Original ContributionCharacteristics of and outcome for patients with chest pain in relation to transport by the emergency medical services in a 20-year perspective
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
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During a period of 20 years, the proportion of patients with chest pain using the EMS increased significantly.
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The comorbidity remained more severe among patients who used the EMS in both registration periods.
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The difference in the proportion of EMS users and nonusers who were hospitalized was less pronounced in 2008 than in 20 years earlier.
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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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2019, American Journal of Emergency MedicineCitation Excerpt :The results can probably be generalised to other prehospital organisations with similar populations. The median age was 65 years which is in agreement with previous experiences that patients who call for EMS is a relatively old group of patients [12]. The study population was recruited from areas outside the largest cities, including rural areas, small and large cities and the areas close to the largest cities.
Factors influencing patient delay before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: The Stent for life initiative in Portugal
2018, Revista Portuguesa de CardiologiaCitation Excerpt :Reducing patient delay is associated with significant improvement in patients’ prognosis,23–26 so current strategies to improve patient prognosis are focused on reducing prehospital times.5 However, during the last decade, efforts to reduce prehospital time have not been effective22 and most patients do not use the EMS to reach the hospital.27,28 During the ten years before Portugal joined the SFL initiative, only 19% of STEMI patients received pPCI and only 23% called 112.28
- 1
Björn W Karlson is an employee of AstraZeneca.