2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes: Developed by the task force on the management of cardiovascular disease in patients with diabetes of the European Society of Cardiology (ESC)

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Template:ESC guidelines Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]; Seyedmahdi Pahlavani, M.D. [3]; Tarek Nafee, M.D. [4]; Alara Ece Dagsali, M.D.[5]

2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes: Developed by the task force on the management of cardiovascular disease in patients with diabetes of the European Society of Cardiology (ESC)[1]

Recommendations for diagnosing diabetes (DO NOT EDIT)[1]

Class I
"1.Screening for diabetes is recommended in all individuals with CVD, using fasting glucose and/or HbA1C[2][3][4][5] (Level of Evidence: A)"
”2.It is recommended that the diagnosis of diabetes is based on HbA1C and/or fasting plasma glucose, or on an OGTT if still in doubt[6][7][8](Level of Evidence: B)"

Recommendations for assessing cardiovascular risk in patients with type 2 diabetes (DO NOT EDIT)[1]

Class I
"1. It is recommended to screen patients with diabetes for the presence of severe TOD (target organ damage)[9][10](Level of Evidence: A)"
”2.It is recommended to asses medical history and the presence of symptoms suggestive of ASCVD (Atherosclerotic cardiovascular disease) in patients with diabetes[11][12][13](Level of Evidence: B)"
”3.In patients with T2DM without symptomatic ASCVD or severe TOD, it is recommended to estimate 10-year CVD risk via SCORE2-Diabetes[14](Level of Evidence: B)"

Recommendations for reducing weight in patients with type 2 diabetes with or without cardiovascular disease (DO NOT EDIT)[1]

Class I
"1.It is recommended that individuals living with overweight or obesity aim to reduce weight and increase physical exercise to improve metabolic control and overall CVD risk profile[15][16] (Level of Evidence: A)"
Class II
"1.Glucose-lowering medications with effects on weight loss (e.g. GLP-1 RAs) should be considered in patients with overweight or obesity to reduce weight.[17](Level of Evidence: B)"
”2.Bariatric surgery should be considered for high and very high risk patients with BMI ≥ 35 kg/m² (≥Class IIC) when repetitive and structured efforts of lifestyle changes combined with weight-reducing medications do not result in maintained weight loss. [18][19][20][21][22](Level of Evidence: B)"

Recommendations for nutrition in patients with type 2 diabetes with or without cardiovascular disease (DO NOT EDIT)

Class I
"1.It is recommended to adopt a Mediterranean or plant-based diet with high unsaturated fat content to lower cardiovascular risk [23][24](Level of Evidence: A)"

Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease

Class I
"1.It is recommended to increase any physical activity (e.g. 10 min daily walking) in all patients with T2DM with and without CVD. Optimal is a weekly activity of 150 min of moderate intensity or 75 min of vigorous endurance intensity.[25][26](Level of Evidence: A)"
”2.It is recommended to adapt exercise interventions to T2DM-associated comorbidities, e.g. frailty, neuropathy, or retinopathy[27][28](Level of Evidence: B)"
”3.It is recommended to introduce structured exercise training in patients with T2DM and established CVD, e.g. CAD, HFpEF, HFmrEF, HFrEF, or AF to improve metabolic control, exercise capacity and quality of life, and to reduce CV events.[27][28][29](Level of Evidence: B)"
”3.It is recommended to perform resistance exercise in addition to endurance exercise at least twice a week.[28][30](Level of Evidence: B)"
Class IIa
"1.The use of behavioural theory-based interventions, such as goal-setting, re-evaluation of goals,self monitoring, and feedback, should be considered to promote physical activity behaviour[31][32](Level of Evidence: B)"
”2.It should be considered to perform a maximally tolerated exercise stress test in patients with T2DM and established CVD before starting a structured exercise programme(Level of Evidence: C)"
”3.It may be considered to use wearable activity trackers to increase physical activity behaviour.[33](Level of Evidence: B)"


Recommendations for smoking cessation in patients with type 2 diabetes with or without cardiovascular disease (DO NOT EDIT)

Class I
"1.It is recommended to stop smoking to reduce cardiovascular risk[34][35][36](Level of Evidence: A)"
Class IIa
"1.Nicotine replacement therapy, varenicline, and bupropion, as well as individual or telephone counselling, should be considered to improve smoking cessation success rate.[37](Level of Evidence: C)"

Recommendations for glycaemic targets in patients with diabetes

Class I
"1.It is recommended to apply tight glycaemic control (HbA1c <7%) to reduce microvascular complications.[38][39][40][41](Level of Evidence: A)"
”'2.It is recommended to avoid hypoglycaemia, particularly in patients with CVD [42][43](Level of Evidence: B)"
”3.It is recommended to individualize HbA1c targets according to comorbidities, diabetes duration, and life expectancy[42][43](Level of Evidence: C)"
Class IIa
"1.Tight glycaemic control should be considered for reducing CAD in the long term, preferably using agents with proven CV benefit.[39][44][45][46](Level of Evidence: B)"

Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk

Class I
"1.It is recommended to prioritize the use of

glucose-lowering agents with proven CV benefits, followed by agents with proven CV safety over agents without proven CV benefit or proven CV safety(Level of Evidence: C)"

”2.SGLT2 inhibitors with proven CV benefitc are

recommended in patients with T2DM and ASCVD to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication.(Level of Evidence: A)"

”3.GLP-1 RAs with proven CV benefitd are

recommended in patients with T2DM and ASCVD to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication(Level of Evidence: A)"

  1. ↑ 1.0 1.1 1.2 1.3 Marx N, Federici M, Schütt K, Müller-Wieland D, Ajjan RA, Antunes MJ; et al. (2023). "2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes". Eur Heart J. 44 (39): 4043–4140. doi:10.1093/eurheartj/ehad192. PMID 37622663 Check |pmid= value (help).
  2. ↑ American Diabetes Association (2021). "2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2021". Diabetes Care. 44 (Suppl 1): S15–S33. doi:10.2337/dc21-S002. PMID 33298413 Check |pmid= value (help).
  3. ↑ Colagiuri S, Lee CM, Wong TY, Balkau B, Shaw JE, Borch-Johnsen K; et al. (2011). "Glycemic thresholds for diabetes-specific retinopathy: implications for diagnostic criteria for diabetes". Diabetes Care. 34 (1): 145–50. doi:10.2337/dc10-1206. PMC 3005450. PMID 20978099.
  4. ↑ Sattar N, Preiss D (2016). "Diabetic microvascular complications as simple indicators of risk for cardiovascular outcomes and heart failure". Lancet Diabetes Endocrinol. 4 (7): 555–6. doi:10.1016/S2213-8587(16)30097-3. PMID 27216887.
  5. ↑ Mak KH, Vidal-Petiot E, Young R, Sorbets E, Greenlaw N, Ford I; et al. (2022). "Prevalence of diabetes and impact on cardiovascular events and mortality in patients with chronic coronary syndromes, across multiple geographical regions and ethnicities". Eur J Prev Cardiol. 28 (16): 1795–1806. doi:10.1093/eurjpc/zwab011. PMID 35022686 Check |pmid= value (help).
  6. ↑ Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (2003). "Report of the expert committee on the diagnosis and classification of diabetes mellitus". Diabetes Care. 26 Suppl 1: S5–20. doi:10.2337/diacare.26.2007.s5. PMID 12502614.
  7. ↑ Cowie CC, Rust KF, Byrd-Holt DD, Gregg EW, Ford ES, Geiss LS; et al. (2010). "Prevalence of diabetes and high risk for diabetes using A1C criteria in the U.S. population in 1988-2006". Diabetes Care. 33 (3): 562–8. doi:10.2337/dc09-1524. PMC 2827508. PMID 20067953.
  8. ↑ Arslanian S, Bacha F, Grey M, Marcus MD, White NH, Zeitler P (2018). "Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association". Diabetes Care. 41 (12): 2648–2668. doi:10.2337/dci18-0052. PMC 7732108 Check |pmc= value (help). PMID 30425094.
  9. ↑ Fox CS, Matsushita K, Woodward M, Bilo HJ, Chalmers J, Heerspink HJ; et al. (2012). "Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis". Lancet. 380 (9854): 1662–73. doi:10.1016/S0140-6736(12)61350-6. PMC 3771350. PMID 23013602.
  10. ↑ Brownrigg JR, Hughes CO, Burleigh D, Karthikesalingam A, Patterson BO, Holt PJ; et al. (2016). "Microvascular disease and risk of cardiovascular events among individuals with type 2 diabetes: a population-level cohort study". Lancet Diabetes Endocrinol. 4 (7): 588–97. doi:10.1016/S2213-8587(16)30057-2. PMID 27216886.
  11. ↑ Ling J, Koye D, Buizen L, Khunti K, Montvida O, Paul SK (2021). "Temporal trends in co-morbidities and cardiometabolic risk factors at the time of type 2 diabetes diagnosis in the UK". Diabetes Obes Metab. 23 (5): 1150–1161. doi:10.1111/dom.14323. PMID 33496366 Check |pmid= value (help).
  12. ↑ Wannamethee SG, Shaper AG, Whincup PH, Lennon L, Sattar N (2011). "Impact of diabetes on cardiovascular disease risk and all-cause mortality in older men: influence of age at onset, diabetes duration, and established and novel risk factors". Arch Intern Med. 171 (5): 404–10. doi:10.1001/archinternmed.2011.2. PMID 21403036.
  13. ↑ Nelson AJ, Peterson ED, Pagidipati NJ (2019). "Atherosclerotic cardiovascular disease and heart failure: Determinants of risk and outcomes in patients with diabetes". Prog Cardiovasc Dis. 62 (4): 306–314. doi:10.1016/j.pcad.2019.07.001. PMID 31301314.
  14. ↑ SCORE2-Diabetes Working Group and the ESC Cardiovascular Risk Collaboration (2023). "SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe". Eur Heart J. 44 (28): 2544–2556. doi:10.1093/eurheartj/ehad260. PMC 10361012 Check |pmc= value (help). PMID 37247330 Check |pmid= value (help).
  15. ↑ Look AHEAD Research Group. Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM; et al. (2013). "Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes". N Engl J Med. 369 (2): 145–54. doi:10.1056/NEJMoa1212914. PMC 3791615. PMID 23796131. Review in: Evid Based Med. 2014 Apr;19(2):64 Review in: Ann Intern Med. 2013 Oct 15;159(8):JC4
  16. ↑ Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L; et al. (2019). "Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial". Lancet Diabetes Endocrinol. 7 (5): 344–355. doi:10.1016/S2213-8587(19)30068-3. PMID 30852132. Review in: Ann Intern Med. 2019 Aug 20;171(4):JC17
  17. ↑ Palmer SC, Tendal B, Mustafa RA, Vandvik PO, Li S, Hao Q; et al. (2021). "Sodium-glucose cotransporter protein-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials". BMJ. 372: m4573. doi:10.1136/bmj.m4573. PMC 7804890 Check |pmc= value (help). PMID 33441402 Check |pmid= value (help). Review in: Ann Intern Med. 2021 Jun;174(6):JC67
  18. ↑ Ikramuddin S, Korner J, Lee WJ, Thomas AJ, Connett JE, Bantle JP; et al. (2018). "Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of Hemoglobin A1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study". JAMA. 319 (3): 266–278. doi:10.1001/jama.2017.20813. PMC 5833547. PMID 29340678.
  19. ↑ Sjöström L (2013). "Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery". J Intern Med. 273 (3): 219–34. doi:10.1111/joim.12012. PMID 23163728.
  20. ↑ Carlsson LMS, Sjöholm K, Jacobson P, Andersson-Assarsson JC, Svensson PA, Taube M; et al. (2020). "Life Expectancy after Bariatric Surgery in the Swedish Obese Subjects Study". N Engl J Med. 383 (16): 1535–1543. doi:10.1056/NEJMoa2002449. PMC 7580786 Check |pmc= value (help). PMID 33053284 Check |pmid= value (help).
  21. ↑ Syn NL, Cummings DE, Wang LZ, Lin DJ, Zhao JJ, Loh M; et al. (2021). "Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants". Lancet. 397 (10287): 1830–1841. doi:10.1016/S0140-6736(21)00591-2. PMID 33965067 Check |pmid= value (help). Review in: Ann Intern Med. 2021 Sep;174(9):JC101
  22. ↑ Doumouras AG, Wong JA, Paterson JM, Lee Y, Sivapathasundaram B, Tarride JE; et al. (2021). "Bariatric Surgery and Cardiovascular Outcomes in Patients With Obesity and Cardiovascular Disease:: A Population-Based Retrospective Cohort Study". Circulation. 143 (15): 1468–1480. doi:10.1161/CIRCULATIONAHA.120.052386. PMID 33813836 Check |pmid= value (help).
  23. ↑ Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F; et al. (2018). "Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts". N Engl J Med. 378 (25): e34. doi:10.1056/NEJMoa1800389. PMID 29897866.
  24. ↑ Delgado-Lista J, Alcala-Diaz JF, Torres-Peña JD, Quintana-Navarro GM, Fuentes F, Garcia-Rios A; et al. (2022). "Long-term secondary prevention of cardiovascular disease with a Mediterranean diet and a low-fat diet (CORDIOPREV): a randomised controlled trial". Lancet. 399 (10338): 1876–1885. doi:10.1016/S0140-6736(22)00122-2. PMID 35525255 Check |pmid= value (help). Review in: Ann Intern Med. 2022 Sep;175(9):JC100
  25. ↑ Sluik D, Buijsse B, Muckelbauer R, Kaaks R, Teucher B, Johnsen NF; et al. (2012). "Physical Activity and Mortality in Individuals With Diabetes Mellitus: A Prospective Study and Meta-analysis". Arch Intern Med. 172 (17): 1285–95. doi:10.1001/archinternmed.2012.3130. PMID 22868663.
  26. ↑ Wahid A, Manek N, Nichols M, Kelly P, Foster C, Webster P; et al. (2016). "Quantifying the Association Between Physical Activity and Cardiovascular Disease and Diabetes: A Systematic Review and Meta-Analysis". J Am Heart Assoc. 5 (9). doi:10.1161/JAHA.115.002495. PMC 5079002. PMID 27628572.
  27. ↑ 27.0 27.1 Kemps H, Kränkel N, Dörr M, Moholdt T, Wilhelm M, Paneni F; et al. (2019). "Exercise training for patients with type 2 diabetes and cardiovascular disease: What to pursue and how to do it. A Position Paper of the European Association of Preventive Cardiology (EAPC)". Eur J Prev Cardiol. 26 (7): 709–727. doi:10.1177/2047487318820420. PMID 30642190.
  28. ↑ 28.0 28.1 28.2 Mannucci E, Bonifazi A, Monami M (2021). "Comparison between different types of exercise training in patients with type 2 diabetes mellitus: A systematic review and network metanalysis of randomized controlled trials". Nutr Metab Cardiovasc Dis. 31 (7): 1985–1992. doi:10.1016/j.numecd.2021.02.030. PMID 33965297 Check |pmid= value (help).
  29. ↑ Murray EM, Whellan DJ, Chen H, Bertoni AG, Duncan P, Pastva AM; et al. (2022). "Physical Rehabilitation in Older Patients Hospitalized with Acute Heart Failure and Diabetes: Insights from REHAB-HF". Am J Med. 135 (1): 82–90. doi:10.1016/j.amjmed.2021.08.001. PMC 8688185 Check |pmc= value (help). PMID 34516959 Check |pmid= value (help).
  30. ↑ Yang Z, Scott CA, Mao C, Tang J, Farmer AJ (2014). "Resistance exercise versus aerobic exercise for type 2 diabetes: a systematic review and meta-analysis". Sports Med. 44 (4): 487–99. doi:10.1007/s40279-013-0128-8. PMID 24297743.
  31. ↑ Cradock KA, ÓLaighin G, Finucane FM, Gainforth HL, Quinlan LR, Ginis KA (2017). "Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis". Int J Behav Nutr Phys Act. 14 (1): 18. doi:10.1186/s12966-016-0436-0. PMC 5299734. PMID 28178985.
  32. ↑ Howlett N, Trivedi D, Troop NA, Chater AM (2019). "Are physical activity interventions for healthy inactive adults effective in promoting behavior change and maintenance, and which behavior change techniques are effective? A systematic review and meta-analysis". Transl Behav Med. 9 (1): 147–157. doi:10.1093/tbm/iby010. PMC 6305562. PMID 29506209.
  33. ↑ Brickwood KJ, Watson G, O'Brien J, Williams AD (2019). "Consumer-Based Wearable Activity Trackers Increase Physical Activity Participation: Systematic Review and Meta-Analysis". JMIR Mhealth Uhealth. 7 (4): e11819. doi:10.2196/11819. PMC 6484266. PMID 30977740.
  34. ↑ Critchley JA, Capewell S (2003). "Mortality risk reduction associated with smoking cessation in patients with coronary heart disease: a systematic review". JAMA. 290 (1): 86–97. doi:10.1001/jama.290.1.86. PMID 12837716.
  35. ↑ Choi JW, Han E, Kim TH (2020). "Association of smoking cessation after new-onset type 2 diabetes with overall and cause-specific mortality among Korean men: a nationwide population-based cohort study". BMJ Open Diabetes Res Care. 8 (1). doi:10.1136/bmjdrc-2020-001249. PMC 7337624 Check |pmc= value (help). PMID 32624482 Check |pmid= value (help).
  36. ↑ Kowalska M, Woźniak M, Kijek M, Mitrosz P, Szakiel J, Turek P (2022). "Management of validation of HPLC method for determination of acetylsalicylic acid impurities in a new pharmaceutical product". Sci Rep. 12 (1): 1. doi:10.1038/s41598-021-99269-x. PMC 8738756 Check |pmc= value (help). PMID 34992227 Check |pmid= value (help).
  37. ↑ Jennings C, Kotseva K, De Bacquer D, Hoes A, de Velasco J, Brusaferro S; et al. (2014). "Effectiveness of a preventive cardiology programme for high CVD risk persistent smokers: the EUROACTION PLUS varenicline trial". Eur Heart J. 35 (21): 1411–20. doi:10.1093/eurheartj/ehu051. PMID 24616337.
  38. ↑ Diabetes Control and Complications Trial Research Group. Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O; et al. (1993). "The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus". N Engl J Med. 329 (14): 977–86. doi:10.1056/NEJM199309303291401. PMID 8366922.
  39. ↑ 39.0 39.1 "Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group". Lancet. 352 (9131): 837–53. 1998. PMID 9742976.
  40. ↑ ADVANCE Collaborative Group. Patel A, MacMahon S, Chalmers J, Neal B, Billot L; et al. (2008). "Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes". N Engl J Med. 358 (24): 2560–72. doi:10.1056/NEJMoa0802987. PMID 18539916. Review in: ACP J Club. 2008 Sep 16;149(3):6-7 Review in: Evid Based Med. 2008 Dec;13(6):168-9 Review in: Evid Based Nurs. 2009 Jan;12(1):12-3
  41. ↑ Zoungas S, Arima H, Gerstein HC, Holman RR, Woodward M, Reaven P; et al. (2017). "Effects of intensive glucose control on microvascular outcomes in patients with type 2 diabetes: a meta-analysis of individual participant data from randomised controlled trials". Lancet Diabetes Endocrinol. 5 (6): 431–437. doi:10.1016/S2213-8587(17)30104-3. PMID 28365411.
  42. ↑ 42.0 42.1 Control Group. Turnbull FM, Abraira C, Anderson RJ, Byington RP, Chalmers JP; et al. (2009). "Intensive glucose control and macrovascular outcomes in type 2 diabetes". Diabetologia. 52 (11): 2288–98. doi:10.1007/s00125-009-1470-0. PMID 19655124.
  43. ↑ 43.0 43.1 International Hypoglycaemia Study Group (2019). "Hypoglycaemia, cardiovascular disease, and mortality in diabetes: epidemiology, pathogenesis, and management". Lancet Diabetes Endocrinol. 7 (5): 385–396. doi:10.1016/S2213-8587(18)30315-2. PMID 30926258.
  44. ↑ Nathan DM, DCCT/EDIC Research Group (2014). "The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview". Diabetes Care. 37 (1): 9–16. doi:10.2337/dc13-2112. PMC 3867999. PMID 24356592.
  45. ↑ Writing Group for the DCCT/EDIC Research Group (2016). "Coprogression of Cardiovascular Risk Factors in Type 1 Diabetes During 30 Years of Follow-up in the DCCT/EDIC Study". Diabetes Care. 39 (9): 1621–30. doi:10.2337/dc16-0502. PMC 5001148. PMID 27436274.
  46. ↑ Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA (2008). "10-year follow-up of intensive glucose control in type 2 diabetes". N Engl J Med. 359 (15): 1577–89. doi:10.1056/NEJMoa0806470. PMID 18784090. Review in: ACP J Club. 2008 Dec 16;149(6):4 Review in: Evid Based Nurs. 2009 Jan;12(1):14 Review in: Evid Based Med. 2009 Feb;14(1):9-10
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