receptor agonists (GLP-1RAs) can reduce the risk of myocardial infarction, stroke and cardiovascular death in patients with type 2 diabetes who are at high cardiovascular risk. “These data have changed the treatment algorithm for patients with atherosclerotic CVD or high/very high cardiovascular risk and the new guidelines provide recommendations for drug-naïve and metformin-treated patients,” notes Prof. Birkeland. “CVOTs also provide the basis for new recommendations to reduce the risk of hospitalisation for heart failure, which is particularly common in patients with diabetes and heart failure.” Furthermore, SGLT2 inhibitors are now recommended to reduce progression of diabetic kidney disease based on results from a large-scale outcome trial in patients with type 2 diabetes and albuminuric chronic kidney disease.
Other changes to medication recommendations relate to antiplatelet therapy. Aspirin for primary prevention is not recommended in patients with diabetes at moderate cardiovascular risk; however, aspirin (75–100 mg/day) may be considered for primary prevention in patients with diabetes at very high/high risk in the absence of clear contraindications. Non-vitamin K antagonist oral anticoagulants (NOACs) are now preferred over vitamin K antagonists (VKAs) for the management of atrial fibrillation, a common comorbidity in patients with diabetes.
Professor Massimo Francesco Piepoli (Guglielmo da Saliceto Hospital, Piacenza, University of Parma, Italy), ESC Guideline Review Coordinator, is keen to emphasise the central role of lifestyle changes in the new guidelines. “Lifestyle is very important to prevent both the conversion of pre-diabetes to diabetes and also to prevent the cardiovascular complications of diabetes. Excess bodyweight is a risk factor for the development of metabolic disorders, including diabetes, and we know that even modest weight loss can delay CVD progression, in diabetes in particular. Reducing calorie intake to induce weight loss is recommended as it may lead to improvements in glucose levels, lipid levels, blood pressure, quality of life and life expectancy. Smoking cessation should be our first recommendation to all our patients and alcohol consumption should be as low as possible. Other lifestyle guidance includes adoption of a Mediterranean diet supplemented with olive oil and/or nuts to reduce CVD risk, and regular exercise, preferably moderate-to-vigorous physical activity of ≥50 minutes/week, to prevent and control diabetes.”
In the 2019 ESC Guidelines, lifestyle changes are also recommended to manage hypertension. Where antihypertensive medication is needed in pre-diabetes, the guidelines have been changed to reflect that the risk of new-onset diabetes is lower with renin-angiotensin-aldosterone system blockers rather than beta-blockers/diuretics. For patients with pre-diabetes or diabetes, individualised blood pressure targets are now advocated in line with 2018 ESC/European Society of Hypertension Guidelines for the management of arterial hypertension.2Prof. Birkeland concludes, “Because the prevalence of diabetes continues to rise, we want to highlight how easy it is to screen patients with CVD for diabetes—HbA1c and/or fasting glucose can be used. An oral glucose tolerance test is not necessary in the first instance but can be employed if the diagnosis is in doubt. Diabetes remains undiagnosed in many patients—cardiologists have an important role to play in its detection and, subsequently, in the reduction of cardiovascular risk by implementation of these new recommendations.”
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1. 2019 ESC Guidelines on diabetes, pre-diabetes and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2019. doi/10.1093/eurheartj/ehz4862. Williams B, et al. Eur Heart J 2018;39:3021–3104.
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