Amsterdam, The Netherlands – Saturday 31 August 2013: HbA1c is used to diagnose diabetes in the new ESC/EASD Guidelines presented today at ESC Congress 2013 by joint Task Force Chairs Professor Lars Rydén (Sweden) of the ESC and Professor Peter J. Grant (UK) of the EASD.
The "2013 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular disease developed in collaboration with EASD," are published today on-line in European Heart Journal1 and on the ESC Website (www.escardio.org/guidelines). They were written jointly by the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD).
Previous ESC/EASD Guidelines on diabetes were published in 2007. The 2013 version introduces glycated haemoglobin (HbA1c) to diagnose diabetes. If HbA1c is elevated the patient is diagnosed with diabetes. If HbA1c is not elevated, patients with cardiovascular disease should receive an oral glucose tolerance test (OGTT). This requires fasting patients to ingest glucose and blood levels are measured before and after 2 hours.
Cardiovascular risk assessment has also been simplified and risk engines are no longer advocated. Patients with diabetes are considered at high cardiovascular risk. Patients with diabetes and cardiovascular disease (myocardial infarction, angina pectoris or peripheral vascular disease) are at very high risk of recurrent cardiovascular disease. Professor Grant said: “Risk engines which accumulate risk factors and produce a low, medium or high risk score are less useful for patients with diabetes.”
Recommendations on revascularization have undergone two major changes since 2007. In patients with stable coronary artery disease and no complex coronary lesions, medical therapy is recommended before interventions. Professor Rydén said: “In former days we were quick to do coronary interventions but based on new trial data we now do not advocate bypass surgery and coronary angioplasty until medical therapy has been tried.”
Also new is the recommendation that patients with several or complex coronary artery stenoses should be offered bypass surgery before percutaneous coronary dilatation. Professor Rydén said: “New trial data clearly shows that morbidity and mortality are inferior with bypass surgery compared to coronary dilatation even with the use of drug eluting stents.”
Targets for blood pressure and glucose are now individualised. The general blood pressure target for diabetics is <140/85mmHg (in 2007 it was 130/80mmHg). In patients who also have kidney disease the target is <130/85mmHg. Control should also be stricter in patients at risk of stroke.
Glycaemic control should be carefully implemented with lower targets in young patients recently diagnosed with diabetes and untouched by cardiovascular disease. Control should be modest in older patients with longstanding diabetes and cardiovascular complications to avoid side effects.
Other changes include the prioritisation of weight stabilisation over reduction and a recommendation against drugs to increase HDL cholesterol. Aspirin is not advocated in patients with diabetes unless they also have cardiovascular disease and in this case novel platelet stabilising drugs may be more effective. A completely new chapter on patient centred care has been included which advocates shared decision making.
The "2013 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular disease developed in collaboration with EASD," are published today on-line in European Heart Journal1 and on the ESC Website (www.escardio.org/guidelines). They were written jointly by the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD).
Previous ESC/EASD Guidelines on diabetes were published in 2007. The 2013 version introduces glycated haemoglobin (HbA1c) to diagnose diabetes. If HbA1c is elevated the patient is diagnosed with diabetes. If HbA1c is not elevated, patients with cardiovascular disease should receive an oral glucose tolerance test (OGTT). This requires fasting patients to ingest glucose and blood levels are measured before and after 2 hours.
Professor Rydén said: “We have simplified diagnosis because many patients may be disclosed with HbA1c, limiting the numbers who need the lengthier test. But a normal HbA1c does not rule out diabetes in high risk patients, who need to have an oral glucose tolerance test.”
Cardiovascular risk assessment has also been simplified and risk engines are no longer advocated. Patients with diabetes are considered at high cardiovascular risk. Patients with diabetes and cardiovascular disease (myocardial infarction, angina pectoris or peripheral vascular disease) are at very high risk of recurrent cardiovascular disease. Professor Grant said: “Risk engines which accumulate risk factors and produce a low, medium or high risk score are less useful for patients with diabetes.”
Recommendations on revascularization have undergone two major changes since 2007. In patients with stable coronary artery disease and no complex coronary lesions, medical therapy is recommended before interventions. Professor Rydén said: “In former days we were quick to do coronary interventions but based on new trial data we now do not advocate bypass surgery and coronary angioplasty until medical therapy has been tried.”
Also new is the recommendation that patients with several or complex coronary artery stenoses should be offered bypass surgery before percutaneous coronary dilatation. Professor Rydén said: “New trial data clearly shows that morbidity and mortality are inferior with bypass surgery compared to coronary dilatation even with the use of drug eluting stents.”
Targets for blood pressure and glucose are now individualised. The general blood pressure target for diabetics is <140/85mmHg (in 2007 it was 130/80mmHg). In patients who also have kidney disease the target is <130/85mmHg. Control should also be stricter in patients at risk of stroke.
Glycaemic control should be carefully implemented with lower targets in young patients recently diagnosed with diabetes and untouched by cardiovascular disease. Control should be modest in older patients with longstanding diabetes and cardiovascular complications to avoid side effects.
Other changes include the prioritisation of weight stabilisation over reduction and a recommendation against drugs to increase HDL cholesterol. Aspirin is not advocated in patients with diabetes unless they also have cardiovascular disease and in this case novel platelet stabilising drugs may be more effective. A completely new chapter on patient centred care has been included which advocates shared decision making.
Professor Grant said: “Diabetes is a complex disease and it is very important that cognitive behavioural strategies are built into the treatment strategy so that the patient is empowered to take care of themselves to a large extent.”
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