European Heart Journal ESC GUIDELINES SUMMARY ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD - Summary The Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD) Authors/Task Force Members: Lars Ryde´n*(ESC Chairperson) (Sweden), Peter J. Grant* (EASD Chairperson) (UK), Stefan D. Anker (Germany), Christian Berne (Sweden), Francesco Cosentino (Italy), Nicolas Danchin (France), Christi Deaton (UK), Javier Escaned (Spain), Hans-Peter Hammes (Germany), Heikki Huikuri (Finland), Michel Marre (France), Nikolaus Marx (Germany), Linda Mellbin (Sweden), Jan Ostergren (Sweden), Carlo Patrono (Italy), Petar Seferovic (Serbia), Miguel Sousa Uva (Portugal), Marja-Riita Taskinen (Finland), Michal Tendera (Poland), Jaakko Tuomilehto (Finland), Paul Valensi (France), and Jose Luis Zamorano (Spain). ESC Committee for Practice Guidelines (CPG): Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), He´ctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Çetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai (Israel), Arno W. Hoes (Netherlands), Paulus Kirchhof (Germany), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Patrizio Lancellotti (Belgium), Ales Linhart (Czech Republic), Petros Nihoyannopoulos (UK), Massimo F. Piepoli (Italy), Piotr Ponikowski (Poland), Per Anton Sirnes (Norway), Juan Luis Tamargo (Spain), Michal Tendera (Poland), Adam Torbicki (Poland), William Wijns (Belgium), Stephan Windecker (Switzerland). Document Reviewers: Guy De Backer (Review Coordinator) (Belgium), Per Anton Sirnes (CPG Review Coordinator) (Norway), Eduardo Alegria Ezquerra (Spain), Angelo Avogaro (Italy), Lina Badimon (Spain), Elena Baranova (Russia), Helmut Baumgartner (Germany), John Betteridge (UK), Antonio Ceriello (Spain), Robert Fagard (Belgium), Christian Funck-Brentano (France), Dietrich C. Gulba (Germany), David Hasdai (Israel), Arno W. Hoes (Netherlands), * Corresponding authors: The two chairmen equally contributed to the document. Chairperson ESC: Professor Lars Ryde´n, Department of Medicine Solna, Karolinska Institutet, Solna SE-171, 76 Stockholm, Sweden, Tel: +46 8 5177 2171, Fax: +46 8 34 49 64, Email: [email protected]; Chairperson EASD: Professor Peter J. Grant, Division Of Cardiovascular & Diabetes Research, University Of Leeds, Clarendon Way, Leeds LS2 9JT, United Kingdom. Tel: +44 113 343 7721, Fax: +44 113 343 7738, Email: [email protected] Other ESC entities having participated in the development of this document: Associations: Acute Cardiovascular Care Association (ACCA), European Association of Cardiovascular Imaging (EACVI), European Association for Cardiovascular Prevention & Re- habilitation (EACPR), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA) Working Groups: Coronary Pathophysiology and Microcirculation, Thrombosis, Cardiovascular Surgery Councils: Cardiovascular Nursing and Allied Professions, Council for Cardiology Practice, Council on Cardiovascular Primary Care, Cardiovascular Imaging The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESC Guidelines represent the views of the ESC and EASD and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient and, where appropriate and necessary, the patient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription. & The European Society of Cardiology 2012. All rights reserved. For permissions please email: [email protected]. Page 2 of 32 ESC Guidelines John K. Kjekshus (Norway), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Eli Lev (Israel), Christian Mueller (Switzerland), Ludwig Neyses (Luxembourg), PeterM. Nilsson (Sweden), JoepPerk (Sweden), Piotr Ponikowski (Poland), Zˇ eljko Reiner (Croatia), Naveed Sattar (UK), Volker Scha¨chinger (Germany), Andre´ Scheen (Belgium), Henrik Schirmer (Norway), Anna Stro¨ mberg (Sweden), Svetlana Sudzhaeva (Belarus), Juan Luis Tamargo (Spain), Margus Viigimaa (Estonia), Charalambos Vlachopoulos (Greece), and Robert G. Xuereb, (Malta). The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines ----------------------------------------------------------------------------------------------------------------------------------------------------------- Keywords Guidelines † Diabetes mellitus † Cardiovascular disease † Impaired glucose tolerance † Patient management † Prevention † Epidemiology † Prognosis † Diagnostics † Risk factors † Pharmacological treatment † Coronary Interventions 1. Introduction the ESC Committee for Practice Guidelines and the EASD Panel for Overseeing Guidelines and Statements. This is a summary of the second iteration of the European Society of Car- To complement the Guidelines, several other documents, based diology’s (ESC) Guidelines on the management of diabetes mellitus on the full text version, are available. Thus, besides this summary, (DM), pre-diabetes, and cardiovascular disease (CVD) developed in col- there are also pocket Guidelines, summary slides, booklets with es- laboration with the European Association for the Study of Diabetes sential messages and an electronic version for digital applications (EASD). These guidelines are designed to assist clinicians and other (Smartphones etc.). These versions are all abridged; thus, if needed, health care workers to make evidence-based management decisions. one should always refer to the full text version, which is freely avail- The growing awareness of the strong relationship between DM and able on the ESC website. CVDpromptedtheseorganizationstocollaboratetogenerateguidelines relevant to their joint interests, the first of which were published in 2007. 2. Abnormalities of glucose The processes involved in generating these guidelines can be found at: metabolism and cardiovascular http://www.escardio.org/guidelines-surveys/esc-guidelines/about/Pages/ rules-writing.aspx. disease EASD and ESC appointed Chairs to direct the activities of the Task Force. Its members were chosen for their particular areas of expert- 2.1 Definition, classification, and diagnosis ise. Initial editing and review of the manuscripts took place at the Task The classification of DM is based on recommendations from the Force meetings, with systematic review and comments provided by World Health Organization (WHO),1,2 and the American Diabetes Table 1 Comparison of 2006 World Health Organization (WHO) and 2003/2011 and 2012 American Diabetes Association (ADA) diagnostic criteria Diagnose/ measurement WHO 20062/WHO 20116 ADA4,5 Diabetes HbA1c Can be used Recommended If measured ≥6.5% ≥6.5% (48 mmol/mol) (48 mmol/mol) Recommended FPG ≥7.0 mmol/L (≥126 mg/dL) ≥7.0 mmol/L (≥126 mg/dL) or or 2hPG ≥11.1 mmol/L (≥200 mg/dL) ≥11.1 mmol/L (≥200 mg/dL) IGT <7.0 mmol/L (<126 mg/dL) FPG <7.0 mmol/L (<126 mg/dL) Not required 2hPG ≥7.8–<11.1 mmol/L If measured 7.8–11.0 mmol/L (≥140–<200 mg/dL) (140–198 mg/dL) IFG FPG 6.1-6.9 mmol/L 5.6–6.9 mmol/L (110–125 mg/dL) (100–125 mg/dL) 2hPG If measured -- <7.8 mmol/L (<140 mg/dL) 2hPG ¼ 2-hour post-load plasma glucose; ADA ¼ American Diabetes Association; FPG ¼ fasting plasma glucose; IGT ¼ impaired glucose tolerance; IFG ¼ impaired fasting glucose; WHO ¼World Health Organization ESC Guidelines Page 3 of 32 3 –5 Association (ADA; Table 1). Glycated haemoglobin A1c (HbA1c) 2.3 Screening for disorders of glucose 6,7 has been recommended as a diagnostic test for DM, but there metabolism remain concerns regarding its sensitivity in predicting DM,8 and There is an increasing interest in identifying people with IGT, since values ,6.5% do not exclude DM that may be detected by blood many develop T2DM and such progress can be retarded by lifestyle glucose measurement.6,7,9 interventions.12 –16 The probability of a false negative test result, compared with the oral glucose tolerance test (OGTT), is substan- tial when attempting to detect DM by measuring only fasting plasma 17 2.2 Epidemiology glucose (FPG) and/or HbA1c. Several DM risk scores have been developed, most of which perform well.18 The FINnish Diabetes The International Diabetes Federation (IDF) global estimates for RIsk SCore (FINDRISC; www.diabetes.fi/english) is the most com- 2011 suggest that 52 million Europeans aged 20–79 years have monly used in Europe. This tool predicts the 10-year risk of T2DM, DM, and that this