ESC Congress in Review - Main Edition 2019 - 13

ESC Congress 2019 In Review

Empagliflozin is recommended in patients with T2DM and
CVD to reduce the risk of death.

Liraglutide, semaglutide, or dulaglutide are recommended in
patients with T2DM and CVD, or at very high/high CV risk,e
to reduce CV events.

Liraglutide is recommended in patients with T2DM and CVD,
or at very high/high CV risk,e to reduce the risk of death.

III

GLP-1 RAs

Thiazolidinediones
Thiazolidinediones are not recommended in patients with HF.

DPP4 inhibitors
Saxagliptin is not recommended in patients with T2DM and
high risk of HF.

Management of patients with DM, and ACS or CCS

Aliskiren (a direct renin inhibitor) is not recommended
for patients with HFrEF and DM because of a higher risk
of hypotension, worsening renal function, hyperkalaemia,
and stroke.

III

Classa

Levelb

SGLT2 inhibitors (empagliflozin, canagliflozin, and dapagliflozin) are recommended to lower risk of HF hospitalisation in patients with DM.

Thiazolidinediones (pioglitazone and rosiglitazone) are
associated with an increased risk of incident HF in patients
with DM, and are not recommended for DM treatment in
patients at risk of HF (or with previous HF).

III

The DPP4 inhibitor saxagliptin is associated with an
increased risk of HF hospitalisation, and is not recommended for DM treatment in patients at risk of HF (or with
previous HF).

III

T2DM treatment to reduce HF risk
Recommendations

ACEIs or ARBs are indicated in patients with DM and CAD to
reduce the risk of CV events.

Management of arrhythmias in patients with DM

Statin therapy is recommended in patients with DM and CAD
to reduce the risk of CV events.

Oral anticoagulation with a NOAC, which is preferred over
VKAs, is recommended in DM patients aged > 65 years with
AF and a CHA2DS2-VASc score ≥ 2, if not contraindicated.

Aspirin at a dose of 75-160 mg/day is recommended as secondary prevention in patients with DM.

Treatment with a P2Y12 receptor blocker, ticagrelor or prasugrel, is recommended in patients with DM and ACS for 1 year
with aspirin, and in those who undergo PCI or CABG.

Concomintant use of a proton pump inhibitor is recommended in patients receiving DAPT or oral anticoagulant monotherapy who are at high risk of gastrointestinal bleeding.

a) ICD therapy is recommended in DM patients with symptomatic HF (New York Heart Association class II or III)
and LVEF ≤ 35% after 3 months of optimal medical
therapy, who are expected to survive for at least 1 year
with good functional status.
b) ICS therapy is recommended in DM patients with documented ventricular fibrillation or haemodynamically
unstable VT in the absence of reversible causes, or within 48 hours of MI.

Clopidogrel is recommended as an alternative antiplatelet
therapy in case of aspirin intolerance.

Beta-blockers are recommended for patients with DM with HF
after acute MI with LVEF < 40%, to prevent sudden cardiac death.

Cononary revascularisation in patients with DM

Diagnosis and management of PAD in patients with DM

It is recommended that the same revascularisation techniques are implemented (e.g. the use of DES and the radial
approach for PCI, and the use of the left internal mammary
artery as the graft for CABG) in patients with and without DM.

It is recommended to check renal function if patients have
taken metformin immediately before angiography and withhold metformin if renal function deteriorates.

Carotid artery disease
In patients with DM and carotid artery disease it is recommended to implement the same diagnostic workup and
therapeutic options (conservative, surgical, or endovascular)
as in patients without DM.

Screening for LEAD is indicated on a yearly basis, with clinical assessment and/or ABI measurement.

Patient education about foot care is recommended in
patients with DM, and especially those with LEAD, even if
asymptomatic. Early recognition of tissue loss and/or infection, and referral to a multidisciplinary team,g is mandatory
to improve limb salvage.

LEAD diagnosis

Treatment of HF in patients with DM
ACEIs and beta-blockers are indicated in symptomatic
patients with HFrEF and DM, to reduce the risk of HF hospitalisation and death.

MRAs are indicated in patients with HFrEF and DM who remain
symptomatic despite treatment with ACEIs and beta-blockers,
to reduce the risk of HF hospitalisation and death.

Device therapy with an ICD, CRT, or CRT-D is recommended in
patients with DM, as in the general population with HF.

An ABI < 0.90 is diagnostic for LEAD, irrespective of symptoms. In case of symptoms, further assessment, including
duplex ultrasound, is indicated.

ARBs are indicated in symptomatic patients with HFrEF and
DM who do not tolerate ACEIs, to reduce the risk of HF hospitalisation and death.

In case of elevated ABI (> 1.40), other non-invasive tests,
including TBI or duplex ultrasound, are indicated.

Duplex ultrasound is indicated as the fist-line imaging
method to assess the anatomy and haemodynamic status
of lower extremity arteries.

CT angiography or magnetic resonance angiography is indicated in case of LEAD when revascularisation is considered.

In patients with DM and symptomatic LEAD, antiplatelet
therapy is recommended.

As patients with DM and LEAD are at very high CV risk,d an
LDL-C target of <1.4 mmoI/L (< 55 mg/dL) or an LDL-C reduction
of at least 50% is recommended.

Sacubitril/valsartan is indicated instead of ACEIs to reduce
the risk of HF hospitalisation and death in patients with
HFrEF and DM who remain symptomatic, despite treatment
with ACEIs, beta-blockers, and MRAs.

Diuretics are recommended in patients with HFpEF, HFmrEF,
or HFrEF with signs and/or symptoms of fluid congestion,
to improve symptoms.

Cardiac revascularisation with CABG surgery has shown
similar benefits for the reduction of long-term risk of death
in patients with HFrEF with and without DM, and is recommended for patients with two- or three-vessel CAD, including
a significant LAD stenosis.

LEAD management

Official Peer-Reviewed Highlights From ESC Congress 2019

ESC Congress in Review - Main Edition 2019

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