The European Society of Cardiology (ESC) has
published its Guidelines on diabetes, pre-diabetes and cardiovascular diseases
in European Heart Journal, and on the ESC website. They were developed in
collaboration with the European Association for the Study of Diabetes (EASD).
The guidelines were presented at the Guidelines at ESC Congress 2019 together
with the World Congress of Cardiology currently being held in Paris, France.
Prof Francesco Cosentino, ESC Chairperson
of the guidelines Task Force and professor of cardiology at the Karolinska
Institute and Karolinska University Hospital in Stockholm, Sweden said: “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.”
Prof Peter J. Grant, EASD Chairperson of
the guidelines Task Force and professor of medicine at the University of Leeds,
UK said: “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.”
The global prevalence of diabetes continues
to increase. It is predicted that more than 600 million individuals will
develop type 2 diabetes worldwide by 2045, with around the same number
developing pre-diabetes. Estimates state that diabetes affects 10% of
populations in previously underdeveloped countries such as China and India,
which are now adopting western lifestyles, and 60 million Europeans, of which
half are undiagnosed.
“These figures pose serious questions to
developing economies, where the very individuals who support economic growth
are those most likely to develop type 2 diabetes and to die of premature
cardiovascular disease,” states the document.
Healthy behaviours are the mainstay of
preventing cardiovascular disease. Lifestyle changes are now advised to avoid
or delay the conversion of pre-diabetes states, such as impaired glucose
tolerance, to diabetes. Physical activity, for example, delays conversion,
improves glycaemic control and reduces cardiovascular complications.
The document states that moderate alcohol
intake should not be promoted as a means to protect against cardiovascular
disease. “There has been a long-standing view that moderate alcohol intake has
beneficial effects on the prevalence of cardiovascular disease,” said Prof
Grant. “Two high-profile analyses have reported this is not the case and that
alcohol consumption does not appear to be beneficial. On the basis of these new
findings we changed our recommendations.”
Self-monitoring of blood glucose and blood
pressure is advocated for patients with diabetes to achieve better control.
Data has emerged to implicate glucose variability in the causes of heart
disease in diabetes. In addition, glucose variation at night is particularly
linked with hypoglycaemia and deterioration in quality of life.
“This indicates that it is no longer appropriate
to depend on occasional glucose measures to manage control, particularly in
type 1 diabetes,” said Prof Cosentino. “At the same time, flash technology has
been developed which uses a small sensor worn on the skin to continuously
monitor glucose levels. Similar arguments pertain to home blood pressure
Statins are not recommended in diabetic
women of childbearing potential and should be used with caution in young
people. “We have no experience of the effects of 50 or 60 years of statin use
in an individual and we do not advocate non-essential drugs in pregnancy when
the potential adverse effects on the unborn child are unknown,” explained Prof
Clinical trials on the cardiovascular
safety of medications for type 2 diabetes have led to a paradigm shift in
glucose-lowering treatment. Two groups of diabetes drugs – GLP-1 receptor
agonists and gliflozins – showed cardiovascular safety and benefit in patients
with diabetes who either already had heart disease and/or had multiple risk factors.
“Our main recommendation in the light of
these findings is that GLP-1 receptor agonists and gliflozins should be used as
first line treatment in type 2 diabetes patients with established
cardiovascular disease or at high risk of cardiovascular disease,” said Prof
Drugs that prevent blood clots –
non-vitamin K antagonist oral anticoagulants, specifically rivaroxaban – have
been reported to benefit peripheral vascular disease and should be considered
in combination with aspirin for patients with diabetes who have poor
circulation in the legs.
PCSK9 inhibitors are advised for patients
with diabetes at very high risk of cardiovascular disease who do not achieve
low-density lipoprotein (LDL) cholesterol goals despite treatment with statins.
In these patients, a more ambitious LDL cholesterol target of below 1.4 mmol/L