2023 ESC Guidelines for the

management of
cardiovascular disease in
patients with diabetes
Nikolaus Marx, Massimo Federici
Conflicts of interest

Nikolaus Marx
• Payment from healthcare industry to department or institution for personal services (speaker,
consultant): Amgen, AstraZeneca, Bayer, Boehringer Ingelheim/Lilly, MSD, Novo Nordisk
• Research funding from healthcare industry under direct/personal responsibility to
department: Boehringer Ingelheim/Lilly, MSD

Massimo Federici
• Consultant for Novo Nordisk in a NAFLD education board; consultant for Organon on CVD
prevention board. Activities were approved by University of Rome Tor Vergata

• Speaker fee in Continuing Medical Education activities (Lilly, Summeet, Collage). Activities
were approved by University of Rome Tor Vergata

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Task Force Members

Katharina Dirk Müller- Ramzi A. Manuel J. Ruxandra M. Carolyn Emanuele Di

Schütt (TF-Co) Wieland (TF-Co) Ajjan Antunes Christodorescu Crawford Angelantonio

Björn Christine Laurent Martin William G. Alexandra Ekaterini

Eliasson Espinola-Klein Fauchier Halle Herrington Kautzky-Willer Lambrinou

Maciej Maddalena Darren K. Wilfried Bianca Naveed

©ESC
Lesiak Lettino McGuire Mullens Rocca Sattar
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (TF-Co: TF Coordinators) (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
2023 ESC Guidelines for the management of cardiovascular disease in
patients with diabetes
Thanks to the REVIEWERS

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
2023 ESC Guidelines for the management of cardiovascular disease in
patients with diabetes
Special thanks to the Clinical Practice Guidelines (CPG) office

Nathalie Cameron
Agnieszka Barnouin
Noemie Nangniot
Louise Green
Matthieu Depuydt

Special thanks to

Marlo Verket (University Hospital Aachen)

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Central figure
Management of
cardiovascular disease
in patients with type
2 diabetes: clinical
approach and key
recommendations

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Recommendation for screening for diabetes in individuals with
cardiovascular disease

Recommendation Class Level

Screening for diabetes is recommended in all individuals with CVD, using fasting
I A
glucose and/or HbA1c.

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Recommendations for assessing cardiovascular risk in patients with
type 2 diabetes

Recommendations Class Level

It is recommended to assess medical history and the presence of symptoms
I B
suggestive of ASCVD in patients with diabetes.
Systematic survey for HF symptoms and/or signs of HF is recommended at each
I C
clinical encounter in all patients with diabetes.
Recommendation Class Level
It is recommended that patients with diabetes are routinely screened for kidney

©ESC
I B
disease by assessing eGFR defined by CKD-EPI and UACR.
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Management of cardiovascular disease in patients with type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Recommendations for glucose-lowering treatment for patients with type
2 diabetes and ASCVD to reduce cardiovascular risk
Novel concept
Special attention is given on the aspect of proven CV benefit and/or
safety of glucose-lowering medications.

Recommendations Class Level

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 I C
benefit or proven CV safety.
It is recommended to switch glucose-lowering treatment from agents without
proven CV benefit or proven safety to agents with proven CV benefit. I C

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Management of cardiovascular disease in patients with type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Glucose-lowering treatment for patients with type 2 diabetes and
atherosclerotic cardiovascular disease to reduce cardiovascular risk

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Glucose-lowering treatment for patients with type 2 diabetes and
atherosclerotic cardiovascular disease to reduce cardiovascular risk

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Management of cardiovascular disease in patients with type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Glucose-lowering treatment of patients with heart failure and
type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Glucose-lowering treatment of patients with heart failure and
type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Management of cardiovascular disease in patients with type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Pharmacological management to reduce cardiovascular or kidney failure
risk in patients with type 2 diabetes and chronic kidney disease

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Pharmacological management to reduce cardiovascular or kidney failure
risk in patients with type 2 diabetes and chronic kidney disease

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Central figure
Management of
cardiovascular disease
in patients with type
2 diabetes: clinical
approach and key
recommendations

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Cardiovascular risk assessment in diabetes

Novel concept
For patients with T2DM without ASCVD or severe target-organ damage,
a novel T2DM-specific risk score is introduced:
SCORE2-Diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
SCORE2-Diabetes: a new risk prediction tool

©ESC
Pennells L et al, Eur Heart J 2023

2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
SCORE2-Diabetes: a new risk prediction tool

SCORE2
10-year risk of (fatal and non-fatal) CV events

©ESC
Hageman S et al, Eur Heart J 2021
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
SCORE2-Diabetes: a new risk prediction tool

~230K individual with type 2 diabetes and information on

age at diagnosis, HbA1c and eGFR

SCORE2-Diabetes

Internal and external validation across Europe

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
SCORE2-Diabetes: a new risk prediction tool

©ESC
Pennells L et al, Eur Heart J 2023

2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Recommendations for assessing CV risk in patients with type 2 diabetes
Recommendation Class Level
In patients with T2DM without symptomatic ASCVD or severe TOD, it is
I B
recommended to estimate 10-year CVD risk via SCORE2-Diabetes.

Severe TOD defined as eGFR <45 mL/min/1.73m2 irrespective of albuminuria; or eGFR 45–59 mL/min/1.73m2 and microalbuminuria (UACR 30–

©ESC
300 mg/g; stage A2); or proteinuria (UACR >300 mg/g; stage A3); or presence of microvascular disease in at least three different sites [e.g.
microalbuminuria (stage A2) plus retinopathy plus neuropathy].
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Recommended low-density lipoprotein-cholesterol targets by
cardiovascular risk categories in patients with type 2 diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Glucose-lowering treatment for patients with T2DM to reduce CV risk
based on the presence of ASCVD/severe TOD and 10-year CVD risk
estimation via SCORE2-Diabetes

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Additional aspects addressed in the guidelines

- Cardiovascular risk reduction in patients with diabetes:

- Lifestyle and diabetes
- Glycaemic targets
- Blood pressure management
- Lipid management
- Antithrombotic therapy
- Multifactorial approach to risk-factor management in diabetes

- Management of coronary artery disease and diabetes

- Arrhythmias and diabetes
- Aortic and peripheral arterial diseases and diabetes
- Type 1 diabetes and CVD

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Person-centred care approach for patients with diabetes with or without
cardiovascular disease

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
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2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
2023 ESC Guidelines on the Management of Cardiovascular Disease in
Patients with Diabetes – JOIN US FOR MORE DETAILS
2023 ESC Guidelines on the Management of Cardiovascular Disease in Patients
with Diabetes
Saturday August 26; 14.00h – 15.15h
Amsterdam Lecture Hall
2023 ESC Guidelines on the Management of Cardiovascular Disease in Patients with
Diabetes: Ask the Guidelines Task Force
Saturday August 26; 16.30 h - 17.30 h
Hub Vermeer - The Hub
Guidelines in Practice: 2023 ESC Guidelines on the Management of Cardiovascular
Disease in Patients with Diabetes
Sunday August 27; 11.15 h – 12.15 h

©ESC
Oslo - Lecture Room
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)
Clinical Practice Guidelines Webinar
DECEMBER 2023 on ESC365

©ESC
2023 ESC Guidelines for the management of cardiovascular disease in patients with diabetes
www.escardio.org/guidelines (European Heart Journal; 2023 – doi:10.1093/eurheartj/ehad192)