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European diabetes and cardiovascular guidelines

By Editor
1st September 2019
Cardiovascular disease, Clinical guidance Type 1 diabetes Type 2 diabetes Type 2 prevention

The European Society of Cardiology has published new guidelines covering diabetes, people at high risk of type 2 diabetes and cardiovascular diseases.

Developed in collaboration with the European Association for the Study of Diabetes (EASD), they were published online on Saturday, August 31, by the European Heart Journal.

Professor Francesco Cosentino, Chairperson of the guidelines Task Force for the European Society of Cardiology (ESC) 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.”

Professor Peter J. Grant, EASD Chairperson of the guidelines Task Force and Professor of Medicine at the University of Leeds, 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 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. Professor Francesco Cosentino

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, largely type 2 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.

The document stated: “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.”

According to the ESC, 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, it said. Physical activity, for example, delays conversion, improves glycaemic control and reduces cardiovascular complications, the ESC said.

Alcohol intake

The document states that moderate alcohol intake should not be promoted as a means to protect against cardiovascular disease. Professor Grant said: “There has been a long-standing view that moderate alcohol intake has beneficial effects on the prevalence of cardiovascular disease. 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.”

Blood glucose monitoring

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.

Professor Cosentino said: “This indicates that it is no longer appropriate to depend on occasional glucose measures to manage control, particularly in type 1 diabetes. 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 monitoring.”


Statins are not recommended in women with diabetes of childbearing potential and should be used with caution in young people. Professor Grant explained: “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.”

Type 2 diabetes drugs

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 SGLT2 inhibitors, also called gliflozins – showed cardiovascular safety and benefit in patients with diabetes who either already had heart disease and, or, had multiple risk factors.

Professor Cosentino said: “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.”

Preventing blood clots

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 people 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 is recommended.

Lifestyle advice for people with diabetes and pre-diabetes from the guidelines

  • Quit smoking
  • Reduce calorie intake to lower excessive body weight
  • Adopt a Mediterranean diet supplemented with olive oil and/or nuts to lower the risk of cardiovascular events
  • Avoid alcohol
  • Do moderate-to-vigorous physical activity (a combination of aerobic and resistance exercise) at least 150 minutes per week to prevent/control diabetes – unless contraindicated, such as in patients with severe comorbidities or limited life expectancy

To access the guidelines, click here.

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