Diabetes as cardiovascular disease — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 62-year-old man in Europe has had type 2 diabetes for 12 years and had a myocardial infarction treated with PCI 3 years ago. He takes metformin, a statin and an ACE inhibitor. His eGFR is 68 mL/min/1.73 m², his UACR is 15 mg/g and his HbA1c is at his individual target. He has no heart failure.^[1]

1. Which ESC 2023 cardiovascular risk category is he in, and why? (1)^[1]
2. Give the ESC 2023 Recommendation Table 8 rows on SGLT2 inhibitors and GLP-1 RAs to reduce CV events that apply to him, with class and level. (2)^[1]
3. Name two SGLT2 inhibitors and two GLP-1 RAs that ESC 2023 lists as having proven CV benefit. (2)^[1]
4. What LDL-C target does ESC 2023 recommend for him, with class and level? (2)^[1]
5. He later develops HF. Which two glucose-lowering drugs does ESC 2023 not recommend in patients at risk of HF or with previous HF, with class and level? (2)^[1]
6. What does ESC 2024 recommend as the systolic BP target for a person with diabetes receiving BP-lowering drugs, with class and level? (1)^[6]

Model answers — SAQ 1

1. Very high CV risk: under ESC 2023 Table 7, patients with T2DM and clinically established ASCVD are at very high CV risk (1 mark).^[1]
2. SGLT2 inhibitors with proven CV benefit are recommended in patients with T2DM and ASCVD to reduce CV events, independent of baseline or target HbA1c and independent of concomitant glucose-lowering medication (ESC 2023, Class I, Level A) (1 mark).^[1] GLP-1 RAs with proven CV benefit are recommended in the same patients for the same purpose, with the same independence from HbA1c and other glucose-lowering drugs (ESC 2023, Class I, Level A) (1 mark).^[1]
3. SGLT2 inhibitors, any two of: empagliflozin, canagliflozin, dapagliflozin, sotagliflozin (1 mark).^[1] GLP-1 RAs, any two of: liraglutide, semaglutide s.c., dulaglutide, efpeglenatide (1 mark).^[1]
4. In T2DM at very high CV risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) (1 mark) and an LDL-C reduction of at least 50% is recommended (ESC 2023, Class I, Level B) (1 mark).^[1]
5. Pioglitazone: associated with an increased risk of incident HF and not recommended for glucose-lowering treatment in patients at risk of HF (or with previous HF) (ESC 2023, Class III, Level A) (1 mark).^[1] Saxagliptin: associated with an increased risk of HF hospitalisation and not recommended for glucose-lowering treatment in patients at risk of HF (or with previous HF) (ESC 2023, Class III, Level B) (1 mark).^[1]
6. In persons with diabetes who are receiving BP-lowering drugs, it is recommended to target systolic BP to 120–129 mmHg, if tolerated (ESC 2024, Class I, Level A) (1 mark).^[6]

SAQ 2 (10 marks)

Practice scenario. A 55-year-old woman in Europe has type 2 diabetes treated with metformin. She has hypertension and smokes, and has no ASCVD or heart failure. Her eGFR is 85 mL/min/1.73 m², her UACR is 10 mg/g and she has no retinopathy or neuropathy. Her 10-year CVD risk by SCORE2-Diabetes is 14%. She has no history of gastrointestinal bleeding or peptic ulcer, no active liver disease and no aspirin allergy.^[1]

1. Which ESC 2023 risk category is she in? (1)^[1]
2. Give the ESC 2023 Recommendation Table 9 row on an SGLT2 inhibitor or GLP-1 RA to reduce her CV risk, with class and level, and say how ESC 2023 explains its level. (2)^[1]
3. Give the two 2026 ESC heart failure guideline rows on SGLT2 inhibitors and GLP-1 RAs in T2DM that apply to her, with class and level. (2)^[4]
4. What does ADA 2026 recommendation 10.40b say, and does it apply to her? (1)^[2]
5. What does ESC 2023 say about aspirin for her, with class and level? (2)^[1]
6. Name two adverse effects to warn her about if she starts an SGLT2 inhibitor. (2)^[4][13][2]

Model answers — SAQ 2

1. High CV risk: she does not fulfil the very high-risk criteria, and her SCORE2-Diabetes 10-year CVD risk is in the 10% to <20% band (ESC 2023) (1 mark).^[1]
2. In T2DM without ASCVD or severe TOD but with a calculated 10-year CVD risk ≥10% by SCORE2-Diabetes, treatment with an SGLT2 inhibitor or GLP-1 RA may be considered to reduce CV risk (ESC 2023, Class IIb, Level C) (1 mark).^[1] ESC 2023 calls it a consensus within the Task Force, based on the assumption that some level of predicted CVD risk appears to be equivalent to severe TOD risk, acknowledging it is a Level C recommendation (1 mark).^[1]
3. An SGLT2 inhibitor is recommended in patients with T2DM at risk of HF (multiple ASCVD risk factors or established ASCVD) to reduce the risk of HF and CV death (ESC 2026 HF, Class I, Level A); smoking and blood pressure are among the conventional CVD risk factors ESC 2023 names (1 mark).^[4][1] A GLP-1 RA should be considered in patients with T2DM and at least one other additional CV risk factor to reduce the risk of HF or CV death (ESC 2026 HF, Class IIa, Level A) (1 mark).^[4]
4. In people with type 2 diabetes and established ASCVD or multiple ASCVD risk factors, or CKD, an SGLT2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of cardiovascular events (ADA 2026, grade A); it applies because she has multiple ASCVD risk factors (1 mark).^[2]
5. In adults with T2DM without a history of symptomatic ASCVD or revascularisation, aspirin (75–100 mg once daily) may be considered to prevent the first severe vascular event, in the absence of clear contraindications (ESC 2023, Class IIb, Level A) (1 mark).^[1] The footnote defines the clear contraindications as high bleeding risk due to gastrointestinal haemorrhage or peptic ulcer within 6 months, active hepatic disease, or aspirin allergy; she has none (1 mark).^[1]
6. Urinary infections and genital fungal infections (vulvovaginitis): ESC 2026 HF, in its section on diabetes, says SGLT2 inhibitors are generally well tolerated but may cause them, with a prevalence of up to 6.9% in women (1 mark).^[4] Diabetic ketoacidosis: more common with dapagliflozin than placebo in DECLARE-TIMI 58 (17,160 patients with type 2 diabetes who had or were at risk for ASCVD, median 4.2 years; 0.3% vs. 0.1%); ADA 2026 advice for people with diabetes at risk of DKA who take SGLT inhibition includes education on the risks and signs of ketoacidosis (1 mark).^[13][2]