The document discusses out of hospital sudden cardiac death (SCD) and whether rates are declining or escalating. Key points include: 1. Over 400,000 SCDs occur annually out of hospital or upon arrival to the emergency room. 2. Pre-hospital delay times in the U.S. have not declined in recent decades and impede treatment of SCD, which remains a major public health challenge. 3. Improving early recognition of heart attack symptoms and rapid intervention through public health initiatives could help reduce SCD rates and save more lives.