The European Society of Cardiology (ESC) recently met and released new guidelines they developed with the European Association for the Study of Diabetes (EASD). The guidelines pertain to diabetes, pre-diabetes and cardiovascular disease.
These professional organizations revised their 2007 guidelines regarding using HbA1c to diagnose diabetes to include a glucose tolerance test in some cases, raised BP targets and revised the use of revascularization only to follow the failure of medical therapy. The American Heart Association’s scientific statement regarding diabetes and cardiovascular disease can be found here. The term cardiovascular disease refers to disease of the blood circulation to the heart and/or the blood vessels through which your blood flows including the blood vessels that travel all the way “down” to the feet and legs.
Cardiovascular disease, glucose intolerance, insulin resistance and resultant abnormal blood sugar levels typically go hand-in-hand with the accelerated development of cardiovascular disease. Foot specialists like myself see this on a regular basis because of the high incidence of peripheral vascular disease in the feet and legs of diabetics. These patients will often develop poor blood flow due to narrowed, or clogged up, blood vessels below the knee that have historically been very difficult to fix. More recently, the development and advancement of endovascular procedures have been helpful in improving the blood flow to the feet. Endovascular procedures use a small wire-like device that is tracked down the blood vessel. It has a “cleaning attachment” on the end that clears away the material that is clogging up the blood vessel. Kind of like using a “snake” to unclog a drain pipe in your home, although not exactly.
The new guidelines recommend using HbA1c to diagnosis diabetes, however patient’s with a normal HbA1c, and evidence of cardiovascular disease, are advised to receive an oral glucose tolerance test. It seems to me this approach recognizes the degree to which insulin resistance and pre-diabetes can impact blood circulation before one is officially diagnosed with diabetes. I believe this is a move in the right direction. Hopefully more glucose-tolerance tests will lead to more action on the part of patients to stop prediabetes and avoid full diabetes with a potentially more rapid worsening of the blood flow to their feet, legs, and elsewhere, including the heart, brain, eyes and kidneys that are so commonly afflicted in diabetes.
“We have simplified diagnosis because many patients may be disclosed with HbA1c, limiting the numbers who need the lengthier test. But a normal HbA1c does not rule out diabetes in high-risk patients, who need to have an oral glucose tolerance test,” ESC chairperson Lars Rydén, MD, PhD, of the cardiology unit at Karolinska Institute, Sweden, stated in a press release.*
The new guidelines also have also eliminated cardiovascular risk assessment into a low-, medium- or high-risk score since they are not considered helpful for diabetics. All diabetics are now considered to be at a high level of cardiovascular risk.
Patients with diabetes are considered at high CV risk. Patients with diabetes and CVD, including MI, angina or peripheral vascular disease, are considered at very high risk for recurrent CVD…*
All diabetics are classified as high risk for cardiovascular disease
Also, as I mentioned in the opening, revascularization guidelines have also been amended. ESC chairperson Lars Rydén, MD, PhD, of the cardiology unit at Karolinska Institute, Sweden:
Medical therapy is now recommended before intervention for patients with stable CAD (coronary artery disease, or blockage of the blood vessels supplying the heart) and no complex coronary lesions. “In former days, we were quick to do coronary interventions, but based on new trial data we now do not advocate bypass surgery and coronary angioplasty until medical therapy has been tried.”*
The guidelines also favor heart bypass surgery over angioplasty procedures with more evolved coronary artery disease:
Patients with several or complex coronary artery stenoses should be offered bypass surgery before percutaneous coronary dilatation. This change was based on new trial data that show superior morbidity and mortality with bypass surgery as compared with coronary dilatation…*
The guidelines also individualize targets for blood pressure and blood sugar control:
The general blood pressure target for patients with diabetes has been raised. It is now less than 140/85 mm Hg. (In 2007, the target was 130/80)
A. Blood pressure in patients with diabetes and kidney disease:
Target blood pressure is less than 130/85 mm Hg.
For patients at risk for stroke:
it should be even less although it doesn’t appear a target was issued.
B: Blood sugar control in patients with diabetes:
Younger patients who have been recently diagnosed with diabetes and do NOT have evidence of cardiovascular disease are encouraged to maintain a lower “tighter” glucose control.
Older patients with a long standing history of diabetes and cardiovascular disease are given more leeway in their advised degree of blood sugar control.
C. Other changes from the 2007 guidelines include:
the prioritization of weight stabilization over reduction, recommendations against drugs to increase HDL levels and aspirin use in patients with diabetes and no CVD, and a new chapter on patient-centered care with emphasis on shared decision-making.
*The attribution and information in this article, including the quotes, can be found here.