2026 ESC Management of Cardiovascular Disease and Chronic Kidney Disease Guideline Now Available

The European Society of Cardiology (ESC) just released a new guideline, Management of Cardiovascular Disease and Chronic Kidney Disease, the first ESC guideline to be dedicated to cardiovascular disease (CVD) and chronic kidney disease (CKD). The guideline aims to help clinicians with the early diagnosis of CKD patients with CVD, the appropriate use of kidney failure risk-modifying therapies in patients with CVD and CKD, the early diagnosis of CVD in patients with CKD, the prevention and treatment of CVD in the setting of CKD, approaches to changes in kidney function during procedural and medical treatments for CKD, and the multidisciplinary management of patients with CVD and CKD between specialties. 

With the guideline, the ESC provides evidence-based recommendations to help ensure patients with CKD, who are at high risk of adverse consequences of CVD, receive effective, timely, and safe care. 

Today, we are featuring key messages from the 2026 ESC guideline on the management of CVD and CKD. These key messages focus on screening, triage, staging, addressing risk, modifying CVD management approaches, and planning health services. View the full-text version of the guideline for the complete look at all the recommendations,

Key Messages of the 2026 Guideline:

The ESC emphasized the acronym STAMP on CKD: Screen, Triage, and Address CKD risk, Modify CVD management, and Plan health services. 

Screen: A key aim of the guideline is to facilitate early diagnosis of CKD in patients with CVD (and vice versa). Screen for CKD by measuring eGFR and albuminuria in all patients with CVD. Stage CKD using eGFR and a spot uACR, and consider chronicity. At least annual re-screening/re-testing for eGFR and uACR is recommended in patients with diabetes, CKD, and CVD.

Triage and Staging of CKD: In CKD categories G3–5, use the KFRE to assess an individual’s absolute risk for progression to needing KRT to allow timely referral for nephrology evaluation and management. CVD risk scores that include eGFR and/or albuminuria should be preferentially used to establish accurate CVD risk in patients with CKD.

Addressing CKD and CVD Risk: A key aim of the guideline is to ensure appropriate early use of kidney failure and CVD risk-modifying therapy in patients with CVD and CKD. 

• Suitably intensive statin-based therapy with or without ezetimibe should be routinely and widely offered to patients with CKD (not on dialysis) irrespective of lipid levels, to reduce risk of ASCVD. 
• An ACEI or ARB, and SGLT2 inhibitor are recommended for most patients with CKD to reduce the risk of CKD progression and CVD risk. 
• SGLT2 inhibitors can safely be initiated at eGFR ≥20 mL/min/1.73 m²and can be continued when eGFR progresses below 20 mL/min/1.73 m² until initiation of KRT (hence it would be reasonable to start them at eGFR <20 mL/min/1.73 m²). 
• Non-steroidal MRA (finerenone) and GLP-1RA (semaglutide) therapy are recommended for patients with CKD with type 2 diabetes and albuminuria to further reduce risk of CKD progression and cardiovascular events. 
• Extra biochemical monitoring after initiation of SGLT2 inhibitors or GLP-1RAs is not routinely required, but 1–4 weeks after initiation of RAAS blockade serum potassium and eGFR should be re-checked. 
• When initiating RAAS blockade/SGLT2 inhibitors for CKD and/or HF, a modest decrease in eGFR (typically <30%) is expected, which does not diminish the beneficial treatment effects. 
• Blood glucose lowering and blood pressure management in CKD should prioritize agents also shown to reduce risk of kidney disease progression and/or cardiovascular events

Modifying Approaches to CVD Management: The guideline aims to highlight key areas where the presence of decreased GFR necessitates changes to CVD management.

• Heart Failure:
  • Foundational medical therapies for treating HF are similarly effective in terms of relative treatment effects in patients with and without CKD. High absolute risk in CKD predicts large absolute treatment benefits.
  • In patients with evidence of volume overload, sufficiently high loop diuretic dosing, measuring diuretic response, and employing combination diuretic therapy in decompensated HF and CKD should achieve maximal decongestion.

• Chronic Coronary Syndrome and Acute Coronary Syndrome:
  • An individualized approach to diagnostic coronary imaging is recommended in patients with CKD. Management of CCS in patients with CKD generally follows a standard approach where an initial conservative approach of optimal medical therapy is recommended.
  • If revascularization is indicated, individualized decision-making is required regarding type of revascularization (PCI vs CABG).
  • Abbreviated DAPT duration (1–3 months vs conventional 6 months) should be considered for patients with CKD and CCS undergoing elective PCI, to reduce the risk of bleeding.
  • Serial assessment of troponin levels in patients with CKD and suspected ACS is important.
  • Patients with ACS and CKD have a higher risk of bleeding and this may impact choice, type, intensity, and duration of (dual) antiplatelet therapy.

• Atrial Fibrillation:
  • Existing stroke and bleeding risk-prediction tools in AF perform poorly in CKD.
  • DOACs are preferred over VKAs for patients with AF and CKD with eGFR >30 mL/min/1.73 m².
  • Oral factor Xa inhibitors may be considered in preference over VKAs for patients with eGFR 15–29 mL/min/1.73 m².
  • Cardioversion success appears to be unaffected by CKD stage, but AF recurrence is high. Catheter ablation may be an effective alternative.
  • Both rate- and rhythm-control strategies in CKD patients need individualized approaches, with considerations for drug pharmacokinetics, electrolyte imbalance, prevalence of structural heart disease, and AF recurrence risks.

• Contrast-Induced Acute Kidney Injury:
  • Permanent harm directly from CI-AKI (i.e. death, dialysis, or sustained important reduction in eGFR after 6 months) is relatively rare and therefore risk of CI-AKI is nearly always outweighed by the benefits of diagnostic imaging and therapeutic interventions (and any potential harm of withholding or delaying procedures or therapies should be avoided).
  • Use of iso-osmolar or low osmolar contrast media in combination with contrast-sparing protocols is indicated when eGFR is <30 mL/min/1.73 m², and peri-procedural intravenous hydration may also be considered.

Planning Health Services for the Complexities of CKD: From a patient perspective, communication and education about CKD is important. All clinicians should engage in managing risk of CVD and risk of CKD progression to reduce the global burden of both conditions. Health services should be set up to recognize high-risk patients, taking into account special considerations in CKD, to minimize risks as well as any delay in treatment that such patients have.

Comparing ESC 2026 CVD and CKD Guideline to 2026 AHA/ACC/ADA/ASN CKM Syndrome Guideline

We're taking a few key recommendations from the 2026 ESC CVD and CKD guideline and comparing them to similar recommendations from the 2026 American College of Cardiology (ACC), American Heart Association (AHA), American Diabetes Association (ADA), and American Society of Nephrology (ASN) guideline Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome. Consult the full-text versions of the guidelines for the complete listing of recommendations and associated rationale.

Management of Patients with Obesity

CVD Risk Assessment

Pharmacological Interventions for Patients with Type 2 Diabetes

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