Original Contribution
Characteristics of and outcome for patients with chest pain in relation to transport by the emergency medical services in a 20-year perspective

https://doi.org/10.1016/j.ajem.2012.02.014Get rights and content

Abstract

Aim

The aims of this study were to describe the characteristics of and outcome of patients with chest pain in relation to transport by the emergency medical services (EMS) and to describe possible changes in this relationship in a 20-year perspective.

Methods

In the 2 periods, 1986 to 1987 and 2008, all patients with chest pain admitted to hospitals in Gothenburg, Sweden, were retrospectively evaluated in terms of previous history, final diagnosis, and mortality. P values were age adjusted.

Results

In 1986 to 1987 and 2008, 34% of 4270 patients with chest pain and 39% of 2286 patients, respectively, were transported to the hospital by the EMS (P = .0001). In both periods, patients who used EMS were older and had a higher prevalence of previous cardiovascular diseases and more often had a final diagnosis of acute myocardial infarction (AMI) than those who did not use EMS. The EMS users were more frequently hospitalized in 1986 to 1987 than in 2008 (P < .0001). Emergency medical service use was related to a significantly higher age-adjusted 1-year mortality in both periods for all patients with chest pain as well as for those hospitalized. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality in 1986 to 1987. Regardless of the use of EMS, there was a decrease in the proportion of patients developing AMI as well as the rate of death at 30 days and 1 year in 2008 as compared with 1986 to 1987.

Conclusions

For 20 years, the proportion of patients with chest pain using the EMS increased. EMS users were more frequently hospitalized in 1986 to 1987 than in 2008. In overall terms, mortality was higher among EMS users than among nonusers in both periods. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality only in 1986 to 1987.

Introduction

The demand for the emergency medical services (EMS) has increased in the past decade [1]. Olia et al [2] in Italy found that 12% of calls for the EMS by patients without trauma were for patients with chest pain. The efficacy of the EMS includes fast receipt, initial therapies, alerts to the hospital, and a shorter treatment delay, as well as acute transferal to an interventional center [3], [4], [5]. In addition, most ambulances are equipped with defibrillators and have paramedics or nurses or physicians who are trained in basic and advanced cardiac life support, thereby increasing survival [6], [7], [8].

The interest for increased use of EMS in acute coronary syndrome (ACS) was particularly marked in patients with ST-elevation AMI (STEMI). Here, the use of telemedicine has been extensively developed [9].

Hitchcock et al [10] found that the prehospital delay for patients with chest pain who chose to call for the EMS was significantly shorter than for those who chose to use another mode of transport. Illustrating the difficulty of evaluation of patients with chest pain, there have been study results indicating that 18% of patients who were reported by the emergency medical dispatch center as having chest pain or other heart symptoms or trauma/accidents did not retrospectively require the EMS [11].

Previous studies have reported that higher age, a history of heart disease, and severe symptoms are associated with EMS use in acute chest pain (ACP) [12], [13] and have also indicated that, among patients with ACP, mortality was higher in those who used the EMS [12], [14]. However, during the last 20 years, changes have taken place in EMS systems. We have seen the introduction of the prehospital electrocardiogram (ECG), the use of prehospital medication, and telecommunication between the EMS and hospital, making the EMS an important integral part in the chain of care of patients with ACP.

The primary objective of this study was to describe the characteristics and outcome of patients with chest pain in relation to the use of the EMS. A secondary objective was to describe possible changes in this relationship in a 20-year perspective.

Section snippets

Patients and data collection

In the first period, all patients with chest pain admitted to Sahlgrenska Hospital from February 15, 1986, to November 9, 1987, were included. At that time, Sahlgrenska Hospital was the main hospital in Gothenburg, Sweden, and served 230 000 inhabitants. In the second period, all patients with chest pain admitted to any of the 3 hospitals in Gothenburg (Sahlgrenska Hospital, Mölndal Hospital, or Östra Hospital) from September 15 to December 15, 2008, were included. Together, these hospitals

Results

Of 5016 patients with chest pain coming to the ED at Sahlgrenska Hospital in 1986 to 1987, 746 patients (15%) were excluded due to missing information about the mode of transportation, leaving 4270 patients eligible for analysis. In 2008, there were 2287 patients with chest pain admitted to the ED at 1 of the 3 hospitals in Gothenburg (Sahlgrenska Hospital, Mölndal Hospital, and Östra Hospital). Only 1 patient was excluded due to missing information about the mode of transportation, and thus,

Major findings

  • 1)

    During a period of 20 years, the proportion of patients with chest pain using the EMS increased significantly.

  • 2)

    The comorbidity remained more severe among patients who used the EMS in both registration periods.

  • 3)

    The difference in the proportion of EMS users and nonusers who were hospitalized was less pronounced in 2008 than in 20 years earlier.

  • 4)

    The mortality was higher in patients who used the EMS, as compared with those who did not, during both registration periods.

Characteristics of patients

In agreement with the findings 20

Conclusions

For 20 years, the proportion of patients with chest pain using the EMS increased. Emergency medical service users were more frequently hospitalized in 1986 to 1987 than in 2008. In overall terms, mortality was higher among EMS users than among nonusers in both periods. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality only in 1986 to 1987.

Clinical implications

Patients with ACP who use EMS remain a high-risk group. The reduction in mortality in this group for 20 years is most likely explained by a reduced time to reperfusion and other anti-ischemic strategies. This finding should encourage the medical profession to try to optimize the chain of care in patients with ACS even further, most likely with an even higher use of EMS in these patients.

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