ESC Guidelines on Diabetes, Pre-Diabetes, and CVD
The increasing prevalence of DM worldwide has led to a situation where approximately 360 million people had DM in 2011, of whom more than 95% would have had type 2 DM (T2DM). This number is estimated to increase to 552 million by 2030 and it is thought that about half of those will be unaware of their diagnosis. In addition, it is estimated that another 300 million individuals had features indicating future risk of developing T2DM, including fasting hyperglycaemia, impaired glucose tolerance (IGT), gestational DM and euglycaemic insulin resistance (IR). The majority of new cases of T2DM occur in the context of westernized lifestyles, high-fat diets and decreased exercise, leading to increasing levels of obesity, IR, compensatory hyperinsulinaemia and, ultimately, beta-cell failure and T2DM. The clustering of vascular risk seen in association with IR, often referred to as the metabolic syndrome, has led to the view that cardiovascular risk appears early, prior to the development of T2DM, whilst the strong relationship between hyperglycaemia and microvascular disease (retinopathy, nephropathy, neuropathy) indicates that this risk is not apparent until frank hyperglycaemia appears. These concepts highlight the progressive nature of both T2DM and associated cardiovascular risk, which pose specific challenges at different stages of the life of an individual with DM. The effects of advancing age, co-morbidities and problems associated with specific groups all indicate the need to manage risk in an individualized manner, empowering the patient to take a major role in the management of his or her condition.
As the world in general—and Europe in particular—changes in response to demographic and cultural shifts in societies, so the patterns of disease and their implications vary. The Middle East, the Asia–Pacific rim and parts of both North and South America have experienced massive increases in the prevalence of DM over the past 20 years, changes mirrored in European populations over the same period. Awareness of specific issues associated with gender and race and, particularly, the effects of DM in women—including epigenetics and in utero influences on non-communicable diseases—are becoming of major importance. In 2011 approximately 60 million adult Europeans were thought to have DM, half of them diagnosed, and the effects of this condition on the cardiovascular health of the individual and their offspring provide further public health challenges that agencies are attempting to address worldwide.
DM and CVD develop in concert with metabolic abnormalities mirroring and causing changes in the vasculature. More than half the mortality and a vast amount of morbidity in people with DM is related to CVD, which caused physicians in the fields of DM and cardiovascular medicine to join forces to research and manage these conditions (Figure 1). At the same time, this has encouraged organizations such as the ESC and EASD to work together and these guidelines are a reflection of that powerful collaboration.
(Enlarge Image)
Figure 1.
Investigational algorithm outlining the principles for the diagnosis and management of cardiovascular disease (CVD) in diabetes mellitus (DM) patients with a primary diagnosis of DM or a primary diagnosis of CVD. The recommended investigations should be considered according to individual needs and clinical judgement and are not meant as a general recommendation to be undertaken by all patients.
ACS = acute coronary syndrome; ECG = electrocardiogram; FPG = fasting plasma glucose; HbA1c = glycated haemoglobin A1c; IGT = impaired glucose tolerance; MI = myocardial infarction; OGTT = oral glucose tolerance test.
The emphasis in these Guidelines is to provide information on the current state of the art in how to prevent and manage the diverse problems associated with the effects of DM on the heart and vasculature in a holistic manner. In describing the mechanisms of disease, we hope to provide an educational tool and, in describing the latest management approaches, an algorithm for achieving the best care for patients in an individualized setting. It should be noted that these guidelines are written for the management of the combination of CVD (or risk of CVD) and DM, not as a separate guideline for each condition. This is important considering that those who, in their daily practice, manage these patients frequently have their main expertise in either DM or CVD or general practice. If there is a demand for a more intricate analysis of specific issues discussed in the present Guidelines, further information may be derived from detailed guidelines issued by various professional organizations such as ESC, the European Atherosclerosis Society and EASD, e.g. on acute coronary care, coronary interventions, hyperlipidaemia or glucose lowering therapy, to mention only a few.
It has been a privilege for the Chairs to have been trusted with the opportunity to develop these guidelines whilst working with some of the most widely acknowledged experts in this field. We want to extend our thanks to all members of the Task Force who gave so much of their time and knowledge, to the referees who contributed a great deal to the final manuscript, and to members of the ESC and EASD committees that oversaw this project. Finally, we express our thanks to the guidelines team at the European Heart House, in particular Catherine Després, Veronica Dean and Nathalie Cameron, for their support in making this process run smoothly.
Stockholm and Leeds, April 2014
Lars Ryden Peter Grant
2. Introduction
The increasing prevalence of DM worldwide has led to a situation where approximately 360 million people had DM in 2011, of whom more than 95% would have had type 2 DM (T2DM). This number is estimated to increase to 552 million by 2030 and it is thought that about half of those will be unaware of their diagnosis. In addition, it is estimated that another 300 million individuals had features indicating future risk of developing T2DM, including fasting hyperglycaemia, impaired glucose tolerance (IGT), gestational DM and euglycaemic insulin resistance (IR). The majority of new cases of T2DM occur in the context of westernized lifestyles, high-fat diets and decreased exercise, leading to increasing levels of obesity, IR, compensatory hyperinsulinaemia and, ultimately, beta-cell failure and T2DM. The clustering of vascular risk seen in association with IR, often referred to as the metabolic syndrome, has led to the view that cardiovascular risk appears early, prior to the development of T2DM, whilst the strong relationship between hyperglycaemia and microvascular disease (retinopathy, nephropathy, neuropathy) indicates that this risk is not apparent until frank hyperglycaemia appears. These concepts highlight the progressive nature of both T2DM and associated cardiovascular risk, which pose specific challenges at different stages of the life of an individual with DM. The effects of advancing age, co-morbidities and problems associated with specific groups all indicate the need to manage risk in an individualized manner, empowering the patient to take a major role in the management of his or her condition.
As the world in general—and Europe in particular—changes in response to demographic and cultural shifts in societies, so the patterns of disease and their implications vary. The Middle East, the Asia–Pacific rim and parts of both North and South America have experienced massive increases in the prevalence of DM over the past 20 years, changes mirrored in European populations over the same period. Awareness of specific issues associated with gender and race and, particularly, the effects of DM in women—including epigenetics and in utero influences on non-communicable diseases—are becoming of major importance. In 2011 approximately 60 million adult Europeans were thought to have DM, half of them diagnosed, and the effects of this condition on the cardiovascular health of the individual and their offspring provide further public health challenges that agencies are attempting to address worldwide.
DM and CVD develop in concert with metabolic abnormalities mirroring and causing changes in the vasculature. More than half the mortality and a vast amount of morbidity in people with DM is related to CVD, which caused physicians in the fields of DM and cardiovascular medicine to join forces to research and manage these conditions (Figure 1). At the same time, this has encouraged organizations such as the ESC and EASD to work together and these guidelines are a reflection of that powerful collaboration.
(Enlarge Image)
Figure 1.
Investigational algorithm outlining the principles for the diagnosis and management of cardiovascular disease (CVD) in diabetes mellitus (DM) patients with a primary diagnosis of DM or a primary diagnosis of CVD. The recommended investigations should be considered according to individual needs and clinical judgement and are not meant as a general recommendation to be undertaken by all patients.
ACS = acute coronary syndrome; ECG = electrocardiogram; FPG = fasting plasma glucose; HbA1c = glycated haemoglobin A1c; IGT = impaired glucose tolerance; MI = myocardial infarction; OGTT = oral glucose tolerance test.
The emphasis in these Guidelines is to provide information on the current state of the art in how to prevent and manage the diverse problems associated with the effects of DM on the heart and vasculature in a holistic manner. In describing the mechanisms of disease, we hope to provide an educational tool and, in describing the latest management approaches, an algorithm for achieving the best care for patients in an individualized setting. It should be noted that these guidelines are written for the management of the combination of CVD (or risk of CVD) and DM, not as a separate guideline for each condition. This is important considering that those who, in their daily practice, manage these patients frequently have their main expertise in either DM or CVD or general practice. If there is a demand for a more intricate analysis of specific issues discussed in the present Guidelines, further information may be derived from detailed guidelines issued by various professional organizations such as ESC, the European Atherosclerosis Society and EASD, e.g. on acute coronary care, coronary interventions, hyperlipidaemia or glucose lowering therapy, to mention only a few.
It has been a privilege for the Chairs to have been trusted with the opportunity to develop these guidelines whilst working with some of the most widely acknowledged experts in this field. We want to extend our thanks to all members of the Task Force who gave so much of their time and knowledge, to the referees who contributed a great deal to the final manuscript, and to members of the ESC and EASD committees that oversaw this project. Finally, we express our thanks to the guidelines team at the European Heart House, in particular Catherine Després, Veronica Dean and Nathalie Cameron, for their support in making this process run smoothly.
Stockholm and Leeds, April 2014
Lars Ryden Peter Grant
SHARE
