Atrial fibrillation (AF) is related to a high incidence of stroke, and anticoagulant treatment of patients with atrial fibrillation reduces the risk of stroke.1,2 In this issue of the journal, Dr Goto and co-workers report new data from the ARISTOTLE study. The authors investigated antithrombotic use, and clinical outcomes of patients with AF and a thrombo-embolic event in the ARISTOTLE study. During follow-up (median 1.8 years), 22 patients (7.1%/year) had a recurrent stroke, 97 (30.1%/year) died, and 10 (6.7%/year) had major bleeding. Compared with patients without a thrombo-embolic event, the short- and long-term adjusted hazards of death in patients with a thrombo-embolic event were high [≤30 days, hazard ratio (HR) 54.3%, 95% confidence interval (CI) 41.4–71.3; >30 days, HR 3.5, 95% CI 2.5–4.8; both P < 0.001]. The adjusted hazards of major bleeding were also high in the short term (HR 10.37. 95% CI 3.87–27.78; P < 0.001) but not in the long-term (HR 1.7, 95% CI 0.77–3.88; P = 0.18). The authors concluded that thrombo-embolic events were rare but were associated with high short- and long-term morbidity and mortality. Substantial numbers of patients are not receiving oral anticoagulation before and, despite this risk, after a first thrombo-embolic event. Despite strong recommendations encouraging the use of anticoagulants in patients with AF at risk of stroke, adherence to anticoagulant therapy in clinical practice is still low.3,4
In another multinational study, Dr Frankenstein and co-workers compared the effectiveness of enalapril, lisinopril, and ramipril in the treatment of patients with chronic heart failure5 in a propensity score-matched cohort study. During a follow-up of 21 939 patient-years, 360 (49.5%), 337 (52.4%), and 1119 (33.4%) patients died among those prescribed enalapril, lisinopril, and ramipril, respectively. There was no significant association between angiotesin-converting enzyme inhibitor (ACEI) choice and all-cause mortality in any of the matched samples. Results were confirmed in subgroup analyses with respect to age, sex, left ventricular ejection fraction, New York Heart Association functional class, cause of heart failure with reduced ejection fraction (HFrEF), rhythm, and systolic blood pressure. The authors concluded that enalapril, lisinopril, and ramipril were equally effective in the treatment of patients with HFrEF when given at equivalent doses.
In a registry study, consisting of >70 000 patients with myocardial infarction (MI), Dr Smedegaard and co-workers from Denmark report temporal trends in MI presentation with or without ST-segment elevation (STE) and the association with use of cardioprotective drugs prior to admission. The incidence rates (IRs) of MI declined between 2003 and 2012, primarily driven by a 35% reduction in IRs for NSTEMI, whereas IRs for STEMI declined after 2007.6,7 Pre-admission use of cardioprotective drugs increased markedly and was associated with lower odds ratios (ORs) of presenting with STEMI than NSTEMI.
Prescription of aspirin, P2Y12 inhibitors, a statin, beta-blockers, and ACEIs or angiotensin receptor blockers (ARBs) is recommended post-acute coronary syndrome (ACS).8 A Dutch study led by Dr van‘t Hof reports registry data from 9202 patients with ACS. The group reports that optimal medical treatment (OMT) prescription and mortality remained stable from 2006 until 2014. Fewer than 45% of the patients were discharged on OMT after an ACS admission. At 1 year, only 25.5% of patients were on OMT. Among survivors of ACS hospitalization, OMT prescription at discharge was associated with a reduction in 1-year mortality after adjustment for variables associated with 1-year mortality and OMT at discharge. Thus, adherence to guidelines pays off.9
We are also proud to publish two excellent review papers. Dr Pinto and co-workers from Portugal present Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and valvular heart disease: systematic review and meta-analysis. Also, Dr Graham and co-workers present a review entitled New strategies for the development of lipid-kowering therapies to reduce cardiovascular risk.
Hopefully the readers will find these papers interesting!
References
Author notes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
