ADA 2026 Standards of Care: What the update means for cardiovascular clinical practice

The American Diabetes Association (ADA) has released its 2026 Standards of Care, reflecting the rapidly evolving evidence base across diabetes, cardiometabolic disease, and integrated care. With expanded guidance on GLP-1–based therapies, clearer pathways for heart failure and atherosclerotic cardiovascular disease, and updated targets for blood pressure and lipids, the recommendations have important implications for cardiovascular practice.

In this Q&A, Former Chief Scientific and Medical Officer of the ADA, Dr Robert Gabbay (Joslin Diabetes Center, Boston, MA, USA) outlines how the Standards place greater emphasis on considering cardiorenal risk early in treatment decisions for type 2 diabetes, highlight stronger roles for GLP-1 and SGLT2 inhibitors across heart failure and ASCVD, tighten blood pressure and LDL-cholesterol targets for high-risk patients, and expand the focus on behavioural health, sleep, and the psychosocial burden of living with diabetes—underscoring a more integrated, whole-person approach to care.

I’m Bob Gabbay, an endocrinologist at the Joslin Diabetes Centre and an Associate Professor at Harvard Medical School, and the former Chief Scientific and Medical Officer of the American Diabetes Association.

It is honestly hard to think of any change over the last several years that has been as dramatic in terms of how we manage disease, and it has really shifted our thinking when choosing pharmacological therapy for people with type 2 diabetes. The first step is to identify their risk for cardiorenal disease, and then choose the agent based on that, before thinking about A1C and whether they are on metformin or not.

In heart failure, it comes down to these two medications being one of the biggest changes. Firstly, something that wasn’t picked up as well in previous Standards of Care was the importance of screening individuals with type 2 diabetes and risk factors, and then the second part of that depends on their stage of heart failure. If they are stage B symptomatic, then they should be considered not only for an SGLT2 inhibitor, but also for a GLP-1 receptor agonist.

For patients with symptomatic heart failure and an ejection fraction of 40%, the new recommendations include adding a GLP-1 receptor agonist alongside SGLT2 inhibitors, ACE inhibitors or ARBs, and finerenone. For atherosclerotic cardiovascular disease, there are stronger recommendations on the use of both GLP-1 and SGLT2 inhibitors.

New this year is that the goal for systolic blood pressure should be less than 130mm Hg, but there is a stronger recommendation for those with renal or cardiovascular disease risk to target 120mm Hg, if safe. So, ideally, really pushing that blood pressure goal down to 120mm Hg, if it can be done safely.

I would also highlight the LDL cholesterol goals, which changed a couple of years ago, but still haven’t gotten enough attention. For people with diabetes and atherosclerotic cardiovascular disease, there is an LDL goal less than 55mg/dL, which is lower than it had been. For those with diabetes and high risk of cardiovascular disease, there’s an LDL goal of less than 70mg/dL.

Well, we know that behavioural health is a critical part of appropriate diabetes management and we’ve long recommended yearly depression screening, because 30% of people with type 2 diabetes have depression, and it affects their adherence and their outcomes. But new this year is screening yearly for anxiety symptoms and also diabetes distress. Another call out is to evaluate sleep health, because we know sleep health can really impact glycaemic control and insulin resistance.

Diabetes continues to evolve; the management certainly does, and that’s why this is a yearly document that’s put together. I think the increasing role of SGLT2 and GLP-1 inhibitors, the powerful tool of continuous glucose monitors, and the strong recommendation for automated insulin delivery devices for anyone on multi-dose insulin therapy are the key takeaways.