Diabetes and Cardiovascular Disease Clinical Practice Guidelines (2019)

European Society of Cardiology

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 30, 2019

In August 2019, the European Society of Cardiology (ESC), in collaboration with the European Association of Diabetes (EASD), published an update to its guidelines on cardiovascular disease management and prevention in individuals with diabetes or pre-diabetes.[1]

Cardiovascular Risk Assessment

In patients with diabetes mellitus (DM) with hypertension or suspected cardiovascular disease (CVD), it is recommended that a resting electrocardiogram (ECG) be performed.

Consideration should be given to plaque detection with carotid or femoral ultrasonography as a means of modifying cardiovascular (CV) risk.

Diabetes Prevention

It is recommended that lifestyle intervention be employed to delay or prevent pre-DM from converting into type 2 DM (T2DM).

Glycemic Control

In T2DM, blood glucose self-monitoring should be considered as an aid to optimal glycemic control.

Avoidance of hypoglycemia is recommended.

Blood Pressure Management

It is recommended that patients with hypertension employ lifestyle changes.

In pre-DM, it is recommended that renin-angiotensin-aldosterone system (RAAS) blockers be employed in place of beta blockers/diuretics for blood pressure (BP) control.

A combination of RAAS blocker and calcium channel blocker or thiazide/thiazide-like diuretic is recommended for the initiation of pharmacologic BP management.

In patients with DM, consideration should be given to home BP self-monitoring.

Consideration should be given to 24-hour ambulatory BP monitoring (ABPM) for BP assessment and antihypertensive treatment adjustment.


A proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is recommended for patients at very high CV risk in whom the maximum tolerated statin dose combined with ezetimibe has failed to ameliorate persistently high levels of low-density lipoprotein cholesterol (LDL-C) or who have statin intolerance.

Antiplatelet and Antithrombotic Drugs

In patients who are undergoing aspirin monotherapy, dual antiplatelet therapy (DAPT), or oral anticoagulant monotherapy and are at high risk of gastrointestinal bleeding, it is recommended that a proton pump inhibitor be concomitantly employed.

Glucose-Lowering Treatment

It is recommended that empagliflozin, canagliflozin, or dapagliflozin be used to reduce CV events in patients with T2DM and CVD or high/very high CV risk.

It is recommended that empagliflozin be used to reduce the mortality risk in patients with T2DM and CVD.

It is recommended that liraglutide, semaglutide, or dulaglutide be used to reduce CV events in patients with T2DM and CVD or high/very high CV risk.

It is recommended that liraglutide be used to reduce the mortality risk in patients with T2DM and CVD or high/very high CV risk.


The same revascularization techniques recommended for patients without DM are recommended for those with the disease.

Treatment of Heart Failure in DM

It is recommended that in heart failure (HF), device therapy be carried out with an implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT), or CRT with an implantable defibrillator (CRT-D).

It is recommended that sacubitril/valsartan be used in place of angiotensin-converting enzyme inhibitors (ACEIs) in HF with reduced ejection fraction (HFrEF) and DM if symptoms are not ameliorated by ACEI, beta-blocker, and mineralocorticoid receptor agonist (MRA) therapy.

It is recommended that a coronary artery bypass graft (CABG) be carried out in patients with HFrEF and DM and two- or three-vessel coronary artery disease (CAD).

If, despite full HF treatment, a patient with HF and DM in sinus rhythm, with a resting heart rate of 70 bpm or greater, remains symptomatic, ivabradine therapy should be considered.

DM Treatment to Reduce Heart Failure Risk

It is recommended that sodium-glucose cotransporter-2 (SGLT2) inhibitors (empagliflozin, canagliflozin, or dapagliflozin) be used to reduce the risk of HF hospitalization.

In patients with DM and HF, along with an estimated glomerular filtration rate (eGFR) of greater than 30 mL/min/1.73m2, metformin therapy should be considered.

Management of Arrhythmias

In the presence of DM and frequent premature ventricular contractions, evaluation for structural heart disease should be considered.

Diagnosis and Treatment of Peripheral Arterial Disease

Patients with DM and symptomatic lower extremity artery disease may be considered for treatment with low-dose rivaroxaban 2.5 mg bid plus aspirin 100 mg once daily.

Management of Chronic Kidney Disease

It is recommended that SGLT2 inhibitors be used to diminish the progression of diabetic kidney disease.

For more information, please go to Type 2 Diabetes Mellitus.

For more Clinical Practice Guidelines, please go to Guidelines.


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