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Introduction The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with myocardial infarction. However, its performance in type 2 myocardial infarction is uncertain. Methods In two cohorts of consecutive patients with suspected acute coronary syndrome from ten hospitals in Scotland (n=48,282) and a tertiary care hospital in Sweden (n=22,589), we calculated the GRACE 2.0 score to estimate death at one year. Discrimination was evaluated by the area under the receiver-operator-curve (AUC), and compared for those with an adjudicated diagnosis of type 1 and type 2 myocardial infarction using DeLong’s test. Results Type 1 myocardial infarction was diagnosed in 4,981 (10%) and 1,080 (5%) patients in Scotland and Sweden, respectively. At one year, 720 (15%) and 112 (10%) patients died with an AUC for the GRACE score of 0.83 (95% confidence interval [CI] 0.82 to 0.85) and 0.85 (95% CI 0.81 to 0.89). Type 2 myocardial infarction occurred in 1,121 (2%) and 247 (1%) patients in Scotland and Sweden respectively, with 258 (23%) and 57 (23%) deaths at one year. The AUC was 0.73 (95% CI 0.70 to 0.77) and 0.73 (95% CI 0.66 to 0.81) in type 2 myocardial infarction, which was lower than for type 1 myocardial infarction in both cohorts (P Conclusions The GRACE score provided good discrimination for all-cause death at one year in patients with type 1 myocardial infarction, and moderate discrimination for those with type 2 myocardial infarction. Conflict of Interest None

Background Type 2 myocardial infarction is common in clinical practice. However, despite these patients having a similar rate of major adverse cardiovascular events as those with atherothrombotic type 1 myocardial infarction, there is currently no consensus on how these patients should be evaluated or managed. Whether risk assessment for coronary artery disease can identify patients at increased risk of death is unclear. Methods The High-STEACS trial was a stepped wedge cluster randomised controlled trial in ten hospitals across Scotland, including 48,282 consecutive patients with suspected acute coronary syndrome. The index diagnosis was adjudicated in all patients and the likelihood of underlying coronary artery disease recorded as either low probability, high-probability, or known based on the clinical history, risk factors and comorbidities. The adjudicators were blinded to the primary and secondary outcomes including all-cause mortality at one year. Results High-sensitivity cardiac troponin I concentrations were above the sex-specific 99th centile in 22% (10,360/48,282) of patients. The adjudicated diagnosis was type 1 and type 2 myocardial infarction in 55% (4,981/9,115) and 12% (1,121/9,115), respectively. Compared to patients with type 1 myocardial infarction, those with type 2 myocardial infarction were older and more likely to be women. In patients with type 2 myocardial infarction, 20% were low-probability, 55% were high-probability and 25% had known coronary artery disease. All-cause mortality was highest in patients with known or suspected coronary artery disease (22.5% and 23.3%, respectively). Those with a low-probability of coronary artery disease had the lowest event rate (8.8%), even compared to those with type 1 myocardial infarction (figure 1). Discussion A simple clinical assessment of whether patients have a low- or high-probability of coronary artery disease is associated with future risk of death in patients with type 2 myocardial infarction. Whether incorporating this assessment into clinical practice to guide secondary prevention could improve outcomes requires prospective evaluation. Conflict of Interest None

Introduction Heart failure (HF) affects approximately 1 million people in the UK, adversely affecting quality of life, functional capacity and cognitive health. This results in frequent hospitalisation and significant healthcare costs1, 2. Iron deficiency complicates heart failure in approximately 50% of patients3, and is increasingly recognised as a significant contributor to morbidity in this group. Intravenous ferric carboxymaltose (FCM) has been shown to improve quality of life (New York Heart Association [NYHA] class and Kansas City Cardiomyopathy Questionnaire [KCCQ]), performance in 6-minute walk test (6MWT), reduce hospitalisations, and is reflected in international guidelines4-7. We aimed to assess the feasibility, safety and cost implications of establishing an IV iron service for patients with HF in a large tertiary cardiology centre. Method Over a 6-month period (July-December 2019), outpatients with symptomatic heart failure (NYHA class ≥2) and severe left ventricular systolic dysfunction (LVEF ≤40%) were screened, and serum iron studies performed. Patients with iron deficiency (ferritin Results Fifty-two patients underwent IV iron replacement (69% male, mean age 66 years) with no significant adverse events or hospital admissions. The financial impact to the trust was a net income of £55 per patient (FCM treatment £290, remuneration £345). Ferritin increased significantly 83.3ug/L to 433ug/L (p Conclusion Utilisation of the existing iron infusion service facilitated the delivery of IV iron replacement for patients with heart failure with little need for additional training and resources. Delivery of the service did not incur additional cost to the trust and in fact there was a small net gain. In-keeping with published data we demonstrated comparable improvements in serum iron parameters and a trend towards improvement in NYHA class. IV iron replacement with FCM is safe and affordable and should be considered in all iron deficient patients with symptomatic heart failure. Conflict of Interest Yes - recieved honorarium from Vifor