ESC Congress in Review - Main Edition 2019 - 8

ESC Clinical Practice Guidelines

Changes in the 2019 guidelines include:
* reclassification of cardiovascular (CV) risk into 3 categories (Table 5);
* new treatment algorithms with glucose-lowering agents
for the prevention and management of CVD (Figure 4);
* rew recommendations regarding the role of aspirin
and of non-vitamin K antagonist oral anticoagulants
(NOACs) in diabetes;
* recommendations on the duration of dual antiplatelet therapy (DAPT) post-acute coronary syndromes
in diabetes;
* new lipid targets relating to severity of CV risk and
new recommendations for the use of PCSK9 inhibitors
[see also: Mach F et al. Eur Heart J. 2019]; and
* introduction of individualised blood pressure targets.
Recent evidence showing the CV safety and benefit of
antidiabetic agents has led to a paradigm shift. The main
recommendation resulting from CV outcomes trials is
that glucagon-like peptide-1 (GLP-1) receptor agonists
and sodium glucose co-transporter 2 (SGLT2) inhibitors should be used first-line in type 2 diabetes mellitus
patients with established CVD or at high/very high CV
risk (Table 6).
Aspirin (75-100 mg/day) for primary prevention is
no longer recommended in patients with diabetes at
moderate CV risk, but rather only for patients identified
at very high/high risk, with concomitant use of a proton pump inhibitor in patients receiving aspirin or oral
anticoagulant monotherapy, or DAPT, at high risk of
gastrointestinal bleeding. Extension of DAPT beyond 12
months should be considered for ≤ 3 years in patients
with diabetes at very high risk who have tolerated DAPT
without major bleeding complications. NOACs are now
recommended in preference to vitamin K antagonists for
the management of arrhythmias in people with diabetes
aged > 65 years (and a CHA2DS2-VASc score ≥ 2), if not
contraindicated.
The key recommendations on 'what to do' and 'what
not to do' in the management of CVD in diabetes patients
are summarised in Table 10 on page 12.
Replay presentation on ESC365

October 2019

Table 5. Cardiovascular Risk Categories in Patients with Diabetes
Moderate risk

Young patients (T1DM < 35 years; T2DM < 50 years) with
DM duration < 10 years, without other risk factors.

High risk

Patients with DM duration ≥ 10 years without target
organ damagea plus any other additional risk factorb

Very high risk

Patients with DM and established CVD
or other target organ damagea
or three or more major risk factors
or early onset T1DM of long duration (> 20 years)

Proteinuria, renal impairment defined as eGFR ≥30 mL/min/1.73 m2, left ventricular hypertrophy, or retinopathy. bAge, hypertension, dyslipidaemia, smoking,
obesity.
a

CVD, cardiovascular disease; DM, diabetes mellitus; T1DM, type 1 DM; T2DM, type 2 DM.
Reproduced and modified from Cosentino F et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the
EASD. Eur Heart J. 2019. Doi:10.1093/eurheartj/ehz486. By permission of Oxford
University Press on behalf of the European Society of Cardiology.

Table 6. Recommendations for Glucose-Lowering Treatment for
Patients with Diabetes
Recommendations

Classa

Levelb

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

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

SGLT2 inhibitors
Empagliflozin, canagliflozin, or dapagliflozin are recommended in patients with T2DM and CVD, or at very
high/high CV risk, to reduce CV events.
Empagliflozin is recommended in patients with T2DM
and CVD to reduce the risk of death.

GLP1-RAs

Biguanides
Metformin should be considered in overweight patients
with T2DM without CVD and at moderate CV risk.

IIa

Class of recommendation; bLevel of evidence.
CV, cardiovascular; CVD, cardiovascular disease; GLP1-RA, glucagon-like peptide-1 receptor agonist; SGLT2, sodium glucose co-transporter 2; T2DM, type 2
diabetes mellitus.
a

Reproduced from Cosentino F et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur
Heart J. 2019. Doi:10.1093/eurheartj/ehz486. By permission of Oxford University
Press on behalf of the European Society of Cardiology.

medicom-publishers.com/mcr

https://doi.org/10.1093/eurheartj/ehz486 https://esc365.escardio.org/Congress/ESC-CONGRESS-2019/Congress-Condensed-2019-Clinical-Practice-Guidelines/191066-2019-esc-easd-diabetes-pre-diabetes-and-cardiovascular-diseases#video https://doi.org/10.1093/eurheartj/ehz486 http://www.medicom-publishers.com/mcr

ESC Congress in Review - Main Edition 2019

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