ESC Guidelines on Diabetes, Pre-diabetes, and Cardiovascular Diseases Developed in Collaboration With the EASD

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)

Lars Rydén (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); Jose Luis Zamorano (Spain); Jose Luis Zamorano (Chairperson) (Spain); Stephan Achenbach (Germany); Helmut Baumgartner (Germany); Jeroen J. Bax (Netherlands); Héctor Bueno (Spain); Veronica Dean (France); Christi Deaton (UK); Çetin Erol (Turkey); Robert Fagard (Belgium); Roberto Ferrari (Italy); David Hasdai (Israel); ArnoW. Hoes (Netherlands); Paulus Kirchhof (Germany UK); 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); 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); John K. Kjekshus (Norway); Juhani Knuuti (Finland); Philippe Kolh (Belgium); Eli Lev (Israel); Christian Mueller (Switzerland); Ludwig Neyses (Luxembourg); Peter M. Nilsson (Sweden); Joep Perk (Sweden); Piotr Ponikowski (Poland); Zeljko Reiner (Croatia); Naveed Sattar (UK); Volker Schächinger (Germany); André Scheen (Belgium);

Disclosures

Eur Heart J. 2013;34(39):3035-3087.

12. Patient-centred Care

12.1 General Aspects

The importance of multifactorial risk assessment and lifestyle management, including diet and exercise, in the prevention and treatment of DM and CVD has been emphasized in earlier sections. However, supporting patients in achieving and maintaining lifestyle changes on an individualized basis, using defined therapeutic goals and strategies, continues to be a substantial challenge. The intensive approach used successfully in clinical trials to prevent and treat DM and CVD is difficult to replicate in practice. Once intensive intervention stops, positive changes in lifestyle and risk factors may end, although ongoing booster sessions at intervals can maintain the effects.^[65]

Effective strategies for supporting patients in achieving positive lifestyle changes and improving self-management can be recommended. Patient-centred care is an approach that facilitates shared control and decision-making between patient and provider; it emphasizes a focus on the whole person and their experiences of illness within social contexts, rather than a single disease or organ system, and it develops a therapeutic alliance between patient and provider.^[534] Patient-centred care fosters a multifactorial approach, working within the context of patient priorities and goals, and allows for lifestyle changes and treatments to be adapted and implemented within cultural beliefs and behaviours. Providers should take into account age, ethnic and gender differences in DM and CVD, including lifestyle, disease prevalence and presentation, response to treatment and outcomes.

Understanding the patient's perspective and priorities enables providers and patients to jointly develop realistic and acceptable goals and programmes for behavioural change and self-management. A Cochrane Collaboration systematic review of 11 clinical trials (n = 1532) concluded that group-based (≥6 participants), patient-centred education resulted in clinically relevant, significant improvements in glycaemic control, DM knowledge, triglyceride concentrations, blood pressure, medication reduction and self-management for 12–14 months. Benefits for 2–4 years, including decreased DM-related retinopathy, were apparent when group classes were provided on an annual basis.^[535] Cognitive behavioural strategies, including problem-solving, goal-setting, self-monitoring, ongoing support and feedback/positive reinforcement in individual or group-based sessions are effective in facilitating behavioural change, especially when multiple strategies are used.^[536–538] However, a systematic review of studies on increasing physical activity found the positive effect of these strategies to be short-term (six months) and to decline thereafter;^[538] this may simply indicate the need for subsequent booster sessions beginning around six months. Similar patient-centred cognitive educational strategies, along with simplification of dosing regimens and increasing convenience, can be effective in improving medication adherence.^[539–541] Research is still needed regarding the most effective strategy combinations and the duration, intensity and timing of sessions.

For patients with greater reluctance or resistance towards making behavioural changes, motivational interviewing is patient-centred counselling with the purpose of working through ambivalence and fostering a patient-driven agenda. Motivational interviewing has been effective in helping patients to decrease body mass index and systolic blood pressure and increase physical activity and fruit and vegetable consumption.^[542] Motivational interviewing techniques are often adapted and incorporated within prevention programmes.^[537]

Multifaceted strategies are most effectively delivered through multidisciplinary teams. The International Diabetes Federation, Diabetes Roundtable and Global Partnership for Effective Diabetes Management are advocates for multidisciplinary team care in DM,^[543] and such teams are essential components of successful disease-management programmes for CVD.^[544] Nurse-led multidisciplinary programmes, including nurse case-management, have been effective in improving multiple cardiovascular risk factors and adherence in patients with CVD and DM within primary and secondary care.^{[536,537,545,546]}

Patient-centred care emphasizes the person, their experiences, priorities and goals in managing various conditions, and the partnership between providers and patients. When this approach is used by a multidisciplinary team with skills in cognitive behavioural strategies, there will be increased success in supporting patients in achieving lifestyle changes and effectively self-managing their conditions. It is also important to recognise that single or limited interventions or sessions on behavioural change are not sufficient to maintain lifestyle changes and that ongoing support and booster sessions will be necessary for sustained change.

12.2 Gaps in Knowledge

Effects of patient-centred interventions on outcome measures, including micro- and macrovascular complications, are not known.

12.3 Recommendations for Patient-centred Care in Diabetes

1 2 3 4 5 6 7 8 9 10 11 12

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Abbreviations and acronyms
2hPG, 2-hour post-load plasma glucose; ABI, ankle–brachial index; ACCOMPLISH, Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension; ACCORD, Action toControlCardiovascular Risk inDiabetes; ACE-I, angiotensin converting enzyme inhibitor; ACS, acute coronary syndrome; ACTIVE, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events; ACTIVE A, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events Aspirin; ACTIVEW, Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular EventsWarfarin; ADA, American Diabetes Association; ADDITION, Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care; ADP, adenosine diphosphate; ADVANCE, Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; AF, atrial fibrillation; AGEs, advanced glycation end-products; AIM-HIGH, Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes; ALTITUDE, Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints; Apo, apolipoprotein; ARB, angiotensin receptor blocker; ARIC, Atherosclerosis Risk In Communities; ARISTOTLE, Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation; ASCOT, Anglo-Scandinavian Cardiac Outcomes Trial; ATLAS, Assessment of Treatment with Lisinopril And Survival; AVERROES, Apixaban VERsus acetylsalicylic acid to pRevent strOkES; AWESOME, AnginaWith Extremely Serious Operative Mortality Evaluation; BARI 2D, Bypass Angioplasty Revascularization Investigation 2 Diabetes; BEST, BEta blocker STroke trial; BMS, bare-metal stent; BP, blood pressure; CABG, coronary artery bypass graft surgery; CAC, coronary artery calcium; CAD, coronary artery disease; CAN, cardiac autonomic neuropathy; CAPRIE, Clopidogrel vs. Aspirin in Patients at Risk of Ischaemic Events; CARDia, Coronary Artery Revascularization in Diabetes; CARDS, Collaborative Atorvastatin Diabetes Study; CETP, cholesterylester transfer protein; CHA₂DS₂-VASc, cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled)-vascular disease, age 65–74 and sex category (female); CHADS₂, cardiac failure, hypertension, age, diabetes, stroke (doubled); CHARISMA, Clopidogrel for High Atherothrombotic Risk and Ischaemic Stabilization, Management and Avoidance; CHARM, Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity; CI, confidence interval; CIBIS, Cardiac Insufficiency Bisoprolol Study; CLI, critical limb ischaemia; COMET, Carvedilol Or Metoprolol European Trial; COPERNICUS, Carvedilol Prospective Randomized Cumulative Survival; COX-1 and 2, cyclo-oxygenase 1 and 2; CTT, Cholesterol Treatment Trialists; CVD, cardiovascular disease; DCCT, Diabetes Control and Complications Trial; DECODE, Diabetes Epidemiology:COllaborative analysis of Diagnostic criteria in Europe; DES, drug-eluting stent; DETECT-2, The Evaluation of Screening and Early DetectionStrategies for T2DM and IGT; DIABHYCAR, Hypertension, Microalbuminuria or Proteinuria, Cardiovascular Events and Ramipril; DIAMOND, Danish Investigations and Arrhythmia ON Dofetilide DIG Digitalis Investigation Group; DIGAMI, Diabetes and Insulin–Glucose Infusion in Acute Myocardial Infarction; DIRECT, DIabetic REtinopathy Candesartan Trials; DM, diabetes mellitus; DPP-4, dipeptidylpeptidase-4; ECG, electrocardiogram; EDIC, Epidemiology of Diabetes Interventions and Complications; eNOS, endothelial nitric oxide synthase; EPC, endothelial progenitor cells; ERFC, Emerging Risk Factor Collaboration; EUROASPIRE, European Action on Secondary Prevention through Intervention to Reduce Events; EUROPA, EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease; FDA, Food and Drug Administration; FFA, free fatty acid; FIELD, Fenofibrate Intervention and Event Lowering in Diabetes; FINDRISC, FINnish Diabetes RIsk SCore; FPG, fasting plasma glucose; FREEDOM, Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease; GFR, glomerular filtration rate; GIK, glucose-insulin-potassium; GLP-1, glucagon-like peptide-1; GLUT-4, glucose transporter 4; HAS-BLED, Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (.65), Drugs/alcohol concomitantly (1 point each); HbA_1c glycated haemoglobin A_1C; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; HI-5, Hyperglycaemia: Intensive Insulin Infusion in Infarction; HOMA-IR, Homeostasis Model Assessment of Insulin Resistance; HOPE, Heart Outcomes Prevention Evaluation; HOT, Hypertension Optimal Treatment; HPS, Heart Protection Study; HPS-2-THRIVE, Heart Protection Study 2 Treatment of HDL to Reduce the Incidence of Vascular Events; HR, hazard ratio; HSP, hexosamine pathway; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; IMMEDIATE, Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care; IMPROVE-IT, IMProved Reduction of Outcomes: Vytorin Efficacy International Trial; INR, international normalized ratio; IR, insulin resistance; IRS-1, insulin receptor substrate-1; ISAR-REACT, Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment; ITA, internal thoracic artery; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein cholesterol; LEAD, lower extremity artery disease; Lp a, lipoprotein a; LV, left ventricular; LVEF, left ventricular ejection fraction; MACCE, major adverse cardiac and cerebrovascular events; MAIN COMPARE, Revascularization for unprotected leftmain coronary artery stenosis: comparison of percutaneous; MERIT-HF, Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure; MetS, metabolic syndrome; MI, myocardial infarction; MRA, mineralocorticoid receptor antagonists; N-ER, niacin; NAPDH, nicotinamide adenine dinucleotide phosphate hydrogen; NDR, National Diabetes Register; NHANES, NationalHealth andNutritionExamination Survey; NICE, National Institute for Health and Clinical Excellence (UK); NNT, number needed to treat; NO, nitric oxide; NOAC, new oral anticoagulants; NYHA, New York Heart Association; OAT, Occluded Artery Trial; OGTT, oral glucose tolerance test; OMT, optimal medical treatment; ONTARGET, ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial; OR, odds ratio; ORIGIN, OutcomeReduction with an Initial Glargine Intervention trial; PAD, peripheral artery disease; PAI-1, plasminogen activator inhibitor-1; PCI, percutaneous coronary intervention; PG, plasma glucose; PI3K, phosphatidylinositol 3-kinases; PKC, protein kinase C; PLATO, PLATelet inhibition and patient Outcomes trial; PPARα, peroxisome proliferator-activated receptor alpha; PPARγ, peroxisome proliferator-activated receptor gamma; PREDIMED, Primary Prevention of Cardiovascular Disease with a Mediterranean Diet; PROActive, PROspective pioglitAzone Clinical Trial In macroVascular Events; PROCAM, Prospective Cardiovascular Münster; RAAS, renin-angiotensin-aldosterone system; RAGE, receptor for advanced glycation end products; RCT, randomized controlled trial; RE-LY, Randomized Evaluation of the Long-term anticoagulant therapy with dabigatran etexilate; REGICOR, Myocardial Infarction Population Registry of Girona; RESOLVE, Safety and Efficacy of Ranibizumab in Diabetic Macular Edema Study; RESTORE, Ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema; RIDE, Ranibizumab Injection in SubjectsWith Clinically Significant Macular Edema (ME)With Center Involvement Secondary to Diabetes Mellitus; RISE, Ranibizumab Injection in SubjectsWith Clinically Significant Macular Edema (ME)With Center Involvement Secondary to Diabetes Mellitus; ROCKET, Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition, compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation; ROS, reactive oxygen species; RRR, relative risk reduction; SCORE®, The European Systematic Coronary Risk Evaluation; SGLT2, sodium–glucose co-transporter-2; SHARP, Study of Heart and Renal Protection; SMI, silent myocardial ischaemia; SR-B, scavenger receptor B; SOLVD, Studies Of Left Ventricular Dysfunction; STEMI, ST-elFevation myocardial infarction; SYNTAX, SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; TACTICS-TIMI 18, Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction; TG, triglyceride; TIA, transient ischaemic attack; tPA, tissue plasminogen activator; TRL, triglyceride-rich lipoprotein; UKPDS, United Kingdom Prospective Diabetes Study; VADT, Veterans Administration Diabetes Trial; VEGF, vascular endothelial growth factor; VKA, vitamin K antagonist; VLDL, very low-density lipoprotein; WHO, World Health Organization

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 & Rehabilitation (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.

Table 3. Comparison of 2006World Health Organization (WHO) and 2003/2011 and 2012 American Diabetes Association (ADA) diagnostic criteria
Diagnose/measurement	WHO 2006³/2011⁷	ADA 2003 and 2012^5,6
Diabetes HbA_1c FPG 2hPG	Can be used If measured ≥6.5% (48 mmol/mol) Recommended ≥7.0 mmol/L (≥126 mg/dL) or ≥11.1 mmol/L (≥200 mg/dL)	Recommended ≥6.5% (48 mmol/mol) ≥7.0 mmol/L (≥126 mg/dL) or ≥11.1 mmol/L (≥200 mg/dL)
IGT FPG 2hPG	<7.0 mmol/L (<126 mg/dL) ≥7.8–<11.1 mmol/L (≥140–<200 mg/dL)	<7.0 mmol/L (<126 mg/dL) Not required If measured 7.8–11.0 mmol/L (140–198 mg/dL)
IFG FPG 2hPG	6.1–6.9 mmol/L (110–125 mg/dL) If measured <7.8 mmol/L (<140 mg/dL)	5.6–6.9 mmol/L (100–125 mg/dL) --

FPG = fasting plasma glucose; IGT = impaired glucose tolerance; IFG = impaired fasting glucose; 2hPG = 2-h post-load plasma glucose.

Table 4. Cut-points for diagnosing DM, impaired glucose tolerance, and impaired fasting glucose based on other blood specimens than the recommended standard, venous plasma
Diagnosis	Venous plasma^a mmol/L (mg/dL)	Venous blood mmol/L (mg/dL)	Capillary blood mmol/L (mg/dL)
IFG –FG	6.1 (110)	5.0 (90)	5.6 (101)
IGT–2hG	7.8 (140)	6.5 (117)	7.2 (130)
Diabetes–FG	7.0 (126)	5.8 (104)	6.5 (117)
Diabetes–2hG	11.1 (200)	9.4 (169)	10.3 (185)

FPG = fasting plasma glucose; FG = Fasting Glucose; IFG = impaired fasting glucose; IGT = impaired glucose tolerance; 2hG = 2-h post-load glucose; 2hPG = 2-h post-load plasma glucose.
^aStandard.

Table 5. Burden of DM in Europe in 2011 and predictions for 2030 ¹
Variable	2011	2030
Total population (millions)	896	927
Adults (20–79 years; millions)	651	670
DM (20–79 years)
European prevalence (%)	8.1	9.5
Number with DM (millions)	52.6	64.0
IGT (20–79 years)
Regional prevalence (%)	9.6	10.6
Number with IGT (millions)	62.8	71.3
Type 1 DM in children (0–14 years)
Number with type 1 DM (thousands)	115.7	–
Number newly diagnosed/year (thousands)	17.8	–
DM mortality (20–79 years)
Number of deaths; men (thousands)	281.3	–
Number of deaths; women (thousands)	316.5	–
Healthcare expenditure due to DM (20–79 years, Europe)
Total expenditure (billions of ¢)	75.1	90.2

DM = diabetes mellitus; IGT = impaired glucose tolerance.

Table 6. Prevention of T2DM by lifestyle intervention – the evidence
Study	Intervention	Patients (n)	Follow-up (years)	RRR^a (%)
Da-Qing Study China⁶²	Diet Exercise Diet + exercise Control	130 141 126 133	6	31 46 42
Diabetes Prevention Study Finland²⁷	Diet + physical activity Control	265 257	3.2	58
US Diabetes Prevention Program Outcomes Study USA²⁸	Diet + physical activity Metformin Placebo	1079 1073 1082	2.8	58 31
Indian Diabetes Prevention Program India³¹	Lifestyle Metformin Lifestyle + metformin Control	133 133 129 136	2.5	29 26 28
Japanese trial in men with IGT Japan⁶⁶	Diet + exercise Control	102 356	4	67
Study on lifestyle-intervention and IGT Maastricht study The Netherlands²⁹	Diet + physical activity Control	74 73	3	58
European Diabetes Prevention Study Newcastle, UK³⁰	Diet + physical activity Control	51 51	3.1	55
Zensharenb Study Japan³¹	Diet + physical activity Control	330 311	3	44

IGT = impaired glucose tolerance; RRR = relative risk reduction; SLIM = Study on lifestyle-intervention and IGT Maastricht.
^aAbsolute risk reduction numbers would have added value but could not be reported since such information is lacking in several of the studies.
^bThe Zensharen study recruited people with IFG, while other studies recruited people with IGT

Table 7. The strategic 'five As' for smoking cessation
A–ASK:	Systematically inquire about smoking status at every opportunity.
A–ADVISE:	Unequivocally urge all smokers to quit.
A–ASSESS:	Determine the person's degree of addiction and readiness to quit.
A–ASSIST:	Agree on a smoking cessation strategy, including setting a quit date, behavioural counselling, and pharmacological support.
A–ARRANGE:	Arrange a schedule for follow-up.

Table 8. Pharmacological treatment options for T2DM
Drug class	Effect	Weight change	Hypoglycaemia (monotherapy)	Comments
Metformin	Insulin sensitizer	Neutral/loss	No	Gastrointestinal side-effects, lactic acidosis, B12 deficiency. Contraindications, low eGFR, hypoxia, dehydration
Sulphonylurea	Insulin provider	Increase	Yes	Allergy Risk for hypoglycaemia and weight gain
Meglitinides	Insulin provider	Increase	Yes	Frequent dosing Risk for hypoglycaemia
Alfa-glucosidase inhibitor	Glucose absorption inhibitor	Neutral	No	Gastrointestinal side-effects Frequent dosing
Pioglitazone	Insulin sensitizer	Increase	No	Heart failure, oedema, fractures, urinary bladder cancer(?)
GLP-1 agonist	Insulin provider	Decrease	No	Gastrointestinal side-effects Pancreatitis Injectable
DPP-4 inhibitor	Insulin provider	Neutral	No	Pancreatitis
Insulin	Insulin provider Increase	Yes	Injectable Risk for hypoglycaemia and weight gain
SGLT2 inhibitors	Blocks renal glucose absorption in the proximal tubuli	Decrease	No	Urinary tract infections

eGFR = estimated glomerular filtration rate; GLP-1 = glucagon-like peptide-1; DDP = Diabetes Prevention Program; SGLT2 = sodium glucose co-transporter 2.

Table 9. Characteristics of dyslipidaemia in type 2 diabetes mellitus
Dyslipidaemia is a major risk factor for CVD.
Dyslipidaemia represents a cluster of lipid and lipoprotein abnormalities including elevation of both fasting and post-prandial TG, Apo B, small dense LDL particles, low HDL-C and Apo A.
Increased waist circumference and elevation of TGs is a simple tool to capture high-risk subjects with metabolic syndrome.

Apo = apolipoprotein; CVD = cardiovascular disease; HDL-C = high-density lipoprotein cholesterol; LDL = low-density lipoprotein; TG = triglyceride; TRL = triglyceride-rich lipoprotein.

Table 10. Summary of treatment targets for managing patients with diabetes mellitus or impaired glucose tolerance and coronary artery disease
Blood pressure (mmHg) In case of nephropathy	<140/85 Systolic <130
Glycaemic control HbA_1c (%)^a	Generally <7.0 (53 mmol/mol) On an individual basis <6.5–6.9% (48–52 mmol/mol)
Lipid profile mmol/l (mg/dL) LDL-cholesterol	Very high risk patients <1.8 mmol/L (<70 mg/dL) or reduced by at least 50% High risk patients <2.5 mmol/L (<100mg/dL)
Platelet stabilization	Patients with CVD and DM ASA 75–160 mg/day
Smoking Passive smoking	Cessation obligatory None
Physical activity	Moderate to vigorous ≥150 min/week
Weight	Aim for weight stabilization in the overweight or obese DM patients based on calorie balance, and weight reduction in subjects with IGT to prevent development of T2DM
Dietary habits Fat intake (% of dietary energy) Total Saturated Monounsaturated fatty acids Dietary fibre intake	<35% <10% >10% >40 g/day (or 20 g/1000 Kcal/day)

CVD = cardiovascular disease; DM = diabetes mellitus; HbA_1c = glycated haemoglobin A1c; IGT = impaired glucose tolerance; LDL = low density lipoprotein; T2DM = type 2 diabetes mellitus.
^aDiabetes Control and Complication Trial standard.

Table 11. History relevant to peripheral artery disease ⁴⁷⁵
- Family history of CVD.
- Symptoms suggesting angina.
- Any walking impairment, e.g. fatigue, aching, cramping, or pain with localization to buttock, thigh, calf, or foot, particularly when symptoms are quickly relieved at rest.
- Any pain at rest localized to the lower legs or feet and its association with the upright or recumbent positions.
- Any poorly healing wounds of the extremities. - Exertional pain in the upper extremities particularly if associated with dizziness or vertigo.
- Any transitory neurological symptom.
- History of abrupt onset hypertension, resistant hypertension (which may result from renal artery stenosis) or renal failure.
- Unusual or post-prandial abdominal pain particularly if related to eating and associated with weight loss.
- Erectile dysfunction.

CVD = cardiovascular disease.

Table 12. Physical examination relevant to peripheral artery disease ⁴⁷⁵
- Measurement of blood pressure in both arms and notation of asymmetry between the arms.
- Auscultation and palpation of the carotid and cervical areas.
- Palpation of the pulses at the upper extremities and if necessary, performance of Allen's test. The hands must be carefully inspected.
- Abdominal palpation and auscultation at different levels including the flanks and the iliac regions.
- Auscultation of the femoral arteries.
- Palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
- Inspection of the feet for colour, temperature, integrity of the skin. Recording of the presence of ulcerations.
-Additional findings suggestive of LEAD, including calf hair loss and skin changes, should be noted.
- ABI, calculated by dividing the systolic blood pressure at the tibial or dorsalis pedal level with the brachial pressure. An index of <0.9 is suggestive of LEAD.

ABI = ankle-brachial index; LEAD = lower extremity artery disease.

Authors and Disclosures

Lars Rydén* (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), Jose Luis Zamorano (Spain), Jose Luis Zamorano (Chairperson) (Spain), Stephan Achenbach (Germany), Helmut Baumgartner (Germany), Jeroen J. Bax (Netherlands), Héctor Bueno (Spain), Veronica Dean (France), Christi Deaton (UK), Çetin Erol (Turkey), Robert Fagard (Belgium), Roberto Ferrari (Italy), David Hasdai (Israel), ArnoW. Hoes (Netherlands), Paulus Kirchhof (Germany UK), 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), 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), John K. Kjekshus (Norway), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Eli Lev (Israel), Christian Mueller (Switzerland), Ludwig Neyses (Luxembourg), Peter M. Nilsson (Sweden), Joep Perk (Sweden), Piotr Ponikowski (Poland), Zeljko Reiner (Croatia), Naveed Sattar (UK), Volker Schächinger (Germany) and André Scheen (Belgium)

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.

*Corresponding authors
The two chairmen equally contributed to the document. Chairperson ESC: Professor Lars Rydén, Cardiology Unit, Department of Medicine Solna, Karolinska Institute, Solna SE-171, 76 Stockholm, Sweden, Tel: +46 8 5177 2171, Fax: +46 8 34 49 64, Email: lars.ryden@ki.se; Chairperson EASD: Professor Peter J. Grant, Division Of Cardiovascular & Diabetes Research, University Of Leeds, ClarendonWay, Leeds LS2 9JT, United Kingdom. Tel: +44 113 343 7721, Fax: +44 113 343 7738, Email: p.j.grant@ac.uk

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ESC Guidelines on Diabetes, Pre-diabetes, and Cardiovascular Diseases Developed in Collaboration With the EASD

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)

12. Patient-centred Care

12.1 General Aspects

12.2 Gaps in Knowledge

12.3 Recommendations for Patient-centred Care in Diabetes

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