2023 ESC clinical practice guidelines for the management of cardiovascular disease in patients with diabetes

Newly-updated European Society of Cardiology (ESC) guidelines for the management of cardiovascular disease (CVD) in patients with diabetes were launched by Prof Nikolaus Marx, RWTH Aachen University, Aachen, Germany; and Prof Massimo Federici, University of Rome Tor Vergata, Rome, Italy; Chairs of the guidelines taskforce, during the 2023 ESC Congress.

A key change from the previous 2019 edition is that the 2023 guidelines only focus on CVD and diabetes, and do not consider pre-diabetes due to the lack of clear evidence.

Another important concept modification is the way that cardiovascular (CV) risk should be assessed in patients with diabetes. All patients with diabetes should be evaluated for the presence of CVD and severe target-organ damage, which is defined based on estimated glomerular filtration rate (eGFR), urinary albumin-to-creatinine ratio (UACR), or the presence of microvascular disease in at least three different sites (eg, microalbuminuria plus retinopathy plus neuropathy).

For patients with type 2 diabetes (T2DM), but without atherosclerotic CVD or severe target-organ damage, the new guidelines introduce a novel, dedicated T2DM-specific 10-year CVD risk score – the SCORE2-Diabetes algorithm. SCORE2-Diabetes integrates information on conventional CVD risk factors (ie, age, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol) with diabetes-specific information (ie, age at diabetes diagnosis, HbA1c, and eGFR) to classify patients as low, moderate, high, or very high CV risk. Given the high prevalence of undetected diabetes in patients with CVD, as well as the elevated risk and therapeutic consequences if both comorbidities co-exist, the new guidelines also recommend systematic screening for diabetes in all patients with CVD.

Over the last decade, various large CV outcome trials in patients with diabetes at high CV risk have studied sodium–glucose co-transporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and a non-steroidal mineralocorticoid receptor antagonist, substantially expanding available therapeutic options.

Based on this evidence, the current guidelines provide clear recommendations on how to treat patients with diabetes and clinical manifestations of cardiovascular-renal disease. As such, in patients with diabetes and atherosclerotic CVD, treatment with GLP-1 RAs and/or SGLT2 inhibitors is recommended to reduce CV risk, independent of glucose control and in addition to standard of care, eg, anti-platelet, anti-hypertensive and lipid-lowering therapy.

“Just as the presence of T2DM informs the prescription of other cardioprotective therapies such as statins regardless of glycaemic considerations, the same should now apply to prescribing SGLT2 inhibitors and/or GLP-1 RAs,” said Prof Federici.

A special focus of the new guidelines is on managing heart failure in diabetes, a field that has been underestimated for years.

A systematic survey for heart failure signs and symptoms is recommended at each clinical encounter in all patients with diabetes. Based on data from large trials, it is recommended that patients with diabetes and chronic heart failure, regardless of left ventricular ejection fraction, are treated with an SGLT2 inhibitor to reduce heart failure hospitalisation or CV death.

Opportunistic screening for atrial fibrillation (AF) by pulse taking or ECG now has a Class I recommendation in patients with diabetes aged ≥65 years. Given that patients with diabetes exhibit a higher AF frequency at a younger age, the concept of opportunistic screening for AF by pulse-taking or ECG in patients with diabetes <65 years of age – particularly when other risk factors are associated – is also introduced.

A dedicated section has been included on managing CV risk in patients with CKD and diabetes covering aspects of screening (including regular screening with eGFR and UACR) and treatment. All patients with diabetes should be evaluated for risk and presence of CKD, and where detected, it is recommended to treat with an SGLT2 inhibitor and/or finerenone to reduce CV events and kidney failure risk.

Overall, identifying and treating risk factors and comorbidities early is recommended.