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Background The diagnosis of ST elevation myocardial infarction (STEMI) is challenging when the culprit is in the left circumflex coronary artery (CX) territory because ST elevations are often not captured by the standard 12-lead electrocardiogram (ECG). Although, guidelines recommend the acquisition of the additional posterior leads V7-V9 (pECG) when the suspicion of acute coronary syndrome (ACS) is high and the ECG non-diagnostic, this is not routinely done. Purpose The purpose of the FLAWLESS trial, was to improve the prehospital CX STEMI diagnostic. The study consisted of 2 parts: a) a training and implementation study, and b) an outcomes study after implementation. In the implementation study we evaluated the FLAWLESS process from the paramedic's point of view on experiences, implementation of pECG lead recordings and its barriers. Methods Before initiating the trial, all active paramedics in 2 health care regions were educated via a specifically designed and mandatory online 30 min course and all 250 ambulances equipped with a SMART-CARD (instructing how to record pECG leads) and FAQ-sheet. All paramedics were invited by email to anonymously answer an online questionnaire (OQ) designed in REDCap® and interviewed. Utility-score and difficulty-score, ranging from 0 (not useful at all/very easy) to 100 (very useful/very difficult), were introduced for quantitative assessments. Results A total of 1268 paramedics were invited to answer the OQ. The response rate was intermediate at 35%. Among responders, 89% had completed the OEP. On duty 80% had used FAQ-sheet and 74% SMART-CARD in the field. The median utility scores were 80 (25th and 75th quartiles 67–90) for OEP, 79 (61–90) for FAQ-sheet and 85 (75–97) for SMART-CARD, respectively. The implementation of pECG leads recordings was fairly high – 54% reported always recording V7-V9 in ACS patients and 36% reported doing it frequently. Difficulty-score for recording V7-V9 leads in the prehospital setting was 50 (19–70). Finally, 43% reported difficulties that were related to technicalities i.e. defibrillators not having dedicated V7, V8 and V9 cables, hence ambulance staff is forced to record and transmit a second ECG after moving the V4, V5 and V6 cables to the V7-V9 positioned electrodes. Conclusion We demonstrated that large-scale online training of paramedics in the recording of prehospital 15-lead ECG is feasible. The evaluation was positive regarding training and support tools in the ambulances but almost 50% of paramedics found the recording very difficult in the field. Future ECG machines used in emergency settings should be constructed with 13 instead of 10 cables to allow simultaneously recording of 15 leads (standard, precordial and the V7-V9 posterior). This would ease acquisition, facilitate implementation of guideline recommendation. Funding Acknowledgement Type of funding sources: None.

Background Out-of-hospital cardiac arrest (OHCA) survivors are a selected group of patients with younger age and less comorbid conditions relative to non-survivors. Long-term risk of stroke, atrial fibrillation or flutter (AF), acute coronary syndrome (ACS) and heart failure (HF) in OHCA survivors not diagnosed with any of these conditions as part of the cardiac arrest is unknown. Purpose To examine 5-year risk of stroke, AF, ACS and HF in 30-day OHCA survivors relative to age- and sex-matched population controls. Methods OHCA 30-day survivors and age- and sex-matched population controls not previously diagnosed with stroke, AF, ACS or HF or during the first 30 days after cardiac arrest were included using Danish Cardiac Arrest Registry data from 2001–2015 as well as the Danish Civil Registration System. Characteristics are compared using totals and percentages for categorical data and median and 25–75% percentiles for continuous data. Five-year outcomes are compared using cumulative incidence plots as well as Shared Frailty Cox regression modeling, unadjusted and adjusted for potential confounders including age, sex, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), peripheral arterial disease (PAD), chronic ischemic heart disease (IHD), transient ischemic attack (TIA), thyroid disease, cholesterol-lowering, antiplatelet and anticoagulant agents. Results Of 4362 30-day survivors, 1063 were stroke-, AF-, ACS- and HF-naïve and 1051 were matched to population controls using age, sex and time of OHCA event as matching variables. The figure depicts the risk of stroke beyond day 30 to 5 years of follow-up was 4.7% versus 1.7% for OHCA survivors vs. controls. Risks of AF, ACS and HF were 7.0% vs. 2.1%, 4.7% versus 1.2% and 12.2% vs. 1.0%, respectively. OHCA 30-day survivors were significantly more likely to have PAD relative to controls, 4.9% vs. 1.1%. Differences in IHD (22.0% vs. 1.7%), hypertension (28.1% vs. 14.6%), diabetes (9.5% vs. 4.1%), lipid-lowering agents (27.6% vs. 9.5%), COPD (11.3% vs. 2.2%) were also significant. When adjusting for these comorbidities as well as for thyroid diseases, chronic kidney disease, cancer, antiplatelet and anticoagulant therapy, differences remained highly significant: HR stroke 3.33 [95% CI 2.21–5.02], HR AF 3.26 [2.28–4.66], HR ACS 3.36 [2.14–5.27] and HR HF 11.50 [8.02–16.48]. Conclusion We demonstrate an increased five-year risk of stroke, atrial fibrillation or flutter, acute coronary syndrome and heart failure in out-of-hospital cardiac arrest survivors without prior existence of any of these conditions. These results indicate that OHCA survivors continue to remain high-risk patients for cardiovascular events and prevention intervention is warranted. Funding Acknowledgement Type of funding source: None

Background Patients who suffer a sudden out-of-hospital cardiac arrest (OHCA) may be preceded by warning symptoms and healthcare system contact. Though, is currently difficult early identification of sudden cardiac arrest patients. Purpose We aimed to examine contacts with the healthcare system up to two weeks and one year before OHCA. Methods OHCA patients were identified from the Danish Cardiac Arrest Registry (2001–2014). The pattern of healthcare contacts (with either general practitioner (GP) or hospital) within the year prior to OHCA of OHCA patients was compared with that of 9 sex- and age-matched controls from the background general population. Additionally, we evaluated characteristics of OHCA patients according to the type of healthcare contact (GP/hospital/both/no-contact) and the including characteristics of contacts, within two weeks prior their OHCA event. Results Out of 28,955 OHCA patients (median age of 72 (62–81) years and with 67% male) of presumed cardiac cause, 16,735 (57.8%) contacted the healthcare system (GP and hospital) within two weeks prior to OHCA. From one year before OHCA, the weekly percentages of contacts to GP were relatively constant (26%) until within 2 weeks prior to OHCA where they markedly increased (54%). In comparison, 14% of the general population contacted the GP during the same period (Figure). The weekly percentages of contacts with hospitals gradually increased in OHCA patients from 3.5% to 6.5% within 6 months, peaking at the second week (6.8%), prior to OHCA. In comparison, only 2% of the general population had a hospital contact in that period (Figure). Within 2 weeks of OHCA, patients contacted GP mainly by telephone (71.6%). Hospital diagnoses were heterogenous, where ischemic heart disease (8%) and heart failure (4.5%) were the most frequent. Conclusions There is an increase in healthcare contacts prior to “sudden” OHCA and overall, 54% of OHCA-patients had contacted GP within 2 weeks before the event. This could have implications for developing future strategies for early identification of patients prior to their cardiac arrest. Figure 1. The weekly percentages of contacts to GP (red) and hospital (blue) within one year before OHCA comparing the OHCA cases to the age- and sex-matched control population (N cases = 28,955; N controls = 260,595). Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020

The impact of insulin secretagogues (ISs) on long-term major clinical outcomes in type 2 diabetes remains unclear. We examined mortality and cardiovascular risk associated with all available ISs compared with metformin in a nationwide study.All Danish residents20 years, initiating single-agent ISs or metformin between 1997 and 2006 were followed for up to 9 years (median 3.3 years) by individual-level linkage of nationwide registers. All-cause mortality, cardiovascular mortality, and the composite of myocardial infarction (MI), stroke, and cardiovascular mortality associated with individual ISs were investigated in patients with or without previous MI by multivariable Cox proportional-hazard analyses including propensity analyses. A total of 107 806 subjects were included, of whom 9607 had previous MI. Compared with metformin, glimepiride (hazard ratios and 95% confidence intervals): 1.32 (1.24-1.40), glibenclamide: 1.19 (1.11-1.28), glipizide: 1.27 (1.17-1.38), and tolbutamide: 1.28 (1.17-1.39) were associated with increased all-cause mortality in patients without previous MI. The corresponding results for patients with previous MI were as follows: glimepiride: 1.30 (1.11-1.44), glibenclamide: 1.47 (1.22-1.76), glipizide: 1.53 (1.23-1.89), and tolbutamide: 1.47 (1.17-1.84). Results for gliclazide [1.05 (0.94-1.16) and 0.90 (0.68-1.20)] and repaglinide and [0.97 (0.81-1.15) and 1.29 (0.86-1.94)] were not statistically different from metformin in both patients without and with previous MI, respectively. Results were similar for cardiovascular mortality and for the composite endpoint.Monotherapy with the most used ISs, including glimepiride, glibenclamide, glipizide, and tolbutamide, seems to be associated with increased mortality and cardiovascular risk compared with metformin. Gliclazide and repaglinide appear to be associated with a lower risk than other ISs.