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intolerance to statins)—significantly reduce LDL-C levels, thus improving CV outcomes. Antithrombotic therapy • Based on the presence of ASCVD and individual CV risk, antiplatelet agents are a cornerstone of preventing CV events in patients with diabetes. • Shortening or scaling down DAPT to clopidogrel should be avoided in patients with diabetes post-ACS, given their high background CV risk, the lack of efficacy data, and the poor bio-activation of clopidogrel. • Platelet-function testing guided de-escalation should be avoided based on lack of evidence and poor bio-activation of clopidogrel. Multifactorial approach • Continuous, multidisciplinary counselling is necessary to achieve long-term lifestyle changes. Management of coronary artery disease • In patients with CAD, SGLT2 inhibitors and/or GLP-1 RAs reduce the risk of CV events. • In patients with diabetes and multivessel CAD, suitable coronary anatomy for revascularization, and low predicted surgical mortality, CABG is superior to PCI. Heart failure • The prognosis of patients with diabetes and HF is worse compared with patients with HF without diabetes. • Beta-blockers, ARNI/ACE-Is, MRAs, and SGLT2 inhibitors are recommended as cornerstone therapies for patients with HFrEF and diabetes. • Empagliflozin and dapagliflozin reduce the combined endpoint of CV death or HF hospitalization in patients with HF and a LVEF >40%. • Glucose-lowering treatment with SGLT2 inhibitors in patients with diabetes and HF reduces HF-related endpoints. • Saxagliptin and pioglitazone increase the risk of HF hospitalization in patients with diabetes and HF. Arrhythmias • AF is common in patients with diabetes, and increases mortality, risk of stroke, and risk of HF. • Opportunistic screening for AF is recommended for patients with diabetes aged ≥65 years by palpating pulse (or using wearable devices) and systematic ECG screening when age is ≥75 years. AF should always be confirmed by ECG. • Opportunistic screening for AF by pulse taking or ECG is recommended in patients with diabetes aged <65 years in view of their risk of AF and the possibly associated risk of ischaemic stroke. Chronic kidney disease • CKD in patients with diabetes is associated with high risk of developing kidney failure and CVD. • Patients with diabetes should be regularly screened for CKD, or have their CKD staged, by assessing eGFR and UACR. • Certain ACE-I/ARBs, SGLT2 inhibitors, and finerenone reduce the risk of kidney failure and the risk of CVD in patients with T2DM and CKD. Aortic and peripheral arterial diseases • LEAD is a common complication in patients with diabetes and associated with poorer prognosis. • Patients with diabetes are at higher risk of CLTI as the first clinical manifestation of LEAD, supporting regular screening with ABI measurement for early diagnosis. • The management of patients with LEAD and indications for different treatment strategies are similar in patients with or without diabetes, although the options for revascularization may be poorer in patients with diabetes because of diffuse and distal lesions. Type 1 diabetes • Glucose-lowering therapy in T1DM should follow principles of patient self-management under the guidance of the diabetes healthcare multidisciplinary team. Person-centred care • A person-centred approach is a key factor in successful selfmanagement, resulting in greater patient satisfaction, adherence to therapeutic plans, and improved health outcomes. • Important factors for self-management of diabetes and comorbidities are education, motivation, empowerment, and continuing supportive care of individuals. 15 Gaps in evidence Diagnosis of diabetes • Global screening programmes for diabetes, adjusted for regional demographics and ethnic groups, are required to establish the most accurate and cost-effective screening test. Lifestyle • RCTs of long-term exercise intervention to reduce CV outcomes are needed in different patient groups with diabetes and CVD, e.g. CAD, HFpEF, HFrEF, AF, or PAD. • Large RCTs assessing the benefit of a multidisciplinary team to increase adherence to lifestyle interventions and optimal medication are needed in patients with T2DM and CVD. • The applicability and best practice of telehealth needs to be evaluated in elderly and frail patients with T2DM and CVD. Glycaemic targets • The independent role of hypoglycaemia, glycaemic variability, time-in-range, and post-prandial hyperglycaemia in CV pathology requires further research. • Large-scale studies are required to understand the role of modern glucose-monitoring strategies (CGM) in improving macrovascular and HF outcomes. Glucose-lowering therapy • It remains unclear if the combination therapy of GLP-1 RAs and SGLT2 inhibitors is complementary in cardio-renal outcomes in patients with T2DM. • It needs to be examined if more intensive glycaemic control, achieved with novel medications, might prove to have incremental CV efficacy. ESC Guidelines 4111 Downloaded from academic.oup.com/eurheartj/article/44/39/4043/7238227 by guest on 07 October 2026