ESC 2023 2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
European Society of Cardiology｜循環器 / 糖尿病 / 予防｜98 ページ｜チャンク 1031｜推奨 317 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.11 | IIb | B | trackers to increase physical activity behaviour. | Table 3 New recommendations |
| p.11 | I | B | In patients with T2DM without symptomatic ASCVD or severe TOD, it is recommended to estimate 10-year CVD risk via SCORE2-Diabetes. | Table 3 New recommendations |
| p.11 | I | A | 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. | Table 3 New recommendations |
| p.11 | IIa | B | 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. | Table 3 New recommendations |
| p.11 | IIa | B | Bariatric surgery should be considered for high and very high risk patients with BMI ≥35 kg/m2 (≥Class II) when repetitive and structured efforts of lifestyle changes combined with weight-reducing medications do not result in maintained weight loss. | Table 3 New recommendations |
| p.11 | I | B | It is recommended to adapt exercise interventions to T2DM-associated comorbidities, e.g. frailty, neuropathy, or retinopathy. | Table 3 New recommendations |
| p.11 | I | B | 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. | Table 3 New recommendations |
| p.11 | IIa | B | 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. It may be considered to use wearable activity | Table 3 New recommendations |
| p.11 | IIa | B | Nicotine replacement therapy, varenicline, and bupropion, as well as individual or telephone counselling, should be considered to improve smoking cessation success rate. | Table 3 New recommendations |
| p.11 | IIa | B | Glycaemic targets—Section 5.2 Tight glycaemic control should be considered for reducing CAD in the long term, preferably using agents with proven CV benefit. | Table 3 New recommendations |
| p.11 | I | C | 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. | Table 3 New recommendations |
| p.11 | IIa | C | If additional glucose control is needed, metformin should be considered in patients with T2DM and ASCVD. | Table 3 New recommendations |
| p.11 | IIb | B | If additional glucose control is needed, pioglitazone may be considered in patients with T2DM and ASCVD without HF. | Table 3 New recommendations |
| p.11 | I | A | Blood pressure and diabetes—Section 5.4 Regular BP measurements are recommended in all patients with diabetes to detect and treat hypertension to reduce CV risk. Lipids and diabetes—Section 5.5 | Table 3 New recommendations |
| p.11 | I | A | A PCSK9 inhibitor is recommended in patients at very high CV risk, with persistently high LDL-C levels above target despite treatment with a maximum tolerated statin dose, in combination with ezetimibe, or in patients with statin intolerance. | Table 3 New recommendations |
| p.11 | IIa | B | If a statin-based regimen is not tolerated at any dosage (even after re-challenge), a PCSK9 inhibitor added to ezetimibe should be considered. | Table 3 New recommendations |
| p.11 | IIa | C | If a statin-based regimen is not tolerated at any dosage (even after re-challenge), ezetimibe should be considered. | Table 3 New recommendations |
| p.11 | IIb | B | High-dose icosapent ethyl (2 g b.i.d.) may be considered in combination with a statin in patients with hypertriglyceridaemia. | Table 3 New recommendations |
| p.11 | I | A | Clopidogrel 75 mg o.d. following appropriate loading (e.g. 600 mg or at least 5 days already on maintenance therapy) is recommended in addition to ASA for 6 months following coronary stenting in patients with CCS, irrespective of stent type, unless a shorter duration is indicated due to the risk or occurrence of life-threatening bleeding. | Table 3 New recommendations |
| p.11 | I | C | In patients with diabetes and ACS treated with DAPT who are undergoing CABG and do not require long-term OAC therapy, resuming a P2Y12 receptor inhibitor as soon as deemed safe after surgery and continuing it up to 12 months is recommended. | Table 3 New recommendations |
| p.11 | IIa | B | Adding very low-dose rivaroxaban to low-dose ASA for long-term prevention of serious vascular events should be considered in patients with diabetes and Continued CCS or symptomatic PAD without high bleeding risk. | Table 3 New recommendations |
| p.12 | I | A | early is recommended. | |
| p.12 | IIa | C | considered to induce behavioural changes. | |
| p.12 | I | B | evaluation in all patients with ACS. | |
| p.12 | I | B | BNP/NT-proBNP. | |
| p.12 | I | C | 12-lead ECG is recommended. | |
| p.12 | I | C | Transthoracic echocardiography is recommended. | |
| p.12 | I | C | Chest radiography (X-ray) is recommended. | |
| p.12 | IIa | C | In patients with ACS or CCS and diabetes undergoing coronary stent implantation and having an indication for anticoagulation prolonging triple therapy with low-dose ASA, clopidogrel, and an OAC should be considered up to 1 month if the thrombotic risk outweighs the bleeding risk in the individual patient. | |
| p.12 | IIb | C | In patients with ACS or CCS and diabetes undergoing coronary stent implantation and having an indication for anticoagulation prolonging triple therapy with low-dose ASA, clopidogrel, and an OAC up to 3 months may be considered if the thrombotic risk outweighs the bleeding risk in the | |
| p.12 | III | B | individual patient. When clopidogrel is used, omeprazole and esomeprazole are not recommended for gastric protection. | |
| p.12 | I | C | Identifying and treating risk factors and comorbidities Multidisciplinary behavioural approaches that combine the knowledge and skills of different caregivers are recommended. Principles of motivational interviewing should be Telehealth may be considered to improve risk | |
| p.12 | I | A | diabetes—Section 6 Myocardial revascularization in CCS is recommended when angina persists despite treatment with anti-anginal drugs or in patients with a documented large area of ischaemia (>10% LV). | |
| p.12 | I | A | Complete revascularization is recommended in patients with STEMI without cardiogenic shock and with multivessel CAD. It is recommended to assess glycaemic status at initial | |
| p.12 | IIa | C | Complete revascularization should be considered in patients with NSTE-ACS without cardiogenic shock and with multivessel CAD. | |
| p.12 | IIa | C | Glucose-lowering therapy should be considered in patients with ACS with persistent hyperglycaemia, while episodes of hypoglycaemia should be avoided. | |
| p.12 | III | B | Routine immediate revascularization of non-culprit lesions in patients with MI and multivessel disease presenting with cardiogenic shock is not recommended. | |
| p.12 | I | C | Heart failure and diabetes—Section 7 Evaluation for heart failure in diabetes If HF is suspected, it is recommended to measure Systematic survey for HF symptoms and/or signs of HF is recommended at each clinical encounter in all patients with diabetes. | |
| p.12 | I | C | Routine blood tests for comorbidities are recommended, including full blood count, urea, creatinine and electrolytes, thyroid function, lipids, and iron status (ferritin and TSAT). | |
| p.12 | I | A | (NYHA class II–IV) and diabetes SGLT2 inhibitors (dapagliflozin, empagliflozin, or sotagliflozin) are recommended in all patients with HFrEF and T2DM to reduce the risk of HF hospitalization and CV death. An intensive strategy of early initiation of | |
| p.12 | I | B | evidence-based treatment (SGLT2 inhibitors, ARNI/ ACE-Is, beta-blockers, and MRAs), with rapid up-titration to trial-defined target doses starting before discharge and with frequent follow-up visits in the first 6 weeks following a HF hospitalization is recommended to reduce re-admissions or mortality. | |
| p.12 | IIa | B | (NYHA class II–IV) and diabetes Hydralazine and isosorbide dinitrate should be considered in self-identified Black patients with diabetes and LVEF ≤35% or with an LVEF <45% combined with a dilated LV in NYHA class III–IV despite treatment with an ACE-I (or ARNI), a beta-blocker, and an MRA, to reduce the risk of HF hospitalization and death. | |
| p.12 | IIb | B | Digoxin may be considered in patients with symptomatic HFrEF in sinus rhythm despite treatment with sacubitril/valsartan or an ACE-I, a beta-blocker, and an MRA, to reduce the risk of hospitalization. | |
| p.12 | I | A | >40% Empagliflozin or dapagliflozin are recommended in patients with T2DM and LVEF >40% (HFmrEF and HFpEF) to reduce the risk of HF hospitalization or CV death. Continued | |
| p.13 | I | A | ezetimibe combination is recommended. | |
| p.13 | I | A | patients with CKD and ASCVD. | |
| p.13 | III | B | Combined use of an ARB with an ACE-I is not recommended. | |
| p.13 | I | C | particularly in those with established CVD. | |
| p.13 | I | C | patients with T2DM with and without HF It is recommended to switch glucose-lowering treatment from agents without proven CV benefit or proven safety to agents with proven CV benefit. Atrial fibrillation and diabetes—Section 8.1 | |
| p.13 | I | C | Opportunistic screening for AF by pulse taking or ECG is recommended in patients with diabetes <65 years of age (particularly when other risk factors are present) because patients with diabetes exhibit a higher AF frequency at a younger age. | |
| p.13 | IIa | B | Systematic ECG screening should be considered to detect AF in patients aged ≥75 years, or those at high risk of stroke. Chronic kidney disease and diabetes—Section 9 Intensive LDL-C lowering with statins or a statin/ | |
| p.13 | I | A | A SGLT2 inhibitor (canagliflozin, empagliflozin, or dapagliflozin) is recommended in patients with T2DM and CKD with an eGFR ≥20 mL/min/1.73 m2 to reduce the risk of CVD and kidney failure. | |
| p.13 | I | A | Finerenone is recommended in addition to an ACE-I or ARB in patients with T2DM and eGFR >60 mL/ min/1.73 m2 with a UACR ≥30 mg/mmol (≥300 mg/ g), or eGFR 25–60 mL/min/1.73 m2 and UACR ≥3 mg/mmol (≥30 mg/g) to reduce CV events and kidney failure. | |
| p.13 | I | B | Low-dose ASA (75–100 mg o.d.) is recommended in Treatment with intensive medical or an initial invasive strategy is recommended in people with CKD, diabetes, and stable moderate or severe CAD, due to similar outcomes. | |
| p.13 | IIb | C | Kidney specialist advice may be considered for managing a raised serum phosphate, other evidence of CKD-MBD, and renal anaemia. | |
| p.13 | I | C | In patients with diabetes and aortic aneurysm, it is recommended to implement the same diagnostic work-up and therapeutic strategies (medical, surgical, or endovascular) as in patients without diabetes. | |
| p.13 | I | C | In patients with T1DM, it is recommended that adjustment of glucose-lowering medication follows principles of patient self-management under the guidance of the diabetes healthcare multidisciplinary team. | |
| p.13 | IIa | B | Avoiding hypoglycaemic episodes is recommended, Statins should be considered for LDL-C lowering in adults older than 40 years with T1DM without a history of CVD to reduce CV risk. | |
| p.13 | IIa | B | Statins should be considered for use in adults younger than 40 years with T1DM and other risk factors of CVD or microvascular end-organ damage or 10-year CVD risk ≥10% to reduce CVD risk. | |
| p.13 | IIb | B | The use of the Scottish/Swedish risk prediction model may be considered to estimate 10-year CVD risk in patients with T1DM. | |
| p.14 | I | A | with high unsaturated fat content to lower CV risk. | Table 4 Revised recommendations |
| p.14 | IIa | A | inhibitors should be considered to prevent gastrointestinal bleeding. | Table 4 Revised recommendations |
| p.14 | I | B | targets is recommended. | Table 4 Revised recommendations |
| p.14 | IIb | C | advanced, systolic HFrEF. | Table 4 Revised recommendations |
| p.14 | IIa | B | A Mediterranean diet, rich in polyunsaturated and monounsaturated fats, should be considered to reduce CV events. Empagliflozin, canagliflozin, or dapagliflozin are recommended in patients with T2DM and CVD, or at very high/high CV risk to reduce Liraglutide, semaglutide, or dulaglutide are recommended in patients with T2DM and CVD, or at very high/high CV risk to reduce | Table 4 Revised recommendations |
| p.14 | IIa | B | When low-dose aspirin is used, proton pump A multifactorial approach to diabetes management with treatment targets should be considered in patients with diabetes and CVD. Heart failure and diabetes—Section 7 | Table 4 Revised recommendations |
| p.14 | IIb | A | GLP-1 RAs (lixisenatide, liraglutide, semaglutide, exenatide, dulaglutide) have a neutral effect on the risk of HF hospitalization, and may be considered for diabetes treatment in patients with HF. Insulin may be considered in patients with | Table 4 Revised recommendations |
| p.14 | IIa | C | Atrial fibrillation and diabetes—Section 8.1 Screening for AF by pulse palpation should be considered in patients aged >65 years with diabetes and confirmed by ECG, if any suspicion of AF, as AF in patients with diabetes increases morbidity and mortality. | Table 4 Revised recommendations |
| p.14 | I | A | It is recommended to adopt a Mediterranean or plant-based diet SGLT2 inhibitors with proven CV benefit 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. | Table 4 Revised recommendations |
| p.14 | IIb | C | In patients with T2DM without ASCVD or severe TOD but with a calculated 10-year CVD risk ≥10%, treatment with an SGLT2 inhibitor or GLP-1 RA may be considered to reduce CV risk. | Table 4 Revised recommendations |
| p.14 | I | A | GLP-1 RAs with proven CV benefit 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. | Table 4 Revised recommendations |
| p.14 | I | A | When antithrombotic drugs are used in combination, proton pump inhibitors are recommended to prevent gastrointestinal bleeding. | Table 4 Revised recommendations |
| p.14 | IIa | A | When a single antiplatelet or anticoagulant drug is used, proton pump inhibitors should be considered to prevent gastrointestinal bleeding, considering the bleeding risk of the individual patient. A multifactorial approach to managing T2DM with treatment | Table 4 Revised recommendations |
| p.14 | IIa | A | GLP-1 RAs (lixisenatide, liraglutide, semaglutide, exenatide ER, dulaglutide, efpeglenatide) have a neutral effect on the risk of HF hospitalization, and should be considered for glucose-lowering treatment in patients with T2DM at risk of or with HF. | Table 4 Revised recommendations |
| p.14 | IIa | B | Basal insulins (glargine and degludec) have a neutral effect on the risk of HF hospitalization, and should be considered for glucose-lowering treatment in patients with T2DM at risk of or with HF. | Table 4 Revised recommendations |
| p.14 | I | B | Opportunistic screening for AF by pulse taking or ECG is recommended in patients ≥65 years of age. | Table 4 Revised recommendations |
| p.15 | IIa | B | Treatment with the GLP-1 RAs liraglutide and semaglutide is associated with a lower risk of renal endpoints and should be considered for diabetes treatment if eGFR is >30 mL/min/ 1.73 m2. Guidelines. | |
| p.15 | I | A | A GLP-1 RA is recommended at an eGFR >15 mL/min/1.73 m2 to achieve adequate glycaemic control, due to low risk of hypoglycaemia and beneficial effects on weight, CV risk, and albuminuria. 3 Diagnosis of diabetes | |
| p.18 | I | A | Screening for diabetes is recommended in all individuals with CVD,c using fasting glucose and/or HbA1c.5–7,36,37,39 | Recommendation Table 1 — Recommendations for diagnosing diabetes |
| p.18 | I | B | 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.d,5–8,10,11 | Recommendation Table 1 — Recommendations for diagnosing diabetes |
| p.19 | I | A | It is recommended to screen patients with diabetes for the presence of severe TOD.c,43,44 | Recommendation Table 2 — Recommendations for assessing cardiovascular risk in patients with type 2 diabetes |
| p.19 | I | B | or severe TOD,c it is recommended to estimate 10-year CVD risk via SCORE2-Diabetes.d,50 | |
| p.19 | I | B | Recommendations to assess cardiovascular risk in patients with diabetes It is recommended to assess medical history and the presence of symptoms suggestive of ASCVD in patients with diabetes.53–55 | Recommendation Table 2 — Recommendations for assessing cardiovascular risk in patients with type 2 diabetes |
| p.20 | I | A | 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.56,79 | Recommendation Table 3 — Recommendations for reducing weight in patients with type 2 diabetes with or without cardiovascular disease |
| p.20 | IIa | B | 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.67 | Recommendation Table 3 — Recommendations for reducing weight in patients with type 2 diabetes with or without cardiovascular disease |
| p.20 | IIa | B | 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.73–77 | Recommendation Table 3 — Recommendations for reducing weight in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | IIb | B | It may be considered to use wearable activity trackers to increase physical activity behaviour.114 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | I | A | It is recommended to adopt a Mediterranean or plant-based diet with high unsaturated fat content to lower cardiovascular risk.82,85 aClass of recommendation. bLevel of evidence. | Recommendation Table 4 — Recommendations for nutrition in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | I | A | © ESC 2023 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.97,98 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | I | B | It is recommended to adapt exercise interventions to T2DM-associated comorbidities, e.g. frailty, neuropathy, or retinopathy.108,115 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | I | B | 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. 108,115,116 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | I | B | It is recommended to perform resistance exercise in addition to endurance exercise at least twice a week.115,117 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | IIa | B | 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.112,113 | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.21 | IIa | C | 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. | Recommendation Table 5 — Recommendations for physical activity/exercise in patients with type 2 diabetes with or without cardiovascular disease |
| p.22 | I | A | cardiovascular risk.118–120 | Recommendation Table 6 — Recommendations for smoking cessation in patients with type 2 diabetes with or without cardiovascular disease |
| p.22 | I | B | It is recommended to avoid hypoglycaemia, particularly in patients with CVD.134–137,147 | Recommendation Table 7 — Recommendations for glycaemic targets in patients with diabetes |
| p.22 | IIa | B | It is recommended to stop smoking to reduce Nicotine replacement therapy, varenicline, and bupropion, as well as individual or telephone counselling, should be considered to improve smoking cessation success rate.121 aClass of recommendation. bLevel of evidence. | Recommendation Table 6 — Recommendations for smoking cessation in patients with type 2 diabetes with or without cardiovascular disease |
| p.22 | I | A | It is recommended to apply tight glycaemic control (HbA1c <7%) to reduce microvascular complications.126–128,133 | Recommendation Table 7 — Recommendations for glycaemic targets in patients with diabetes |
| p.22 | I | C | It is recommended to individualize HbA1c targets according to comorbidities, diabetes duration, and life expectancy.134,137 | Recommendation Table 7 — Recommendations for glycaemic targets in patients with diabetes |
| p.22 | IIa | B | Tight glycaemic control should be considered for reducing CAD in the long term, preferably using agents with proven CV benefit.c,129–132 | Recommendation Table 7 — Recommendations for glycaemic targets in patients with diabetes |
| p.30 | I | C | It is recommended to prioritize the use of glucose-lowering agents with proven CV benefitsc,d followed by agents with proven CV safetye over agents without proven CV benefit or proven CV safety. Sodium–glucose co-transporter-2 inhibitors | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.30 | I | A | 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.71,150–152,155,189 Glucagon-like peptide-1 receptor agonists | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.30 | I | A | 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.70,72,161,163,164 | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.30 | IIa | C | risk If additional glucose control is needed, metformin should be considered in patients with T2DM and ASCVD. | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.30 | IIb | B | If additional glucose control is needed, pioglitazone may be considered in patients with T2DM and ASCVD without HF.165 | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.30 | IIa | C | In patients with T2DM without ASCVD or severe TODc at low or moderate risk, treatment with metformin should be considered to reduce CV risk.183 | Recommendation Table 9 — Recommendation for glucose-lowering treatment for patients with type 2 diabetes without atherosclerotic cardiovascular disease or severe target-organ damage to reduce cardiovascular risk |
| p.30 | IIb | C | In patients with T2DM without ASCVD or severe TODc but with a calculated 10-year CVD riskd ≥10%, treatment with a SGLT2 inhibitor or GLP-1 RA may be considered to reduce CV risk.155,164 | Recommendation Table 8 — Recommendations for glucose-lowering treatment for patients with type 2 diabetes and atherosclerotic cardiovascular disease to reduce cardiovascular risk |
| p.32 | I | A | for people with diabetes when office BP is ≥140/ 90 mmHg.196,202,234,235 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | I | A | Screening for hypertension Regular BP measurementsc are recommended in all patients with diabetes to detect and treat hypertension to reduce CV risk.193,232,233 Treatment targets Anti-hypertensive drug treatment is recommended | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | I | A | It is recommended to treat hypertension in patients with diabetes in an individualized manner. The BP goal is to target SBP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg. In older people (age >65 years), it is recommended to target SBP to 130– 139 mmHg.196,236–238 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | IIb | B | An on-treatment SBP target of <130 mmHg may be considered in patients with diabetes at particularly high risk of a cerebrovascular event to further reduce their risk of stroke.194–198,239,240 Treatment and evaluation | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | I | A | Lifestyle changes (weight loss if overweight, physical activity, alcohol restriction, sodium restriction, increased consumption of vegetables, using low-fat dairy products) are recommended in patients with diabetes and hypertension.205–207,210 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | I | A | It is recommended to initiate treatment with a combination of a RAS inhibitor and a CCB or thiazide/thiazide-like diuretic.196,213–216,218,241 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | IIa | B | Home BP self-monitoring should be considered in patients with diabetes on anti-hypertensive treatments to check that BP is appropriately controlled.242 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.32 | IIa | B | 24 h ambulatory blood pressure monitoring should be considered to assess abnormal 24 h BP patterns, including nocturnal hypertension and reduced or reversed nocturnal BP dipping, and to adjust anti-hypertensive treatment.243 | Recommendation Table 10 — Recommendations for blood pressure management in patients with diabetes |
| p.34 | I | A | Lipid targets In patients with T2DM at moderate CV risk, an LDL-C target of <2.6 mmol/L (<100 mg/dL) is recommended.248,249 | Recommendation Table 11 — Recommendations for the management of dyslipidaemia in patients with diabetes |
| p.34 | I | A | In patients with T2DM at high CV risk, an LDL-C target of <1.8 mmol/L (<70 mg/dL) and LDL-C reduction of at least 50% is recommended.248,249 | Recommendation Table 11 — Recommendations for the management of dyslipidaemia in patients with diabetes |
| p.35 | I | B | In patients with T2DM at very high CV risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% is recommended.248,249 | |
| p.35 | I | B | In patients with T2DM, a secondary goal of a non-HDL-C target of <2.2 mmol/L (<85 mg/dL) in very high CV risk patients and <2.6 mmol/L (<100 mg/dL) in high CV risk patients is recommended.283–285 Lipid-lowering treatment | |
| p.35 | I | A | Statins are recommended as the first-choice LDL-C-lowering treatment in patients with diabetes and above-target LDL-C levels. Administration of statins is defined based on the CV risk profile of the patients and the recommended LDL-C (or non-HDL-C) target levels.247–249 | |
| p.35 | I | A | A PCSK9 inhibitor is recommended in patients at very high CV risk, with persistently high LDL-C levels above target despite treatment with a maximum tolerated statin dose, in combination with ezetimibe, or in patients with statin intolerance.267,286 | |
| p.35 | I | B | If the target LDL-C is not reached with statins, combination therapy with ezetimibe is recommended.259,260 | |
| p.35 | IIa | B | If a statin-based regimen is not tolerated at any dosage (even after re-challenge), a PCSK9 inhibitor added to ezetimibe should be considered.287,288 | |
| p.35 | IIa | C | If a statin-based regimen is not tolerated at any dosage (even after re-challenge), ezetimibe should be considered.259,260 | |
| p.35 | IIb | B | High-dose icosapent ethyl (2 g b.i.d.) may be considered in combination with a statin in patients with hypertriglyceridaemiac.274 | |
| p.35 | IIb | A | In adults with T2DM without a history of symptomatic ASCVD or revascularization, ASA (75– 100 mg o.d.) may be considered to prevent the first severe vascular event, in the absence of clear contraindications.c,292,293 | Recommendation Table 12 — Recommendations for patients with diabetes without a history of symptomatic atherosclerotic cardiovascular disease or revascularization |
| p.38 | I | B | of ASA intolerance.333 | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | I | A | ASA at a dose of 75–100 mg o.d. is recommended in patients with diabetes and previous MI or revascularization (CABG or stenting).291,325,326 | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | I | A | In patients with ACS and diabetes who undergo PCI, a P2Y12 receptor inhibitor (ticagrelor or prasugrel) is recommended in addition to ASA (75–100 mg o.d.), maintained over 12 months. 310–312,314 Clopidogrel 75 mg o.d. following appropriate loading | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | I | A | (e.g. 600 mg or at least 5 days already on maintenance therapy) is recommended in addition to ASA for 6 months following coronary stenting in patients with CCS, irrespective of stent type, unless a shorter duration is indicated due to the risk or occurrence of life-threatening bleeding.327–332 Clopidogrel is recommended as an alternative in case | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | I | C | require long-term OAC therapy, resuming a P2Y12 receptor inhibitor as soon as deemed safe after surgery and continuing it up to 12 months is recommended.315,334,335 | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | IIa | A | Prolonging DAPT beyond 12 months after ACS should be considered for up to 3 years in patients with diabetes who have tolerated DAPT without major bleeding complications.c,317,318,336 | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.38 | IIa | B | Adding very low-dose rivaroxaband to low-dose ASA for long-term prevention of serious vascular events should be considered in patients with diabetes and CCS or symptomatic PAD without high bleeding risk.304,305 dRivaroxaban 2.5 mg b.i.d. Continued | Recommendation Table 13 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome without indications for long-term oral anticoagulation |
| p.39 | I | A | In patients with AF and receiving antiplatelet therapy, eligible for anticoagulation, and without a contraindication,c NOACs are recommended in preference to a VKA.339,340,343 In patients with ACS or CCS and diabetes | Recommendation Table 14 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome and/or postpercutaneous coronary intervention requiring longterm oral anticoagulation |
| p.39 | I | A | undergoing coronary stent implantation and having an indication for anticoagulation, triple therapy with low-dose ASA, clopidogrel, and an OAC is recommended for at least 1 week, followed by dual therapy with an OAC and a single, oral, antiplatelet agent.339–342,344,345 | Recommendation Table 14 — Recommendations for antithrombotic therapy in patients with diabetes and acute or chronic coronary syndrome and/or postpercutaneous coronary intervention requiring longterm oral anticoagulation |
| p.39 | IIa | C | In patients with ACS or CCS and diabetes undergoing coronary stent implantation and having an indication for anticoagulation, prolonging triple therapy with low-dose ASA, clopidogrel, and an OAC should be considered up to 1 month if the thrombotic risk outweighs the bleeding risk in the individual patient.341–344 | Recommendation Table 15 — Recommendations for gastric protection in patients with diabetes taking antithrombotic drugs |
| p.39 | IIb | C | In patients with ACS or CCS and diabetes undergoing coronary stent implantation and having an indication for anticoagulation, prolonging triple therapy with low-dose ASA, clopidogrel, and an OAC up to 3 months may be considered if the thrombotic risk outweighs the bleeding risk in the individual patient.341–344 | |
| p.39 | I | A | When antithrombotic drugs are used in combination, proton pump inhibitors are recommended to prevent gastrointestinal bleeding.337,347,348,351–353,355 | Recommendation Table 15 — Recommendations for gastric protection in patients with diabetes taking antithrombotic drugs |
| p.39 | IIa | A | When a single antiplatelet or anticoagulant drug is used, proton pump inhibitors should be considered to prevent gastrointestinal bleeding, considering the bleeding risk of the individual patient.338,347,348,351,352 | Recommendation Table 15 — Recommendations for gastric protection in patients with diabetes taking antithrombotic drugs |
| p.39 | III | B | When clopidogrel is used, omeprazole and esomeprazole are not recommended for gastric protection.356 aClass of recommendation. bLevel of evidence. Continued | Recommendation Table 15 — Recommendations for gastric protection in patients with diabetes taking antithrombotic drugs |
| p.40 | I | A | early is recommended.357,358 | Recommendation Table 16 — Recommendations for a multifactorial approach in patients with type 2 diabetes with and without cardiovascular disease |
| p.40 | I | B | treatment targets is recommended.361 | Recommendation Table 16 — Recommendations for a multifactorial approach in patients with type 2 diabetes with and without cardiovascular disease |
| p.40 | IIa | C | Principles of motivational interviewing should be considered to induce behavioural changes.372–374 | Recommendation Table 16 — Recommendations for a multifactorial approach in patients with type 2 diabetes with and without cardiovascular disease |
| p.40 | IIb | B | Telehealth may be considered to improve risk profile.378,379 | Recommendation Table 16 — Recommendations for a multifactorial approach in patients with type 2 diabetes with and without cardiovascular disease |
| p.40 | I | C | Identifying and treating risk factors and comorbidities A multifactorial approach to managing T2DM with Multidisciplinary behavioural approaches that combine the knowledge and skills of different caregivers are recommended.104,380 T2DM, type 2 diabetes mellitus. aClass of recommendation. bLevel of evidence. | Recommendation Table 16 — Recommendations for a multifactorial approach in patients with type 2 diabetes with and without cardiovascular disease |
| p.42 | I | A | It is recommended that similar revascularization 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 diabetes.400 | Recommendation Table 17 — Recommendations for revascularization in patients with diabetes |
| p.42 | I | A | Myocardial revascularization in CCS is recommended when angina persists despite treatment with anti-anginal drugs or in patients with a documented large area of ischaemia (>10% LV).382,401,402,402a | Recommendation Table 17 — Recommendations for revascularization in patients with diabetes |
| p.42 | I | A | Complete revascularization is recommended in patients with STEMI without cardiogenic shock and with multivessel CAD.403–405 | Recommendation Table 17 — Recommendations for revascularization in patients with diabetes |
| p.42 | IIa | C | Complete revascularization should be considered in patients with NSTE-ACS without cardiogenic shock and with multivessel CAD.406,407 | Recommendation Table 17 — Recommendations for revascularization in patients with diabetes |
| p.42 | III | B | Routine immediate revascularization of non-culprit lesions in patients with MI and multivessel disease presenting with cardiogenic shock is not recommended.408 | Recommendation Table 17 — Recommendations for revascularization in patients with diabetes |
| p.43 | I | B | It is recommended to assess glycaemic status at initial evaluation in all patients with ACS.141,367,430 | Recommendation Table 18 — Recommendations for glycaemic control in patients with diabetes and acute coronary syndrome |
| p.43 | I | C | It is recommended to frequently monitor blood glucose levels in patients with known diabetes or hyperglycaemia (defined as glucose levels ≥11.1 mmol/L or ≥200 mg/dL). | Recommendation Table 18 — Recommendations for glycaemic control in patients with diabetes and acute coronary syndrome |
| p.43 | IIa | C | Glucose-lowering therapy should be considered in patients with ACS with persistent hyperglycaemia, while episodes of hypoglycaemia should be avoided.423,424 ACS, acute coronary syndrome. aClass of recommendation. bLevel of evidence. | Recommendation Table 18 — Recommendations for glycaemic control in patients with diabetes and acute coronary syndrome |
| p.46 | I | B | BNP/NT-proBNP.485 | Recommendation Table 19 — Recommendations for heart failure screening and diagnosis in patients with diabetes |
| p.46 | I | C | 12-lead ECG is recommended. | Recommendation Table 19 — Recommendations for heart failure screening and diagnosis in patients with diabetes |
| p.46 | I | C | Transthoracic echocardiography is recommended. | Recommendation Table 19 — Recommendations for heart failure screening and diagnosis in patients with diabetes |
| p.46 | I | C | Chest radiography (X-ray) is recommended. | Recommendation Table 19 — Recommendations for heart failure screening and diagnosis in patients with diabetes |
| p.46 | I | C | Evaluating for heart failure If HF is suspected, it is recommended to measure Systematic survey for HF symptoms and/or signs of HF is recommended at each clinical encounter in all patients with diabetes. | Recommendation Table 19 — Recommendations for heart failure screening and diagnosis in patients with diabetes |
| p.46 | I | C | Routine blood tests for comorbidities are recommended, including full blood count, urea, creatinine and electrolytes, thyroid function, lipids, and iron status (ferritin and TSAT). | |
| p.48 | I | A | diabetes SGLT2 inhibitors (dapagliflozin, empagliflozin, or sotagliflozinc) are recommended in all patients with HFrEF and T2DM to reduce the risk of HF hospitalization and CV death.189,491,494,497 | Recommendation Table 20 — Recommendations for heart failure treatments in patients with heart failure with reduced ejection fraction and diabetes |
| p.48 | I | A | Sacubitril/valsartan or an ACE-I is recommended in all patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death.471,501,502,527 | Recommendation Table 20 — Recommendations for heart failure treatments in patients with heart failure with reduced ejection fraction and diabetes |
| p.48 | I | A | Beta-blockersd are recommended in patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death.509–512,528 | Recommendation Table 20 — Recommendations for heart failure treatments in patients with heart failure with reduced ejection fraction and diabetes |
| p.48 | I | A | MRAse are recommended in patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death.507,529 An intensive strategy of early initiation of | |
| p.48 | I | B | evidence-based treatment (SGLT2 inhibitors, ARNI/ ACE-Is, beta-blockers, and MRAs), with rapid up-titration to trial-defined target doses starting before discharge and with frequent follow-up visits in the first 6 weeks following a HF hospitalization is recommended to reduce re-admissions or mortality.490 | |
| p.48 | I | A | Device therapy with an ICD, CRT-P, or CRT-D is recommended in patients with diabetes, as in the general population with HFrEF.522–525 | |
| p.48 | I | A | ARBs are recommended in symptomatic patients with HFrEF and diabetes who do not tolerate sacubitril/valsartan or ACE-Is, to reduce the risk of HF hospitalization and CV death.513–515 | |
| p.48 | I | C | Diuretics are recommended in patients with HFrEF and diabetes with signs and/or symptoms of fluid congestion to improve symptoms, exercise capacity, and HF hospitalization.520 | |
| p.48 | IIa | B | Ivabradine should be considered to reduce the risk of HF hospitalization and CV death in patients with HFrEF and diabetes in sinus rhythm, with a resting heart rate ≥70 b.p.m., who remain symptomatic despite treatment with beta-blockers (maximum tolerated dose), ACE-Is/ARBs, and MRAs.516 | |
| p.48 | IIa | B | Hydralazine and isosorbide dinitrate should be considered in self-identified Black patients with diabetes and LVEF ≤ 35% or with LVEF <45% combined with a dilated left ventricle in NYHA class III–IV despite treatment with an ACE-I (or ARNI), a beta-blocker, and an MRA, to reduce the risk of HF hospitalization and death.517,518 | |
| p.48 | IIb | B | hospitalization.519 | Recommendation Table 20 — Recommendations for heart failure treatments in patients with heart failure with reduced ejection fraction and diabetes |
| p.49 | I | A | Empagliflozin or dapagliflozin are recommended in patients with T2DM and LVEF >40% (HFmrEF and HFpEF) to reduce the risk of HF hospitalization or CV death.530–533 | Recommendation Table 21 — Recommendations for heart failure treatments in patients with diabetes and left ventricular ejection fraction over 40% |
| p.49 | I | C | Diuretics are recommended in patients with HFpEF or HFmrEF and diabetes with signs and/or symptoms of fluid congestion to improve symptoms, exercise capacity, and HF hospitalization.520 | Recommendation Table 21 — Recommendations for heart failure treatments in patients with diabetes and left ventricular ejection fraction over 40% |
| p.52 | I | A | multiple ASCVD risk factors or established ASCVD to reduce the risk of HF hospitalization.71,150–153,541 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | I | A | HF hospitalization and CV death.189,491,494,497 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | I | A | hospitalization or CV death.530,532,533 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | IIa | A | GLP-1 RAs (lixisenatide, liraglutide, semaglutide, exenatide ER, dulaglutide, efpeglenatide) have a neutral effect on the risk of HF hospitalization, and should be considered for glucose-lowering treatment in patients with T2DM at risk of or with HF.70,158–164,545 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | IIa | A | DPP-4 inhibitors (sitagliptin and linagliptin) have a neutral effect on the risk of HF hospitalization, and should be considered for glucose-lowering treatment in patients with T2DM at risk of or with HF.174,179,180 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | IIa | B | Basal insulins (glargine and degludec) have a neutral effect on the risk of HF hospitalization and should be considered for glucose-lowering treatment in patients with T2DM at risk of or with HF.553,554 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | IIa | B | Metformin should be considered for glucose-lowering treatment in patients with T2DM and HF.d,555,556,558 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | III | A | treatment in patients at risk of HF (or with previous HF).165,566 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | III | B | for glucose-lowering treatment in patients at risk of HF (or with previous HF).172 | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.52 | I | C | CV benefit.e | Recommendation Table 22 — Recommendations for glucose-lowering medications in patients with type 2 diabetes with and without heart failure |
| p.56 | I | B | Screening Opportunistic screening for AF by pulse taking or ECG is recommended in patients ≥65 years of age.577,611,630,631 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | I | C | Opportunistic screening for AF by pulse taking or ECG is recommended in patients with diabetes <65 years of age (particularly when other risk factors are present) because patients with diabetes exhibit a higher AF frequency at a younger age.577,611,631,632 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | IIa | B | Systematic ECG screening should be considered to detect AF in patients aged ≥75 years, or those at high risk of stroke.577,633–635 Anticoagulation | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | I | A | Oral anticoagulation is recommended for preventing stroke in patients with AF and diabetes and with at least one additional (CHA2DS2-VASc) risk factor for stroke.636 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | I | A | For preventing stroke in AF, NOACs are recommended in preference to VKAs, with the exception of patients with mechanical valve prostheses or moderate to severe mitral stenosis.637 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | IIa | B | Oral anticoagulation should be considered for preventing stroke in patients with AF and diabetes but no other CHA2DS2-VASc risk factor for stroke. This includes patients with T1DM or T2DM <65 years old.638–640 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.56 | IIa | B | Use of a formal, structured, bleeding risk score (HAS-BLED score) should be considered to identify modifiable and non-modifiable risk factors for bleeding in patients with diabetes and AF, and to identify patients in need of closer follow-up.641–643 | Recommendation Table 23 — Recommendations for atrial fibrillation in patients with diabetes |
| p.61 | I | A | ezetimibe combination is recommended.c,697,698 | Recommendation Table 24 — Recommendations for patients with chronic kidney disease and diabetes |
| p.61 | I | A | reduce risk of CVD and albuminuria.196 | Recommendation Table 24 — Recommendations for patients with chronic kidney disease and diabetes |
| p.61 | I | A | recommended.705–709 | Recommendation Table 24 — Recommendations for patients with chronic kidney disease and diabetes |
| p.61 | I | A | Intensive LDL-C lowering with statins or a statin/ A BP target of ≤130/80 mmHg is recommended to Personalized HbA1c targets 6.5–8.0% (48–64 mmol/ mol) are recommended, with a target <7.0% (<53 mmol/mol) to reduce microvascular complications, wherever possible.132,133 The maximum tolerated dose of an ACE-I or ARB is | Recommendation Table 24 — Recommendations for patients with chronic kidney disease and diabetes |
| p.61 | I | A | A SGLT2 inhibitor (canagliflozin, empagliflozin, or dapagliflozin)d is recommended in patients with T2DM and CKD with an eGFR ≥20 mL/min/1.73 m2 to reduce the risk of CVD and kidney failure.150,153,542,543,711,714,715 | Recommendation Table 24 — Recommendations for patients with chronic kidney disease and diabetes |
| p.62 | I | A | patients with CKD and ASCVD.325,735 | |
| p.62 | III | B | recommended.710 | |
| p.62 | I | A | Finerenone is recommended in addition to an ACE-I or ARB in patients with T2DM and eGFR >60 mL/ min/1.73 m2 with a UACR ≥30 mg/mmol (≥300 mg/ g), or eGFR 25–60 mL/min/1.73 m2 and UACR ≥3 mg/mmol (≥30 mg/g) to reduce CV events and kidney failure.718–720 | |
| p.62 | I | A | A GLP-1 RA is recommended at eGFR >15 mL/min/ 1.73 m2 to achieve adequate glycaemic control, due to low risk of hypoglycaemia and beneficial effects on weight, CV risk, and albuminuria.164 Low-dose ASA (75–100 mg o.d.) is recommended in | |
| p.62 | I | B | It is recommended that patients with diabetes are routinely screened for kidney disease by assessing eGFR defined by CKD-EPI and UACR.43,678,745 | |
| p.62 | I | B | Treatment with intensive medical or an initial invasive strategy is recommended in people with CKD, diabetes, and stable moderate or severe CAD, due to similar outcomes.e,740,746 | |
| p.62 | IIb | C | Kidney specialist advice may be considered for managing a raised serum phosphate, other evidence of CKD-MBD, and renal anaemia. Combined use of an ARB with an ACE-I is not | |
| p.64 | I | A | In patients with diabetes and symptomatic LEAD, antiplatelet therapy is recommended.325 | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | B | Lower-extremity arterial disease In patients with diabetes and CLTI, it is recommended to assess the risk of amputation; the WIfI score is useful for this purpose.747,758 | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | B | As patients with diabetes and LEAD are at very high CV risk, a LDL-C target of <1.4 mmol/L (<55 mg/dL) and a LDL-C reduction of at least 50% is recommended.778,779 | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | C | Screening for LEAD is recommended on a regular basis, with clinical assessment and/or ABI measurement. Patient education about foot care is recommended in | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | C | patients with diabetes, and especially those with LEAD, even if asymptomatic. Early recognition of tissue loss and/or infection, and referral to a multidisciplinary team, is mandatory to improve limb | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | C | salvage. An ABI ≤0.90 is diagnostic of LEAD, irrespective of symptoms. In symptomatic cases, further assessment including duplex ultrasound is recommended. | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.64 | I | C | When ABI is elevated (>1.40), other non-invasive tests, including TBI or duplex ultrasound, are recommended. | Recommendation Table 25 — Recommendations for peripheral arterial and aortic diseases in patients with diabetes |
| p.65 | I | C | whenever feasible for limb salvage.747,758 | |
| p.65 | I | C | Duplex ultrasound is recommended as the first-line imaging method to assess the anatomy and haemodynamic status of lower-extremity arteries. In case of CLTI, revascularization is recommended | |
| p.65 | IIa | B | In patients with chronic, symptomatic LEAD without high bleeding risk, a combination of low-dose rivaroxaban (2.5 mg b.i.d.) and ASA (100 mg o.d.) should be considered.766 | |
| p.65 | I | C | Carotid artery disease In patients with diabetes and carotid artery disease, it is recommended to implement the same diagnostic work-up and therapeutic strategies (medical, surgical, or endovascular) as in patients without diabetes. | |
| p.65 | I | C | Aortic aneurysm In patients with diabetes and aortic aneurysm, it is recommended to implement the same diagnostic work-up and therapeutic strategies (medical, surgical, or endovascular) as in patients without diabetes. 11 Type 1 diabetes and cardiovascular disease | |
| p.66 | I | C | particularly in those with established CVD.780–782 | Recommendation Table 26 — Recommendations for patients with type 1 diabetes |
| p.66 | I | C | In patients with T1DM, it is recommended that adjustment of glucose-lowering medication follows principles of patient self-management under the guidance of the diabetes healthcare multidisciplinary team. | Recommendation Table 26 — Recommendations for patients with type 1 diabetes |
| p.66 | IIa | B | Avoiding hypoglycaemic episodes is recommended, Statins should be considered for LDL-C lowering in adults older than 40 years with T1DM without a history of CVD to reduce CV risk.787 | Recommendation Table 26 — Recommendations for patients with type 1 diabetes |
| p.66 | IIa | B | Statins should be considered for use in adults younger than 40 years with T1DM and other risk factors of CVD or microvascular end-organ damage or 10-year CVD risk ≥10% to reduce CVD risk.787,788 | Recommendation Table 26 — Recommendations for patients with type 1 diabetes |
| p.66 | IIb | B | The use of the Scottish/Swedish risk prediction model may be considered to estimate 10-year CVD risk in patients with T1DM.793 12 Person-centred care | Recommendation Table 26 — Recommendations for patients with type 1 diabetes |
| p.68 | I | A | Structured education programmes are recommended in patients with diabetes to improve diabetes knowledge, glycaemic control, disease management, and patient empowerment.811,812,821 | Recommendation Table 27 — Recommendations for person-centred care in diabetes |
| p.68 | I | C | Person-centred care is recommended to facilitate shared control and decision-making within the context of person priorities and goals.822–824 | Recommendation Table 27 — Recommendations for person-centred care in diabetes |
| p.68 | IIa | B | Providing individual empowerment strategies should be considered to enhance self-efficacy, self-care, and motivation in patients with diabetes.825,826,831–834 aClass of recommendation. bLevel of evidence. 13 Practical guidance | Recommendation Table 27 — Recommendations for person-centred care in diabetes |
| p.71 | I | A | Screening for diabetes is recommended in all individuals with CVD, using fasting glucose and/or HbA1c. | |
| p.71 | I | B | 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. | |
| p.71 | I | A | It is recommended to screen patients with diabetes for the presence of severe TOD. | |
| p.71 | I | B | It is recommended to assess medical history and the presence of symptoms suggestive of ASCVD in patients with diabetes. | |
| p.71 | I | B | SCORE2-Diabetes. | |
| p.71 | I | A | 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. | |
| p.71 | I | A | It is recommended to adopt a Mediterranean or plant-based diet with high unsaturated fat content to lower cardiovascular risk. | |
| p.71 | I | A | weekly activity of 150 min of moderate intensity or 75 min of vigorous endurance intensity. | |
| p.71 | I | B | It is recommended to adapt exercise interventions to T2DM-associated comorbidities, e.g. frailty, neuropathy, or retinopathy. | |
| p.71 | I | B | 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. | |
| p.71 | I | B | It is recommended to perform resistance exercise in addition to endurance exercise at least twice a week. | |
| p.71 | I | A | It is recommended to stop smoking to reduce cardiovascular risk. | |
| p.71 | I | A | It is recommended to apply tight glycaemic control (HbA1c <7%) to reduce microvascular complications. | |
| p.71 | I | B | It is recommended to avoid hypoglycaemia, particularly in patients with CVD. | |
| p.71 | I | C | It is recommended to individualize HbA1c targets according to comorbidities, diabetes duration, and life expectancy. | |
| p.71 | I | C | agents without proven CV benefit or proven CV safety. | |
| p.71 | I | A | SGLT2 inhibitors with proven CV benefit 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. | |
| p.71 | I | A | GLP-1 RAs with proven CV benefit 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. | |
| p.72 | I | A | Regular BP measurements are recommended in all patients with diabetes to detect and treat hypertension to reduce CV risk. | |
| p.72 | I | A | Anti-hypertensive drug treatment is recommended for people with diabetes when office BP is ≥140/90 mmHg. | |
| p.72 | I | A | It is recommended to treat hypertension in patients with diabetes in an individualized manner. The BP goal is to target SBP to 130 mmHg and <130 mmHg if tolerated, but not <120 mmHg. In older people (age >65 years), it is recommended to target SBP to 130–139 mmHg. | |
| p.72 | I | A | using low-fat dairy products) are recommended in patients with diabetes and hypertension. | |
| p.72 | I | A | It is recommended to initiate treatment with a combination of an RAS inhibitor and a CCB or thiazide/thiazide-like diuretic. | |
| p.72 | I | A | In patients with T2DM at moderate CV risk, an LDL-C target of <2.6 mmol/L (<100 mg/dL) is recommended. | |
| p.72 | I | A | In patients with T2DM at high CV risk, an LDL-C target of <1.8 mmol/L (<70 mg/dL) and LDL-C reduction of at least 50% is recommended. | |
| p.72 | I | B | recommended. | |
| p.72 | I | B | L (<100 mg/dL) in high CV risk patients, is recommended. | |
| p.72 | I | A | Administration of statins is defined based on the CV risk profile of the patients and the recommended LDL-C (or non-HDL-C) target levels. | |
| p.72 | I | A | a maximum tolerated statin dose, in combination with ezetimibe, or in patients with statin intolerance. | |
| p.72 | I | B | If the target LDL-C is not reached with statins, combination therapy with ezetimibe is recommended. | |
| p.72 | I | A | ASA at a dose of 75–100 mg o.d. is recommended in patients with diabetes and previous MI or revascularization (CABG or stenting). | |
| p.72 | I | A | In patients with ACS and diabetes who undergo PCI, a P2Y12 receptor inhibitor (ticagrelor or prasugrel) is recommended in addition to ASA (75–100 mg o.d.), maintained over 12 months. | |
| p.72 | I | B | Clopidogrel is recommended as an alternative in case of ASA intolerance. | |
| p.72 | I | C | In patients with diabetes and ACS treated with DAPT who are undergoing CABG and do not require long-term OAC therapy, resuming a P2Y12 receptor inhibitor as soon as deemed safe after surgery and continuing it up to 12 months is recommended. | |
| p.72 | I | A | In patients with AF and receiving antiplatelet therapy, eligible for anticoagulation, and without a contraindication, NOACs are recommended in preference to a VKA. | |
| p.72 | I | A | When antithrombotic drugs are used in combination, proton pump inhibitors are recommended to prevent gastrointestinal bleeding. | |
| p.72 | III | B | When clopidogrel is used, omeprazole and esomeprazole are not recommended for gastric protection. | |
| p.72 | I | A | Identifying and treating risk factors and comorbidities early is recommended. | |
| p.72 | I | B | A multifactorial approach to managing T2DM with treatment targets is recommended. | |
| p.72 | I | C | Multidisciplinary behavioural approaches that combine the knowledge and skills of different caregivers are recommended. | |
| p.73 | I | A | It is recommended that similar revascularization 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 diabetes. | |
| p.73 | I | A | Myocardial revascularization in CCS is recommended when angina persists despite treatment with anti-anginal drugs or in patients with a documented large area of ischaemia (>10% LV). | |
| p.73 | I | A | Complete revascularization is recommended in patients with STEMI without cardiogenic shock and with multivessel CAD. | |
| p.73 | III | B | not recommended. | |
| p.73 | I | B | It is recommended to assess glycaemic status at initial evaluation in all patients with ACS. | |
| p.73 | I | C | ≥11.1 mmol/L or ≥200 mg/dL). | |
| p.73 | I | B | If HF is suspected, it is recommended to measure BNP/NT-proBNP. | |
| p.73 | I | C | Systematic survey for HF symptoms and/or signs of HF is recommended at each clinical encounter in all patients with diabetes. | |
| p.73 | I | C | 12-lead ECG is recommended. | |
| p.73 | I | C | Transthoracic echocardiography is recommended. | |
| p.73 | I | C | Chest radiography (X-ray) is recommended. | |
| p.73 | I | C | Routine blood tests for comorbidities are recommended, including full blood count, urea, creatinine and electrolytes, thyroid function, lipids, and iron status (ferritin and TSAT). | |
| p.73 | I | A | HF hospitalization and death. | |
| p.73 | I | A | Sacubitril/valsartan or an ACE-I is recommended in all patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death. | |
| p.73 | I | A | Beta-blockers are recommended in patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death. | |
| p.73 | I | A | MRAs are recommended in patients with HFrEF and diabetes to reduce the risk of HF hospitalization and death. | |
| p.73 | I | A | Device therapy with an ICD, CRT-P, or CRT-D is recommended in patients with diabetes, as in the general population with HFrEF. | |
| p.73 | I | A | risk of HF hospitalization and death. | |
| p.73 | I | C | exercise capacity, and HF hospitalization. | |
| p.73 | I | A | hospitalization or CV death. | |
| p.73 | I | C | symptoms, exercise capacity, and HF hospitalization. | |
| p.73 | I | A | multiple ASCVD risk factors or established ASCVD to reduce the risk of HF hospitalization. | |
| p.73 | I | A | hospitalization and death. | |
| p.74 | I | A | hospitalization or CV death. | |
| p.74 | III | A | treatment in patients at risk of HF (or with previous HF). | |
| p.74 | III | B | for glucose-lowering treatment in patients at risk of HF (or with previous HF). | |
| p.74 | I | B | Opportunistic screening for AF by pulse taking or ECG is recommended in patients ≥65 years of age. | |
| p.74 | I | C | risk factors are present) because patients with diabetes exhibit a higher AF frequency at a younger age. | |
| p.74 | I | A | (CHA2DS2-VASc) risk factor for stroke. | |
| p.74 | I | A | prostheses or moderate to severe mitral stenosis. | |
| p.74 | I | A | Intensive LDL-C lowering with statins or a statin/ezetimibe combination is recommended. | |
| p.74 | I | A | A BP target of ≤130/80 mmHg is recommended to reduce risk of CVD and albuminuria. | |
| p.74 | I | A | microvascular complications, wherever possible. | |
| p.74 | I | A | The maximum tolerated dose of an ACE-I or ARB is recommended. | |
| p.74 | I | A | min/1.73 m2 to reduce the risk of CVD and kidney failure. | |
| p.74 | I | A | mmol (≥300 mg/g), or eGFR 25–60 mL/min/1.73 m2 and UACR ≥3 mg/mmol (≥30 mg/g) to reduce CV events and kidney failure. | |
| p.74 | I | A | beneficial effects on weight, CV risk, and albuminuria. | |
| p.74 | I | A | Low-dose ASA (75–100 mg o.d.) is recommended in patients with CKD and ASCVD. | |
| p.74 | I | B | It is recommended that patients with diabetes are routinely screened for kidney disease by assessing eGFR defined by CKD-EPI and UACR. | |
| p.74 | I | B | severe CAD, due to similar outcomes. | |
| p.74 | III | B | Combined use of an ARB with an ACE-I is not recommended. | |
| p.74 | I | A | In patients with diabetes and symptomatic LEAD, antiplatelet therapy is recommended. | |
| p.74 | I | B | In patients with diabetes and CLTI, it is recommended to assess the risk of amputation; the WIfI score is useful for this purpose. | |
| p.74 | I | B | least 50% is recommended. | |
| p.74 | I | C | Screening for LEAD is recommended on a regular basis, with clinical assessment and/or ABI measurement. | |
| p.74 | I | C | Patient education about foot care is recommended in patients with diabetes, and especially those with LEAD, even if asymptomatic. Early recognition of tissue loss and/or infection, and referral to a multidisciplinary team, is mandatory to improve limb salvage. | |
| p.74 | I | C | An ABI ≤0.90 is diagnostic of LEAD, irrespective of symptoms. In symptomatic cases, further assessment including duplex ultrasound is recommended. | |
| p.74 | I | C | When ABI is elevated (>1.40), other non-invasive tests, including TBI or duplex ultrasound, are recommended. | |
| p.74 | I | C | Duplex ultrasound is recommended as the first-line imaging method to assess the anatomy and haemodynamic status of lower-extremity arteries. | |
| p.75 | I | C | In case of CLTI, revascularization is recommended whenever feasible for limb salvage. | |
| p.75 | I | C | strategies (medical, surgical, or endovascular) as in patients without diabetes. | |
| p.75 | I | C | (medical, surgical, or endovascular) as in patients without diabetes. | |
| p.75 | I | C | under the guidance of the diabetes healthcare multidisciplinary team. | |
| p.75 | I | C | Avoiding hypoglycaemic episodes is recommended, particularly in those with established CVD. | |
| p.75 | I | A | management, and patient empowerment. | |
| p.75 | I | C | Person-centred care is recommended to facilitate shared control and decision-making within the context of person priorities and goals. |