ESC 2023 Updates Guideline for Managing Cardiovascular Disease in Diabetes

The European Society of Cardiology (ESC) released Guidelines for Managing Cardiovascular Disease in Patients with Diabetes, 2023.

The guideline, published in the latest issue (25th August 2023) of the European Heart Journal, replaces the 2019 guideline and includes updated and revised recommendations with significant and paradigm-shifting additional treatment options that benefit Cardiovascular disease patients with diabetes.

The guideline update addresses a new scoring system called SCORE2-Diabetes (T2DM-specific risk score) to estimate the 10-year risk of fatal and nonfatal myocardial infarction and stroke in patients with type 2 diabetes mellitus (T2DM).

It also advises an annual screening for chronic kidney disease among patients with T2DM and an inaugural recommendation to screen these patients for atrial fibrillation at age 65.

Below are the summarised highlights of the revised recommendation from the new guideline-

Level A

• Change in Diet and Nutrition in Patients with Diabetics: Mediterranean or plant-based with high unsaturated fat content diet is recommended to lower cardiovascular (CV) risk in diabetes patients. The current guideline strengthens the level of recommendation to A from B in the previous guideline.
• Atherosclerotic cardiovascular disease risk reduction by glucose-lowering medications: SGLT2(Sodium-glucose cotransporter-2) inhibitors with proven CV benefit are recommended in patients with T2DM and ASCVD (atherosclerotic cardiovascular disease) to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication.GLP-1 RAs (Glucagon-like peptide-1 receptor agonists) with proven CV benefit are recommended in patients with T2DM and ASCVD to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication.
• Antithrombotic Therapy in Patients with Diabetics: The current guideline still recommends the use of proton pump inhibitors (PPIs) while using an antithrombotic therapy combination in diabetes patients to prevent the incidence of gastrointestinal bleeding. It added that PPI should be used considering the bleeding risk of an individual while a single antiplatelet or anticoagulant drug is used.
• Heart Failure and Diabetes: The recommendations for GLP-1 RAs (lixisenatide, liraglutide, semaglutide, exenatide ER, dulaglutide, efpeglenatide) for glucose-lowering treatment in patients with T2DM at risk of or with HF remain unchanged.
• Chronic Kidney Disease and Diabetes: The new guideline recommended using GLP-1 RA in chronic kidney disease patients with diabetes at an eGFR(estimated glomerular filtration rate) >15 mL/min/1.73 m2, displacing the 2019 guideline that advised the use of GLP-1 RA at eGFR >30 mL/min/ 1.73 m2.

Level B

• Multifactorial Approach to Risk Factor Management in Diabetes: The recommendation for the multifactorial approach to managing T2DM with treatment targets remains unchanged.
• Heart Failure and Diabetes: The recommendation level for using basal insulins (glargine and degludec) for glucose-lowering treatment in patients with T2DM at risk of or with HF has been upgraded to B in the new guideline.
• Atrial Fibrillation and Diabetes: The new guideline recommends screening for AF by pulse taking, or ECG is recommended in patients ≥65 years of age.

Level C

• Atherosclerotic cardiovascular disease risk reduction by glucose-lowering medications: In patients with T2DM without ASCVD or severe TOD (target organ damage) but with a calculated 10-year CVD risk ≥10%, treatment with an SGLT2 inhibitor or GLP-1 RA may be considered to reduce CV risk. In patients with T2DM without ASCVD or severe TOD but with a calculated 10-year CVD risk ≥10%, treatment with an SGLT2 inhibitor or GLP-1 RA may be considered to reduce CV risk.

Revised Concept of Guideline 2023: The current guideline defines CV risk categories in T2DM patients based on ASCVD, severe target-organ damage, or the 10-year CVD risk using SCORE2-Diabetes. The current Guidelines give separate recommendations for patients with and without ASCVD/severe target-organ damage based on various meta-analyses, including data from CVOTs with SGLT2 inhibitors and GLP-1 RAs. The update focuses on glucose-lowering medications' proven CV benefits and/or safety. Given the outcome trials in patients with HF (HFrEF, HFmrEF, HFpEF) with and without diabetes, the current guidelines provide recommendations for the treatment of HF in patients with diabetes across the whole spectrum of left ventricular ejection fraction, including the use of glucose-lowering medications, screening and diagnosis of HF in patients with diabetes.

The new guideline introduced the concept of opportunistic screening of AF by pulse taking or ECG (electrocardiogram) in patients with diabetes <65 years of age, given higher AF frequency in diabetics at a younger age. It also introduced the screening, treatment and management of CV risk in patients with chronic kidney disease and diabetes. The current guidelines no longer cover the aspects of prediabetes.

Reference: Nikolaus Marx et al., 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes Developed by the task force on the management of cardiovascular disease in patients with diabetes of the European Society of Cardiology (ESC), European Heart Journal (2023) 00, 1–98 https://doi.org/10.1093/eurheartj/ehad192