Reacción a "Spain has experienced the largest increase in sudden death–attributable mortality in Europe over the past decade"

This elegant study is underpinned by the analysis of a very large population-based cohort—26 European countries and more than 53 million deaths—drawn from official WHO records, ensuring strong consistency and international comparability. Its design, based on age-adjusted mortality rates and trend regression models, provides a robust description of the temporal evolution of sudden death mortality. However, it is important to emphasise that this is a descriptive study: it does not seek to identify causal mechanisms, but rather to characterise the phenomenon, thereby opening the door to interpretation and hypothesis generation. In this context, the findings are particularly noteworthy, highlighting sudden death as a growing public health concern, with a sustained increase over the past decade, and underscoring the need to develop global strategies and health policies aimed at its prevention and management.

In the case of Spain, the observed increase is likely the result of a multifactorial interplay, in which population ageing stands out clearly. Spain has one of the highest life expectancies in Europe and worldwide, which translates into a greater proportion of individuals in higher-risk age groups. Advanced age remains the main risk factor for experiencing sudden death, closely linked to the prevalence of atherosclerotic cardiovascular disease, the leading underlying cause. This is compounded by changes in lifestyle, particularly among women, including greater physical inactivity and a rise in cardiovascular risk factors (such as obesity, diabetes, and hypertension), which may contribute to the more pronounced increase observed in this subgroup. Moreover, the potential influence of factors related to the chain of survival cannot be ruled out, including lower levels of public training in cardiopulmonary resuscitation and variability in out-of-hospital emergency response, as well as the availability and use of automated external defibrillators—factors that critically shape outcomes following cardiac arrest.

Finally, a relevant methodological aspect that may influence the interpretation of the results in Spain should be considered: the study’s reliance on death certificates and ICD-10 coding. In this regard, Spain may be relatively overrepresented in terms of sudden death due to significant advances in the identification and certification of these cases, driven by increasing integration between forensic medicine, primary care, emergency medical services (061), intensive care, and cardiology in the investigation of sudden death. While this progress is positive from both a clinical and scientific perspective, it may introduce a methodological artefact by improving the detection and classification of such events compared with countries with lower diagnostic accuracy, thereby partially contributing to the observed increase.