Professor Peter J Grant and Professor Francesco Cosentino highlight the key recommendations from the 2019 ESC/EASD guideline on diabetes, pre-diabetes, and CVD

Photo of Professor Peter Grant

Figure 2: Treatment algorithm for metformin-treated patients with type 2 diabetes mellitus1

Francesco Cosentino, Peter J Grant, Victor Aboyans et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The Task Force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and the European Association for the Study of Diabetes (EASD). European Heart Journal 2019; 00: 1–69. doi:10.1093/eurheartj/ehz486. Reprinted and modified by permission of Oxford University Press on behalf of the European Society of Cardiology. Please visit: www.escardio.org/Guidelines

Coronary artery revascularisation

In general, with more complex disease presentation it is recommended to revascularise patients with diabetes by coronary artery bypass graft (CABG) rather than percutaneous coronary intervention (PCI) if they have stable coronary artery disease (CAD) and suitable anatomy for both procedures. The evidence for the use of CABG in three-vessel CAD and left main CAD is stronger than for the use of PCI except in low complexity left main disease where both CABG and PCI are recommended as equally valid options.1 The same revascularisation techniques, that is, the use of drug-eluting stents and the radial approach for PCI and the use of the left internal mammary artery as the graft for CABG, are recommended in patients with and without diabetes.1

Summary

Diabetes is associated with a two- to three-fold increase in CVD, a figure which increases markedly in patients with young-onset, long-duration diabetes and in the presence of co-morbidities (previous vascular events, CKD, and risk factor clustering).

Clinical studies indicate that simple improvements in glycaemic control reduce the risk of developing microvascular disease (eyes, nerves, and kidneys) but have little beneficial effect on CVD in the medium term.1 The importance of co-morbidities and risk clustering have stimulated the need to manage CV risk factors aggressively to prevent the development of CVD. To aid in this process, a new CV risk stratification is presented to simplify management decisions and to acknowledge the complexity of disease management in diabetes. Unfortunately, there remains strong evidence that despite major advances in our understanding of how to ameliorate CVD in patients with diabetes, most are undermanaged and do not achieve treatment goals.13

All healthcare professionals who manage patients with diabetes should provide them with clear education and appropriate care consonant with each individual’s risk profile. In general, the younger a patient is at diagnosis, the more life years will be lost with poor diabetes management. In this group, aggressive treatment to improve glycaemic control and to achieve other risk targets (BP, lipids, and antiplatelet agents) is important.

In addition, whatever treatment modalities are used (drug therapies, PCI with stents, or CABG), patients with diabetes generally have worse outcomes than those without the disease, a difference referred to as residual risk. The cause of residual risk remains unclear; until the cause is identified it further emphasises the need to treat CV risk factors to target in all patient groups. Bearing in mind the importance of early management, in all individuals who present with vascular events, FPG and HbA1c should be measured to exclude the presence of diabetes and to support appropriate individualised care.

The new guideline has been produced to aid the appropriate management of dyslipidaemia and BP, in both instances by using the new CV risk classification.

Finally, perhaps the major novel recommendations in the management of patients with type 2 diabetes involve the repositioning of metformin, SGLT-2 inhibitors, and GLP-1 receptor agonists. The guideline recommends that metformin should remain first-line therapy in overweight, drug-naïve, newly diagnosed patients with type 2 diabetes without CVD or who are not at high or very high CV risk,1 which the committee thought was in line with the original UKPDS results.12 However, in overweight, drug-naïve, newly diagnosed patients with type 2 diabetes with CVD or who are at high or very high CV risk, either an SGLT-2 inhibitor or a GLP-1 receptor agonist should be used as first-line treatment. The latter recommendations are consistent with the reductions in CV outcomes and amelioration of the renal impairment deterioration reported consistently with both groups of agents.

Professor Peter J Grant

Guideline Chair representing the European Association for the Study of Diabetes; Professor of Medicine, University of Leeds

Professor Francesco Cosentino

Guideline Chair representing the European Society of Cardiology; Professor of Cardiology, Karolinska University Hospital, Stockholm, Sweden

Acknowledgements

Producing these guidelines has been a labour of love over the last 2 years and could not have taken place without the support provided by the members of the Guidelines Task Force and the ESC Guidelines Team led by Veronica Dean.

Key points

  • Measure the HbA1c and FPG to diagnose diabetes
  • CV risk is reclassified as moderate, high, or very high in the 2019 ESC/EASD guideline and forms the basis of patient management
  • Recommendations for individualised BP targets are now provided
  • Lipid targets should relate to level of CV risk
  • Aspirin may be considered for use in patients at high or very high CV risk, but not for those at moderate CV risk
  • NOACs may be used in patients who have AF
  • Dual antiplatelet therapy is recommended for up to 3 years in patients post-ACS
  • Evidence from several CVOTs indicates CV benefits from the use of SGLT-2 inhibitors and GLP-1 RAs in patients with CVD, or at very high/high CV risk
  • SGLT-2 inhibitors and GLP-1 RAs slow decline in renal function in patients with CKD
  • Metformin should be first-line treatment in drug-naïve patients without CVD or high/very high CV risk
  • The choice between CABG and PCI for revascularisation depends on the complexity of the CAD.

ESC=European Society of Cardiology; EASD=European Association for the Study of Diabetes; HbA1c =haemoglobin A1c; FPG=fasting plasma glucose; CV=cardiovascular; BP=blood pressure; NOACs=non-vitamin K antagonist oral anticoagulants; AF=atrial fibrillation; ACS=acute coronary syndromes; CVOTs=cardiovascular outcome trials; SGLT-2=sodium-glucose co-transporter-2; GLP-1 RA=glucagon-like peptide-1 receptor agonist; CVD=cardiovascular disease; CKD=chronic kidney disease; CABG=coronary artery bypass graft; PCI=percutaneous coronary intervention; CAD=coronary artery disease

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Establish a multidisciplinary process to critically analyse these guidelines and compare them to existing NICE guidance
  • Be aware that there are considerable disparities between some of the recommendations in these guidelines and current practice and NICE guidelines
  • Assess the potential impact on both primary care workload and prescribing budgets if these recommendations were to be locally adopted
  • Decide which recommendations are adopted locally and publish these on local formulary websites, with explanations if there are differences from current NICE guidance. 

STP=sustainability and transformation partnership; ICS=integrated care system

References

  1. Cosentino F, Grant P, Aboyans V et al. 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2019; ehz486. Epub ahead of print. Available at: doi.org/10.1093/eurheartj/ehz486
  2. Rydén L, Grant P, Anker S et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: the Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J 2013; 34 (39): 3035–3087.
  3. ASCEND Study Collaborative Group, Bowman L, Mafham M, Wallendszus K et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018; 379 (16): 1529–1539.
  4. Eikelboom J, Connolly S, Bosch J et al for the COMPASS Investigators. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017; 377 (14): 1319–1330.
  5. Nissen S, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 2007; 356 (24): 2457–2471.
  6. Marso S, Daniels G, Brown-Frandsen K et al for the LEADER Steering Committee on behalf of the LEADER Trial Investigators. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016; 375 (4): 311–322.
  7. Marso S, Bain S, Consoli A et al for the SUSTAIN-6 Investigators. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016; 375 (19): 1834–1844.
  8. Zinman B, Wanner C, Lachin J et al for the EMPA-REG OUTCOME Investigators. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015; 373 (22): 2117–2128.
  9. Neal B, Perkovic V, Mahaffey K et al for the CANVAS Program Collaborative Group. Canagliflozin and cardiovascular and renal events in type 2 diabetes. N Engl J Med 2017; 377 (7): 644–657.
  10. Wiviott S, Raz I, Bonaca M et al for the DECLARE-TIMI 58 Investigators. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2019; 380 (4): 347–357.
  11. Perkovic V, Jardine M, Neal B et al for the CREDENCE Trial Investigators. Canagliflozin and renal outcomes in type 2 diabetes and nephropathy. N Engl J Med 2019; 380 (24): 2295–2306.
  12. UK Prospective Diabetes Study Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998; 352 (9131): 854–865.
  13. Khunti K, Ceriello A, Cos X, De Block C. Achievement of guideline targets for blood pressure, lipid, and glycaemic control in type 2 diabetes: A meta-analysis. Diabetes Res Clin Pract 2018; 137: 137–148.