Recommendations to reduce cardiovascular risk in patients with diabetes published today

Diabetes and the Heart

Risk Factors and Prevention

Patients with type 2 diabetes are more than twice as likely to develop cardiovascular disease (CVD) than their healthy peers.

- Advice to lower that risk is launched today in the 2023 European Society of Cardiology (ESC) Guidelines for the management of cardiovascular disease in patients with diabetes, published in European Heart Journal.¹

https://doi/10.1093/eurheartj/ehad192

https://www.dagensdiabetes.se/index.php/submit-an-article

“Patients with type 2 diabetes have a two- to four-fold higher risk of coronary artery disease, stroke, heart failure, atrial fibrillation and peripheral artery disease compared to those without type 2 diabetes and when CVD occurs, the prognosis is worse.

For example, death due to cardiovascular disease is 50–90% higher in patients with heart failure and diabetes compared to those with heart failure alone.

- It is therefore essential to have dedicated recommendations to guide the prevention and management of CVD in patients with diabetes. Interdisciplinary, patient-centred care is mandatory to reduce morbidity and mortality and to improve quality of life,” said Guidelines task force chairperson Professor Nikolaus Marx of University Hospital Aachen, Germany.

It is estimated that 25-40% of patients with CVD have undetected type 2 diabetes. Given that the presence of both conditions has a major impact on prognosis and treatment, the Guidelines recommend systematic screening for diabetes in all patients with CVD.

It is equally important to evaluate all patients with diabetes for the risk and presence of CVD.

• The Guidelines introduce a novel score, called SCORE2-Diabetes, to estimate the 10-year risk of fatal and non-fatal myocardial infarction and stroke in patients with type 2 diabetes.

The score integrates information on conventional CVD risk factors (age, smoking, blood pressure, cholesterol) with diabetes-specific information (age at diagnosis, blood sugar level, kidney function) to classify patients as low, moderate, high or very high risk.

The Guidelines recommend lifestyle changes for all patients with diabetes to reduce the likelihood of CVD. In obese patients with diabetes, weight reduction is one of the cornerstones of treatment, and the Guidelines recommend weight reduction and daily exercise

- All patients with diabetes should stop smoking and adopt a Mediterranean or plant-based diet high in unsaturated fat to lower cardiovascular risk. In addition, they should increase activity to 150 minutes of moderate intensity or 75 minutes of vigorous intensity exercise per week according to the concept “every step counts”.

Recommendations for patients with diabetes and existing CVD have been revised following the results of large clinical trials.

The Guidelines now recommend SGLT2 inhibitors and/or GLP-1 receptor agonists to reduce the risk of heart attack and stroke in all patients with diabetes and CVD, independent of glucose control and concomitant glucose medication, and in addition to standard of care antiplatelet, antihypertensive and lipid-lowering therapies.

- “Just as the presence of type 2 diabetes 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 receptor agonists,” said Guidelines task force chairperson Professor Massimo Federici of the University of Rome Tor Vergata, Italy.

A special focus of the Guidelines is managing heart failure in patients with diabetes.

Those with diabetes have a two- to four-fold risk of developing heart failure compared to patients without diabetes and many are unaware that they have heart failure. The Guidelines recommend systematic screening for heart failure signs and symptoms during each clinical encounter to allow early use of life-saving therapies.

Based on data from large clinical trials, the Guidelines recommend that patients with diabetes and chronic heart failure receive SGLT2 inhibitors to reduce the likelihood of heart failure hospitalisation or cardiovascular death.

Diabetes-induced kidney damage

is a leading cause of chronic kidney disease globally. In patients with diabetes, chronic kidney disease is associated with a high risk of kidney failure and CVD.

The Guidelines recommend screening patients with diabetes for chronic kidney disease at least annually by measuring glomerular filtration rate and albumin levels in the urine. Patients with both type 2 diabetes and chronic kidney disease should receive an SGLT2 inhibitor and/or finerenone, since these agents reduce the risk of CVD and kidney failure on top of standard of care.

Each year with diabetes confers a 3% increase in the risk of atrial fibrillation, which raises the likelihood of stroke, heart failure and death.

For the first time, the Guidelines recommend opportunistic screening for atrial fibrillation by pulse taking or electrocardiogram (ECG) in patients with diabetes aged 65 years and above.

- Opportunistic screening is also advised in those below 65 years of age, particularly when other risk factors such as high blood pressure are present.

- Also new is a recommendation for regular blood pressure measurements in all patients with diabetes to detect and treat hypertension and reduce the risk of CVD.

Diabetes is a stronger risk factor for CVD in women compared with men.

Data from large clinical trials do not indicate that women and men require different treatments, but women have been under-represented in trials and are less likely to receive recommended therapies.

The Guidelines recommend sex-balanced recruitment strategies for future clinical trials alongside pre-specified analyses addressing sex differences. The document states: “Most importantly, every effort should be made to ensure women receive equal healthcare opportunities in managing CVD in diabetes.”

From

https://www.escardio.org/The-ESC/Press-Office/Press-releases/Recommendations-to-reduce-cardiovascular-risk-in-patients-with-diabetes-published-today

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From ESC Meeting Amsterdam

2023 ESC Clinical Practice Guidelines for the management of cardiovascular disease in patients with diabetes

27 Aug 2023

Prof. Nikolaus Marx

Prof. Massimo Federici

Professor Nikolaus Marx (RWTH Aachen University - Aachen, Germany) and Professor Massimo Federici (University of Rome Tor Vergata - Rome, Italy), Chairs of the Guidelines Task Force, presented the new ESC Guidelines for the management of CVD in patients with diabetes¹to a packed main auditorium yesterday.

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 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 (e.g. 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 (i.e. age, smoking status, systolic blood pressure, total and high-density lipoprotein cholesterol) with diabetes-specific information (i.e. 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-1RAs) 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-1RAs and/or SGLT2 inhibitors is recommended to reduce CV risk, independent of glucose control and in addition to standard of care, e.g. 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-1RAs,” says 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 LVEF, 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 chronic kidney disease (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. Prof. Marx concludes, “The Task Force hopes that the new guidelines might provide a blueprint for approaching multimorbid patients with common, chronic non-communicable diseases such as atherosclerotic CVD, heart failure, diabetes and CKD, and contribute to the ultimate goal of improving prognosis and health-related quality of life.”

Read the recommendations in full – now published in the European Heart Journal.

References

1. Marx N, et al. 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes. Eur Heart J. 2023. doi:10.1093/eurheartj/ehad192.