Patients with diabetes mellitus, especially those who develop the disease when young and consequently live with it for a long time and who have comorbid conditions, are at elevated risk of cardiovascular disease (CVD). To guide clinicians on preventing and managing the effects of diabetes on the cardiovascular system, the European Society of Cardiology (ESC) and European Association for the Study of Diabetes have issued new CVD risk factor categories and lipid targets while recommending specific testing protocols to assess for CVD risk. Several articles in the European Heart Journal describe these recommendations, including a list of “10 commandments” that highlight the guidelines’ main points.

Diabetes, in comparison with other CVD risk factors such as smoking, dyslipidemia, and hypertension “adds a more sinister item to the presentation of cardiovascular diseases, with poorer prognosis,” wrote guideline author Victor Aboyans, MD, PhD, FESC in his summary of the recommendations. The document comes at a timely moment, with the release of heart-friendly new agents such as peptide-1 (GLP-1) receptor agonists and sodium-glucose co-transporter 2 (SGLT-2) inhibitors. Cardiologists in turn, have become more proactive in their treatment of diabetic patients.

In wake of the growing epidemic of diabetes and prediabetes, “all clinical cardiologists, as well as those specialized in any subspecialty in cardiology, must be aware of these very updated guidelines,” Aboyans suggested.

He and his colleagues recommended that all patients presenting with CVD undergo fasting blood glucose and HbA1c to exclude for diabetes. These tests are good candidates because they’re simple and inexpensive and provide good pickup without inconveniencing patients, explained Peter Grant, MD, FMedSci, corresponding author of the guidelines and professor of medicine at the University of Leeds UK. If tests are inconclusive, clinicians should follow up with an oral glucose tolerance test (OGTT).

OGTT should only be used if there is a strong suspicion of impaired glucose tolerance in the presence of normal fasting tests, Grant said.

Several chapters address CVD risk factors in diabetic patients, outlining the benefits and limitations of various tests. Guideline authors established several tiers of CVD risk in diabetes patients. Those who have had type 2 diabetes for more than 2 decades, already have CVD or end-target organ damage classify as “very high” risk. Additionally, individuals who have had diabetes for more than 10 years should be considered at high risk, while others who don’t fit into these higher risk categories have a moderate risk, according to Aboyans. 

To identify patients at risk for developing CVD and/or renal dysfunction, clinicians should routinely assess for microalbuminuria, “the only marker recommended for all diabetes patients,” Aboyans wrote. If clinicians suspect CVD, or if patients have both diabetes and hypertension, the authors recommended a resting electrocardiogram. Coronary calcium score, ankle-brachial index, peripheral vascular ultrasound, and cardiac function imaging tests are suitable for refining diabetes risk in moderate or high-risk cases, or assessing for structural heart disease. Novel biomarkers, however, should not be used to assess for CVD risk. As a general rule, the data just isn’t there to support their use. “This may change with time,” Grant told CLN Stat.

Clinicians should take steps to manage cardiovascular risk factors such as blood pressure (BP), glycemic control, lipids, and antiplatelet agents in individual patients.

The panelists modified lipid targets to reflect the new risk categories in the guidelines. For moderate, high-, and very high-risk patients, they set low-density lipoprotein-cholesterol (LDL-C) thresholds of 100 mg/dL, 70 mg/dL, and 55 mg/dL, respectively. For the high- and very high-risk categories, an LDL-C reduction of at least 50% should take place.