As usual, this issue opens with a comment by Fernando A. Navarro, providing us with the last instalment on the topic of eponyms. Terms such as Western blot, tako-tsubo, Student t, and Pilates sometimes refer to people's names and other times have nothing to do with persons in the world of medicine.
In the first of the editorials in this issue, López-Mínguez et al. discuss 3 original articles on stroke prevention in nonvalvular atrial fibrillation. In the first of these, Anguita Sánchez et al. report the results of the FANTASIIA registry, which included 2178 consecutive outpatients with nonvalvular atrial fibrillation between June 2013 and October 2014. After a median follow-up of 32.4 months, patients receiving direct oral anticoagulants had lower crude rates of stroke, severe bleedings, cardiovascular mortality, and all-cause mortality. However, while the adjusted analysis showed a trend in favor of direct oral anticoagulants, the results were not statistically significant. As mentioned by López-Mínguez et al., it is difficult to translate the results of clinical trials to real-world clinical practice and there are often discrepancies between distinct registries on the effectiveness of a drug in clinical practice, as shown by several examples in their commentary.
The second original article, by Cruz-González et al., aimed to examine the safety and effectiveness of left atrial appendage occlusion in patients aged 85 years or older with nonvalvular atrial fibrillation. This study is a subanalysis of the EWOLUTION registry, and identified 84 patients aged ≥ 85 years, among a total of 1025 who had undergone left atrial appendage occlusion. Although this subgroup obviously had higher stroke and bleeding risks than younger patients, the success rate was similar in both groups (98.0% vs 98.5%) and there were no differences in the rate of adverse events at 7 days or in the annualized stroke rate. These results show that this procedure is equally safe and effective in this this subgroup of especially vulnerable patients. As discussed by López-Mínguez et al., the study is important, firstly because this subgroup is highly underrepresented in clinical trials, and secondly because these patients are at greater risk of bleeding complications; bleeding risk is poorly estimated by the HAS-BLED score in older persons, because it assigns the same risk score after the age of 65 years.
In the last of the original articles discussed by López-Mínguez et al., Cruz-González et al. again examine the subject of left atrial appendage occlusion. Specifically, the authors analyze the safety and effectiveness of left atrial appendage occlusion as secondary prevention in patients with nonvalvular atrial fibrillation who have had a stroke despite oral anticoagulant therapy (“resistant stroke”). The study is a subanalysis of the Amplatzer Cardiac Plug multicenter registry. Of 1047 patients included in the registry, 115 had a resistant stroke. No significant differences were observed in this subgroup, which had higher ischemic and bleeding risk, compared with the remaining patients in periprocedural major safety events, while there was a significant reduction in events (stroke and bleeding) during follow-up. López-Mínguez et al. point out that the main finding of this study is that left atrial appendage occlusion is safe and effective in this subgroup of complex patients and, more importantly, reduces bleeding events during follow-up to zero.
The next editorial, by Sanmartín Fernández and Abellás Sequeiros, discusses a study by Álvarez Álvarez et al. aiming to analyze the association between early coronary angiography (first 24hours after admission) and all-cause mortality and cardiovascular mortality in patients with non–ST-segment elevation acute coronary syndrome. This retrospective observational study included 5673 consecutive patients with this condition in 2 Spanish hospitals. Among the total, early coronary angiography was performed in only 2087 patients. After propensity score matching, early revascularization was associated with significantly lower mortality in high-risk patients. Sanmartín Fernández and Abellás Sequeiros stress that the findings of this study, despite the known limitations of observational designs, are in line with the latest recommendations of the ESC guideline on myocardial revascularization and corroborate the findings of clinical trials indicating a benefit of the early strategy in very high-risk patients, with this benefit extending beyond the hospital phase.
The last of the editorials in this issue, by Banegas and Townsend, discusses an original article by Gómez-Sánchez et al. aiming to quantify reference values for various indices of arterial stiffness in a representative sample and to establish their association with cardiovascular risk factors. The cross-sectional study was performed in a sample that was correctly selected through random sampling stratified by age and sex. Almost all the values analyzed were higher in men and increased with age and blood pressure. Banegas and Townsend review the concept of arterial stiffness and its association with arteriosclerosis and cardiovascular disease and compare the findings of the study with those of previously published work.
Bystander assistance is decisive in improving the results of out-of-hospital cardiac arrest. In the last original article in this issue, González-Salvado et al. publish a systematic review describing the possible training methods in basic life support for the adult population and analyzing their effectiveness. The authors reviewed all studies evaluating basic life support training from January 2006 to July 2018. Of a total of 1263 studies identified, 27 were finally included, with only a minority being randomized controlled trials. Although contents, methods and assessment tools varied widely, it seems that the best results were obtained with instructor-led methods with feedback-supported hands-on practice. The editorial is published as an open access article and is accompanied by an Editor's pick video.
Heart failure is a complex entity associated with high morbidity and mortality. Moreover, its natural history is complex and the approach to end-stage disease is difficult. Consequently, this issue includes 2 closely-related articles providing in-depth discussion of the problem of palliative care in end-stage heart failure. One of these articles is a narrative review by Slavin and Warraich that analyzes, based on the literature, the optimal timing of palliative care in this condition. The other, closely-related article, is a consensus document of the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology. The document discusses the various aspects related to palliative care in heart failure and establishes a consensus and series of recommendations to identify the appropriate timing to start the progressive application of this therapeutic modality.
As always, don’t forget to take a look at the excellent images in this issue or read the letters. We also encourage you to take part in our ECG Contest.
Ignacio Ferreira-González
Editor-in-chief