FAQ: Understanding New ESC/ERA Guideline on Cardiovascular Disease and Chronic Kidney Disease

The European Society of Cardiology (ESC), in collaboration with the European Renal Association (ERA), published its first guideline specifically on managing cardiovascular disease and chronic kidney disease (CKD) on August 29, 2026, in the European Heart Journal.

The task force, which was co-chaired by Kevin Damman, MD, PhD, and William G. Herrington, MD, MBBS, developed the guideline in response to the estimated 100 million people in Europe living with CKD and the tight bidirectional relationship between CKD and cardiovascular conditions including coronary artery disease, heart failure, arrhythmias, stroke, and peripheral arterial disease.

The document organizes its recommendations around a “STAMP on CKD” framework — Screen, Triage and stage, Address CKD and CVD risk, Modify CVD management, and Plan health services — and covers the full range of cardiovascular disease in a single document, flagging where CKD requires a change in standard cardiology practice.

Frequently Asked Questions

What does this guideline cover, and who is it written for?

The guideline covers the full range of cardiovascular disease — coronary artery disease, heart failure, atrial fibrillation, valvular disease, peripheral arterial and aortic disease, and peri-procedural kidney injury — in patients who have or are at risk for chronic kidney disease. It is written primarily for the cardiology community but is intended to be relevant to any clinical team caring for patients with both conditions. It does not cover nephrology-specific management in detail (e.g., kidney replacement therapy, renal anemia); for those topics the task force points readers to the relevant KDIGO guidelines.

What is new about this guideline?

This is the first ESC guideline dedicated specifically to the intersection of CVD and CKD. It is a joint effort with the European Renal Association rather than a cardiology-only document, and it consolidates guidance that previously would have been scattered across separate disease-specific guidelines into a single framework.

What is the “STAMP on CKD” framework the guideline is organized around?

Screen for CKD in all patients with CVD (and vice versa)

Triage and stage CKD severity

Address CKD and CVD risk with appropriate risk-modifying therapy

Modify standard CVD management approaches where CKD changes the calculus

Plan health services to coordinate care for patients with both conditions.

What is the key screening recommendation?

The guideline recommends systematic screening for CKD by measuring estimated glomerular filtration rate (eGFR) and albuminuria in all patients with CVD, with at least annual re-screening in patients who have diabetes, CKD, and CVD together.

What are the key recommendations for addressing CKD and CVD risk pharmacologically?

An ACE inhibitor or ARB plus an SGLT2 inhibitor is recommended for most patients with CKD to reduce both CKD progression and cardiovascular risk. Suitably intensive statin-based therapy, with or without ezetimibe, is recommended for patients with CKD regardless of lipid levels. SGLT2 inhibitors can be safely initiated at eGFR ≥20 mL/min/1.73m² and continued as eGFR falls below that threshold until kidney replacement therapy begins. A non-steroidal mineralocorticoid receptor antagonist (finerenone) and a GLP-1 receptor agonist (semaglutide) are recommended for patients with CKD, type 2 diabetes, and albuminuria to further reduce CKD progression and cardiovascular events.

How does the guideline address heart failure specifically in patients with CKD?

Foundational heart failure therapies are similarly effective in relative terms in patients with and without CKD, and the higher absolute risk in CKD predicts larger absolute treatment benefit. SGLT2 inhibitor therapy is recommended independent of ejection fraction. For HFrEF, an ARNI (or single ACEI/ARB), beta-blocker, and MRA are recommended; for HFpEF, a non-steroidal MRA should be added. In decompensated HF with CKD, higher loop diuretic doses and early combination diuretic therapy should be considered given increased diuretic resistance.

What does the guideline recommend for anticoagulation in atrial fibrillation and CKD?

Direct oral anticoagulants are preferred over vitamin K antagonists in patients with AF and CKD with eGFR >30 mL/min/1.73m², and oral factor Xa inhibitors may be preferred over VKAs specifically at eGFR 15–29 mL/min/1.73m². The guideline notes that existing stroke and bleeding risk-prediction tools for AF perform poorly in the CKD population.

How is the strength of each recommendation graded?

The guideline uses the standard ESC framework of Class of Recommendation (I, IIa, IIb, III) paired with a Level of Evidence (A, B, or C). A Level of Evidence A can exceptionally be assigned on a single very large randomized controlled trial with convincing evidence, provided at least 90% of the task force agrees.

What gaps in evidence does the task force identify?

The task force notes that patients with CKD have been historically understudied in cardiovascular RCTs across nearly every guideline section, and flags specific open questions — including optimal natriuretic peptide cutoffs for diagnosing heart failure in CKD, the optimal duration of dual antiplatelet therapy in CKD patients with chronic coronary syndromes, and a lack of RCT data on anticoagulation safety and efficacy at eGFR <15 mL/min/1.73m².

Who developed the guideline, and where was it published?

The guideline was developed by an ESC task force in collaboration with the European Renal Association, with contributions from ESC subspecialty associations, councils, and working groups spanning cardiovascular nursing, acute cardiovascular care, cardiovascular imaging, preventive cardiology, percutaneous intervention, heart rhythm, and heart failure. It was published in the European Heart Journal on August 29, 2026 (DOI: 10.1093/eurheartj/ehag098).

References

1. Damman K, ter Maaten JM, Mayne KJ, et al. 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA). Eur Heart J. 2026;00:1-102. doi:10.1093/eurheartj/ehag098 https://doi.org/10.1093/eurheartj/ehag098