Factors that influence the use of ambulance in acute coronary syndrome

The Pandemic of Coronary Heart Disease in the Middle East and North Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Coronary heart disease (CHD) is the leading cause of morbidity, mortality, and disability in the Middle East and North Africa (MENA). While the prevention, diagnosis, and management of CHD have been detailed in international guidelines, we aimed in this review to quantify the pandemic of CHD in the MENA region and highlight regional patient characteristics, clinical challenges, and future directions to optimize CHD care in the region.

RECENT FINDINGS

Patients with CHD in the MENA feature younger age at presentation and worse prognosis in women. Despite the high burden of CHD risk factors, many of these factors remain underrecognized, undertreated, and uncontrolled. Additionally, CHD care is hampered by poor patient awareness, inefficient preventive strategies, and limited access to guideline-recommended therapeutics. All stakeholders involved in healthcare should work together to develop and execute strategies aimed at tackling the burden of CHD in the MENA.

Association of Symptoms and Mode of Transportation to Emergency Department in Patients With Acute Coronary Syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with symptoms matching their expectations of a heart attack are more likely to use emergency medical services (EMS) than not.

OBJECTIVE

To determine whether presenting symptom clusters are associated with EMS use in ACS patients and if EMS use or symptom clusters are associated with prehospital delay.

METHODS

This secondary analysis used data from the PROMOTION trial, a randomized clinical trial that enrolled 3522 subjects with a history of or at risk for ACS from 5 sites in the United States, Australia, and New Zealand. Subjects were randomized to usual care or an educational intervention to reduce prehospital delay. During the 2-year follow-up, subjects admitted for ACS were asked about symptoms, time of symptom onset, and mode of transportation to the hospital. Symptoms were grouped into classic ACS, pain symptoms, and stress symptoms clusters.

RESULTS

Of 3522 subjects enrolled, 331 sought care for ACS during follow-up; 278 had transportation mode documented; 121 (44%) arrived via EMS. Classic ACS plus pain symptoms (adjusted odds ratio [AOR], 2.66; P = .011), classic ACS plus stress symptoms (AOR, 2.61; P = .007), and classic ACS plus both pain and stress symptoms (AOR, 3.90; P = .012) were associated with higher odds of EMS use versus classic ACS symptoms alone. Emergency medical services use resulted in a 68.5-minute shorter median delay (P = .002) versus non-EMS use. Symptom clusters were not predictive of delay time in the adjusted model (P = .952).

DISCUSSION

Although chest symptoms were the most prevalent symptoms for most (85%), the combination of classic ACS symptoms with other symptom clusters was associated with higher EMS use. Further research is needed to determine whether a combination of symptom clusters helps patients correctly interpret ACS symptoms to better understand how symptom clusters influence EMS use.

Inequities in ambulance allocation associated with transfer delay and mortality in acute coronary syndrome patients: evidence from 89 emergency medical stations in China

BACKGROUND

Allocation of healthcare resources has a great influence on treatment and outcome of patients. This study aimed to access the inequality of ambulance allocation across regions, and estimate the associations between ambulance density and pre-hospital transfer time and mortality of acute coronary syndromes (ACS) patients.

METHODS

This cross-sectional study was based on an integrated database of electronic medical system for 3588 ACS patients from 31 hospitals, ambulance information of 89 emergency medical stations, and public geographical information of 8 districts in Shenzhen, China. The primary outcomes were the associations between ambulance allocation and transfer delay and in-hospital mortality of ACS patients. The Theil index and Gini coefficient were used to assess the fairness and inequality degree of ambulance allocation. Logistic regression was used to model the associations.

RESULTS

There was a significant inequality in ambulance allocation in Shenzhen (Theil index: 0.59), and the inequality of inter-districts (Theil index: 0.38) was greater than that of intra-districts (Theil index: 0.21). The gap degree of transfer delay, ambulance allocation, and mortality across districts resulted in a Gini coefficient of 0.35, 0.53, 0.65, respectively. Ambulance density was negatively associated with pre-hospital transfer time (OR = 0.79, 95%CI: 0.64,0.97, P = 0.026), with in-hospital mortality (OR = 0.31, 95%CI:0.14,0.70, P = 0.005). The ORs of Theil index in transfer time and in-hospital mortality were 1.09 (95%CI:1.01,1.10, P < 0.001) and 1.80 (95%CI:1.15,3.15, P = 0.009), respectively.

CONCLUSIONS

Regional inequities existed in ambulance allocation and has a significant impact on pre-hospital transfer delay and in-hospital mortality of ACS patients. It was suggested to increase the ambulance accessibility and conduct health education for public.

Factors Responsible for Prehospital Delay in Patients with Acute Coronary Syndrome in Bangladesh

Background: Acute coronary syndrome (ACS) remains a cause of high morbidity and mortality among adults, despite advances in treatment. Treatment modality and outcomes of ACS mainly depend on the time yielded since the onset of symptoms. Prehospital delay is the time between the onset of myocardial ischemia/infarction symptoms and arrival at the hospital, where either pharmacological or interventional revascularization is available. This delay remains unacceptably long in many countries worldwide, including Bangladesh. The current study investigates several sociodemographic characteristics as well as clinical, social, and treatment-seeking behaviors, with an aim to uncover the factors responsible for the decision time to get medical help and home-to-hospital delay. Materials and Methods: A prospective cross-sectional study was conducted between July 2019 and June 2020 in 21 district hospitals and 6 medical college hospitals where cardiac care facilities were available. The population selected for this study was patients with ACS who visited the studied hospitals during the study period. Following confirmation of ACS, a semi-structured data sheet was used to collect the patient data and was subsequently analyzed. Results: This study evaluated 678 ACS patients from 30 districts. The majority of the patients were male (81.9%), married (98.2%), rural residents (79.2), middle-aged (40–60 years of age) (55.8%), low-income holders (89.4%), and overweight (56.9%). It was found that 37.5% of the patients received their first medical care after 12 h of first symptom presentation. The study found that the patients’ age, residence, education, and employment status were significant factors associated with prehospital delay. The patients with previous myocardial infarction (MI) and chest pain arrived significantly earlier at the hospital following ACS onset. Location of symptom onset, first medical contact with a private physician, distance from symptom onset location to location of first medical contact, the decision about hospitalization, ignorance of symptoms, and mode of transportation were significantly associated with prehospital delay. Conclusions: Several factors of prehospital delay of the ACS patients in Bangladesh have been described in this study. The findings of this study may help the national health management system identify the factors related to treatment delay in ACS and thus reduce ACS-related morbidity and mortality.

Barriers associated with emergency medical service activation in patients with ST-segment elevation acute coronary syndromes

Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation included patients with any acute coronary syndrome (ACS) without representation of southern European populations. We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy. A prospective, single-center, survey administered to all patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 01/06/2018 to 31/05/2020. The questionnaire was filled out by 293 patients. Of these, 191 (65.2%) activated the EMS after symptoms onset. The main reasons for failing to contact EMS were the perception that the symptoms were unrelated to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). Patients who called a private doctor after symptoms onset did not call EMS more frequently than those who did not and 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred. Previous history of cardiovascular disease was the only predictor of EMS call. Information campaigns are urgently needed to increase EMS activation in case of suspected STEACS and should be primary focused on patients without cardiovascular history, on the misperception that a private vehicle is faster than EMS activation, and on the fact that cardiac arrest occurs early and may be prevented by EMS activation.

Gender differences, inequalities and biases in the management of Acute Coronary Syndrome

OBJECTIVE

The approach to Acute Coronary Syndrome from a gender perspective is relatively recent. Research is extensive at epidemiological and clinical levels. However, available evidence, besides neglecting the social dimensions of the disease, has made women invisible. The objective of this review was to analyze the inequalities and gender biases in Acute Coronary Syndrome, from the beginning of the disease process to the final resolution.

METHODS

An exhaustive review of the literature of the entire health care process, from risk factors to rehabilitation and recovery, was carried out. The search for articles on gender, gender inequalities, or gender bias was conducted in indexed journals of social and health sciences. Also, a specific search was performed for each stage of the process, such as risk factors, prehospital phase, diagnosis, treatment, and rehabilitation.

RESULTS

Results showed the presence of gender biases throughout the entire health care process in Acute Coronary Syndrome. It is shown gender inequalities in the access to medical care, including a poor recognition among women themselves as well as among health professionals; longer prehospital delays; inadequate diagnoses and treatments; or less assistance to cardiac rehabilitation programmes. These biases occurred at the different levels of the health services involved. Finally, this review included recommendations proposed or arising from the revised papers.

CONCLUSIONS

Reducing gender biases in Acute Coronary Syndrome implies developing strategies to raise awareness among women, improve training of professionals serving at the different levels of health services, reduce delays, develop health management measures, and promote a research agenda.

Development of a prehospital prediction model for risk stratification of patients with chest pain

INTRODUCTION

Chest pain is one of the most common reasons for contacting the emergency medical services (EMS). About 15% of these chest pain patients have a high-risk condition, while many of them have a low-risk condition with no need for acute hospital care. It is challenging to at an early stage distinguish whether patients have a low- or high-risk condition. The objective of this study has been to develop prediction models for optimising the identification of patients with low- respectively high-risk conditions in acute chest pain early in the EMS work flow.

METHODS

This prospective observational cohort study included 2578 EMS missions concerning patients who contacted the EMS in a Swedish region due to chest pain in 2018. All the patients were assessed as having a low-, intermediate- or high-risk condition, i.e. occurrence of a time-sensitive diagnosis at discharge from hospital. Multivariate regression analyses using data on symptoms and symptom onset, clinical findings including ECG, previous medical history and Troponin T were carried out to develop models for identification of patients with low- respectively high-risk conditions. Developed models where then tested hold-out data set for internal validation and assessing their accuracy.

RESULTS

Prediction models for risk-stratification based on variables mutual for both low- and high-risk prediction were developed. The variables included were: age, sex, previous medical history of kidney disease, atrial fibrillation or heart failure, Troponin T, ST-depression on ECG, paleness, pain debut during activity, constant pain, pain in right arm and pressuring pain quality. The high-risk model had an area under the receiving operating characteristic curve of 0.85 and the corresponding figure for the low-risk model was 0.78.

CONCLUSIONS

Models based on readily available information in the EMS setting can identify high- and low-risk conditions with acceptable accuracy. A clinical decision support tool based on developed models may provide valuable clinical guidance and facilitate referral to less resource-intensive venues.

Worse Cardiac Arrest Outcomes During The COVID-19 Pandemic In Boston Can Be Attributed To Patient Reluctance To Seek Care

Delays in seeking emergency care stemming from patient reluctance may explain the rise in cases of out-of-hospital cardiac arrest and associated poor health outcomes during the COVID-19 pandemic. In this study we used emergency medical services (EMS) call data from the Boston, Massachusetts, area to describe the association between patients' reluctance to call EMS for cardiac-related care and both excess out-of-hospital cardiac arrest incidence and related outcomes during the pandemic. During the initial COVID-19 wave, cardiac-related EMS calls decreased (-27.2 percent), calls with hospital transportation refusal increased (+32.5 percent), and out-of-hospital cardiac arrest incidence increased (+35.5 percent) compared with historical baselines. After the initial wave, although cardiac-related calls remained lower (-17.2 percent), out-of-hospital cardiac arrest incidence remained elevated (+24.8 percent) despite fewer COVID-19 infections and relaxed public health advisories. Throughout Boston's fourteen neighborhoods, out-of-hospital cardiac arrest incidence was significantly associated with decreased cardiac-related calls, but not with COVID-19 infection rates. These findings suggest that patients were reluctant to obtain emergency care. Efforts are needed to ensure that patients seek timely care both during and after the pandemic to reduce potentially avoidable excess cardiovascular disease deaths.

Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study

OBJECTIVES

To describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions.

DESIGN

Prospective observational cohort study.

SETTING

Two centre study in a Swedish county emergency medical services (EMS) organisation.

PARTICIPANTS

Unselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018.

PRIMARY OUTCOME MEASURES

Low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.

RESULTS

Of included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both.

CONCLUSIONS

A majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a more personalised care possible with increased patient safety.

Choice of Transport to Hospital in Nonurban Areas in Life-Threatening Situations: A Qualitative Research

The time it takes to begin treatment in life-threatening situations is critical. Ambulance transport to the hospital in such situations ensures quick and effective treatment but is not always readily available in nonurban areas, or not preferred by the public, for various reasons. The purpose of this qualitative study was to examine the factors that deter or encourage ambulance use in life-threatening situations in the geographic periphery from clients' perspectives. We conducted interviews with 71 patients in 3 medical centers who had arrived by ambulance or by private transport, and with the 3 emergency department directors. The findings revealed that awareness of the clinical situation and health literacy, accessibility of emergency services, geographical conditions, and social and economic factors are central in the decision to utilize this service. We detail research recommendations for strengthening public health literacy and access to services.

Patient-level and system-level barriers associated with treatment delays for ST elevation myocardial infarction in China

OBJECTIVE

This study aims to understand the current ST elevated myocardial infarction (STEMI) treatment process in Guangdong Province and explore patient-level and system-level barriers associated with delay in STEMI treatment, so as to provide recommendations for improvement.

METHODS

This is a qualitative study. Data were collected using semistructured, face-to-face individual interviews from April 2018 to January 2019. Participants included patients with STEMI, cardiologists and nurses from hospitals, emergency department doctors, primary healthcare providers, local health governors, and coordinators at the emergency medical system (EMS). An inductive thematic analysis was adopted to generate overarching themes and subthemes for potential causes of STEMI treatment delay. The WHO framework for people-centred integrated health services was used to frame recommendations for improving the health system.

RESULTS

Thirty-two participants were interviewed. Patient-level barriers included poor knowledge in recognising STEMI symptoms and not calling EMS when symptoms occurred. Limited capacity of health professionals in hospitals below the tertiary level and lack of coordination between hospitals of different levels were identified as the main system-level barriers. Five recommendations were provided: (1) enhance public health education; (2) strengthen primary healthcare workforce; (3) increase EMS capacity; (4) establish an integrated care model; and (5) harness government's responsibilities.

CONCLUSIONS

Barriers associated with delay in STEMI treatment were identified at both patient and system levels. The results of this study provide a useful evidence base for future intervention development to improve the quality of STEMI treatment and patient outcomes in China and other countries in a similar situation.

An Italian registry of chest pain patients in the emergency department: clinical predictors of acute coronary syndrome

BACKGROUND

The aim of this study was to describe the population of patients arriving in several Italian Emergency Departments (EDs) complaining of chest pain suggestive of acute coronary syndrome (ACS) in order to evaluate the incidence of ACS in this cohort and the association between ACS and different clinical parameters and risk factors.

METHODS

This is an observational prospective study, conducted from the 1st January to the 31st December 2014 in 11 EDs in Italy. Patients presenting to ED with chest pain, suggestive of ACS, were consecutively enrolled.

RESULTS

Patients with a diagnosis of ACS (N.=1800) resulted to be statistically significant older than those without ACS (NO ACS; N.=4630) (median age: 70 vs. 59, P<0.001), and with a higher prevalence of males (66.1% in ACS vs. 57.5% in NO ACS, P<0.001). ECG evaluation, obtained at ED admission, showed new onset alterations in 6.2% of NO ACS and 67.4% of ACS patients. Multiple logistic regression analysis showed that the following parameters were predictive for ACS: age, gender, to be on therapy for cardio-vascular disease (CVD), current smoke, hypertension, hypercholesterolemia, heart rate, ECG alterations, increased BMI, reduced SaO2.

CONCLUSIONS

Results from this observational study strengthen the importance of the role of the EDs in ruling in and out chest pain patients for the diagnosis of ACS. The analysis put in light important clinical and risk factors that, if promptly recognized, can help Emergency Physicians to identify patients who are more likely to be suffering from ACS.

Mobile Intensive Care Unit versus Hospital walk-in patients, in the treatment of first episode ST- elevation myocardial infarction

OBJECTIVE

To determine the impact of the attention given by emergency medical services teams working in mobile intensive care units (MICU) versus patients arriving at the hospital under their own means with ST-elevation myocardial infarction (STEMI) event in terms of time to reperfusion (TR), mortality at 30 days and six months.

METHODS

We retrospectively studied 634 consecutive patients with STEMI who underwent primary a percutaneous coronary intervention from January 1st 2015 to December 31st 2018 in a single centre. Depending on the first medical contact patients were classified into two groups, MICU versus walk-in patients. We extracted data on patients' characteristics, symptoms, treatments, times to reperfusion and mortality.

RESULTS

In our study 634 patients were included, of whom 59.0% were initially attended by the MICU. Differences were seen between the two groups in time delays to the first medical contact (120.0 vs 63.0 min; p < 0.001) and TR (208.0 Vs 150.0 min; p < 0.001). Patients attended by the MICUs presented a shorter ICU and hospital stay. The lowest 30-day mortality rate was observed in MICU group: 9.0% in contrast with 4.5%, p = 0.03; remaining after 6 months. The multivariable analysis showed that the initial attention given by MICU to STEMI patients was a protective agent against mortality [OR: 0.32 (0.11-0.90); p = 0.03].

CONCLUSION

Initial attention of the patients with STEMI by doctor-on-board-MICU and available 24 h a day 7 days a week as part of a regional network (CORECAM), was associated with a decrease in the ischemia time, hospital stay and mortality of these patients in our environment.

Pre-hospital delay and emergency medical services in acute myocardial infarction

BACKGROUND/AIMS

Minimising total ischemic time (TIT) is important for improving clinical outcomes in patients with ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention (PCI). TIT has not shown a significant improvement due to persistent pre-hospital delay. This study aimed to investigate the risk factors associated with pre-hospital delay.

METHODS

Individuals enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health between 2011 and 2015 were included in this study. The study population was analyzed according to the symptom-to-door time (STDT; within 60 or > 60 minutes), and according to the type of hospital visit (emergency medical services [EMS], non-PCI center, or PCI center).

RESULTS

A total of 4,874 patients were included in the analysis, of whom 28.4% arrived at the hospital within 60 minutes of symptom-onset. Old age (> 65 years), female gender, and renewed ischemia were independent predictors of delayed STDT. Utilising EMS was the only factor shown to reduce STDT within 60 minutes, even when cardiogenic shock was evident. The overall frequency of EMS utilisation was low (21.7%). Female gender was associated with not utilising EMS, whereas cardiogenic shock, previous myocardial infarction, familial history of ischemic heart disease, and off-hour visits were associated with utilising EMS.

CONCLUSION

Factors associated with delayed STDT and not utilising EMS could be targets for preventive intervention to improve STDT and TIT.

Barriers to the use of emergency medical services for ST-elevation myocardial infarction: Determining why many patients opt for self-transport

RATIONALE, AIMS, AND OBJECTIVES

Access to timely ST-elevation myocardial infarction (STEMI) care is facilitated by paramedics and emergency medical services (EMS). However, a large proportion of STEMI patients do not access care through EMS. This study sought to identify patient-reported factors for their decision to use (or not use) EMS.

METHODS

Semi-structured interviews were conducted with a sample of STEMI patients admitted to a large tertiary care centre between November 2011 and January 2012. Participants were grouped according to mode of transportation to hospital at time of index event (EMS vs self-transport). Participant responses were classified using a published framework (modified for a STEMI population) as barriers or facilitators to EMS use, and compared between groups.

RESULTS

Data were collected on 61 patients (32 EMS, 29 self-transport). Mean age was 60.3 (SD 11.5), and 23% were female. EMS users were more likely to have a Killip Class >1 (25% vs 4%; P = 0.03). Self-transport patients were more likely to perceive EMS as slower (48% vs 0%) and express concerns over resources misuse (34% vs 3%; P = 0.002), when compared to EMS patients. Patients who accessed EMS were more likely to acknowledge the benefits of EMS (44% vs 7%; P = 0.001) and were more likely to have been encouraged by a family member to call EMS (34% vs 4%; P = 0.003).

CONCLUSIONS

STEMI patient perceptions are a key factor in determining EMS use. Health care stakeholders should target the identified barriers to improve utilization of EMS, and develop strategies to optimize care for patients who do not access EMS.

Differences in symptoms, first medical contact and pre-hospital delay times between patients with ST- and non-ST-elevation myocardial infarction

Aim:

In ST-elevation myocardial infarction, time to reperfusion is crucial for the prognosis. Symptom presentation in myocardial infarction influences pre-hospital delay times but studies about differences in symptoms between patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction are sparse and inconclusive. The aim was to compare symptoms, first medical contact and pre-hospital delay times in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction.

Methods and results:

This multicentre, observational study included 694 myocardial infarction patients from five hospitals. The patients filled in a questionnaire about their pre-hospital experiences within 24 h of hospital admittance. Chest pain was the most common symptom in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (88.7 vs 87.0%, p=0.56). Patients with cold sweat (odds ratio 3.61, 95% confidence interval 2.29–5.70), jaw pain (odds ratio 2.41, 95% confidence interval 1.04–5.58), and nausea (odds ratio 1.70, 95% confidence interval 1.01–2.87) were more likely to present with ST-elevation myocardial infarction, whereas the opposite was true for symptoms that come and go (odds ratio 0.58, 95% confidence interval 0.38-0.90) or anxiety (odds ratio 0.52, 95% confidence interval 0.29–0.92). Use of emergency medical services was higher among patients admitted with ST-elevation myocardial infarction. The pre-hospital delay time from symptom onset to first medical contact was significantly longer in non-ST-elevation myocardial infarction (2:05 h vs 1:10 h, p=0.001).

Conclusion:

Patients with ST-elevation myocardial infarction differed from those with non-ST-elevation myocardial infarction regarding symptom presentation, ambulance utilisation and pre-hospital delay times. This knowledge is important to be aware of for all healthcare personnel and the general public especially in order to recognise symptoms suggestive of ST-elevation myocardial infarction and when to decide if there is a need for an ambulance.

Usage of ambulance transport and influencing factors in acute coronary syndrome: a cross-sectional study at a tertiary centre in China

OBJECTIVES

The aim of this study was to explore the choice of transportation mode to hospital in patients with acute coronary syndrome (ACS) and to determine the factors influencing the use of ambulance.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study was conducted in a tertiary and teaching hospital in China. The study was carried out between 24 August 2015 and 24 July 2016. A total of 828 patients with ACS presented at the emergency department (ED) were included. The study population was dichotomised according to their primary mode of transport (ambulance or self-transport) to hospital. Social demographics, cardiovascular history, risk factors, prehospital medications, clinical characteristics and symptom characteristics were collected. Multivariable logistic regression was used to examine the factors associated with ambulance use.

RESULTS

We found that only 179 (21.6%) patients with ACS chose taking ambulance to hospital. Factors associated with ambulance use were single (OR 1.66, 95% CI 1.07 to 2.57), taking Suxiaojiuxin pills (OR 1.91, 1.31 to 2.80) or nitrates (OR 2.91, 1.70 to 4.99) before going to hospital, diagnosed as ST-elevation myocardial infarction (STEMI) (OR 2.43, 1.45 to 4.05), with persistent symptoms (OR 1.95, 1.33 to 2.86) and symptoms accompanied with vomiting (OR 2.35, 1.19 to 4.62). The patients who had symptoms precipitated or aggravated by exercise (OR 0.37, 0.14 to 0.98) tended to choose self-transport.

CONCLUSION

The usage of ambulance in patients with ACS presenting to the ED was low in China. Factors like single, taking Suxiaojiuxin pills or nitrates before going to hospital, diagnosed as STEMI, accompanied with vomiting and persistent symptoms were independently associated with ambulance use. Future education programmes should focus on these factors and increase people's knowledge on ACS and the benefits of ambulance use.

The barriers associated with emergency medical service use for acute coronary syndrome: the awareness and influence of an Australian public mass media campaign

BACKGROUND

Emergency medical services (EMS) transport to hospital is recommended in acute coronary syndrome (ACS) guidelines, but only half of patients with ACS currently use EMS. The recent Australian Warning Signs campaign conducted by the Heart Foundation addressed some of the known barriers against using EMS. Our aim was to examine the influence of awareness of the campaign on these barriers in patients with ACS.

METHODS

Interviews were conducted with patients admitted to an Australian tertiary hospital between July 2013 and April 2014 with a diagnosis of ACS. Patient selection criteria included: aged 35-75 years, competent to provide consent, English speaking, not in residential care and medically stable. Multivariable logistic regression was used to examine factors associated with EMS use.

RESULTS

Only 54% of the 199 patients with ACS interviewed used EMS for transport to hospital. Overall 64% of patients recalled seeing the campaign advertising, but this was not associated with increased EMS use (52.0%vs56.9%, p=0.49) or in the barriers against using EMS. A large proportion of patients (43%) using other transport thought it would be faster. Factors associated with EMS use for ACS were: age >65 years, ST-elevation myocardial infarction, a sudden onset of pain and experiencing vomiting.

CONCLUSION

In medically stable patients with ACS, awareness of the Australian Warning Signs campaign was not associated with increased use of EMS or a change in the barriers for EMS use. Future education strategies could emphasise the clinical role that EMS provide in ACS.

Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: An observational study

OBJECTIVE

To determine factors associated with ambulance use in patients with confirmed and potential acute coronary syndrome presenting to the ED.

METHODS

A convenience sample of patients (n = 247) presenting to the ED from April 2014 to January 2015 with suspected acute coronary syndrome were included in the study. Data on mode of transport and patient demographics were collected from the Emergency Department Information System database. Clinical data were collected from chart records and information systems. A questionnaire assessed reasons for using a chosen method of transport, symptom timing and characteristics, acute coronary syndrome knowledge, and awareness of the National Heart Foundation Early Warning Symptoms campaign.

RESULTS

Approximately half the patients (49.4%) assessed with symptoms of potential acute coronary syndrome used ambulance transport to the ED. Patients who arrived by ambulance were older than those not arriving by ambulance (mean 56.7 years vs 51.7 years, P = 0.01). Risk factors were not associated with ambulance use. Dizziness (P < 0.01), sweating (P = 0.03), nausea (P = 0.03) and vomiting (P = 0.04) were associated with increased ambulance use. Mean systolic blood pressure was lower in the ambulance group (136 mmHg, standard deviation [SD] = 19.8) than in the non-ambulance group (143 mmHg, SD = 25.9). Awareness of the National Heart Foundation Heart Attack Warning Signs campaign was not associated with ambulance use.

CONCLUSIONS

Patients with possible ischaemic symptoms who are at a high risk of cardiac disease do not utilise ambulance services more than low risk patients. In general, transport to hospital using ambulance services by patients with symptoms of possible acute coronary syndrome is low despite community campaigns.

Factors Associated With Emergency Services Use by Patients With Recurrent Myocardial Infarction: From the Monitoring Trends and Determinants in Cardiovascular Disease/Cooperative Health Research in the Region of Augsburg Myocardial Infarction Registry

BACKGROUND

Although emergency medical services (EMS) use is the recommended mode of transport in case of acute coronary symptoms, many people fail to use this service.

OBJECTIVE

The objective of this study was to determine factors associated with EMS use in a population-based sample of German patients with recurrent acute myocardial infarction (AMI).

METHODS

The sample consisted of 998 persons with a first and recurrent AMI, recruited from 1985 to 2011. Logistic regression modeling adjusted for sociodemographic, situational, and clinical variables, previous diseases, and presenting AMI symptoms was applied.

RESULTS

Emergency medical services was used by 48.8% of the patients at first, and 62.6% at recurrent AMI. In first AMI, higher age, history of hyperlipidemia, ST-segment elevation AMI, more than 4 presenting symptoms, symptom onset in daytime, and later year of AMI were significantly related with EMS use. Pain in the upper abdomen and pain between the shoulder blades were significantly less common in EMS users. In recurrent AMI, EMS use at first AMI, presence of any other symptom except chest pain, ST-segment elevation myocardial infarction, and later year of AMI were significantly related with EMS use. Significant predictors of EMS use in recurrent AMI in patients who failed to use EMS at first AMI were unmarried, experience of any symptom except chest symptoms at reinfarction, bundle branch block (first AMI), any in-hospital complication (first AMI), longer duration between first and recurrent AMI, and later year of reinfarction.

CONCLUSIONS

Patients with AMI and their significant others may profit by education about the benefits of EMS use.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi

Introduction

Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi.

Objectives

To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi.

Methods

We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS.

Results

Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10 years. Less than half of the responders (42%) were “Somewhat Satisfied” (35%) or “Very Satisfied” (7%) with current EMS level of care for STEMI patients. Most respondents were “Very Likely” (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. “Strongly Agree”) of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties.

Conclusions

Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.

Ambulance use in acute coronary syndrome in Ireland: A cross-sectional study

BACKGROUND

As myocardial salvage is time dependent, prompt emergency department attendance is imperative in the presence of unresolved acute coronary syndrome symptoms. Although ambulance use is the recommended mode of transport during an acute coronary syndrome event, people regularly have misperceptions about its role. Consequently, many fail to use this service when warranted.

AIM

To evaluate factors associated with ambulance usage among patients admitted to emergency departments with acute coronary syndrome symptoms in Ireland.

METHODS

Patients (N=1947) diagnosed with acute coronary syndrome were recruited across five hospitals. The ACS Response Index was used to identify mode of transport to access the emergency department, symptom context and experience and the rationale for non-ambulance use. Using logistic regression, predictors of ambulance use were identified.

RESULTS

Only 40.1% of the sample used an ambulance. The primary reason for non-ambulance use was the perception that it was unwarranted (31%). A further 23.8% thought another mode of transportation would be faster. Independent predictors of ambulance usage differed among the three sub-diagnoses of acute coronary syndrome. For each group, visiting the general practitioner with symptoms was associated with a greater likelihood of not using an ambulance.

CONCLUSION

The use of ambulance services is not positively embraced by the public. Furthermore, it appears that general practitioners may not always promote its use, particularly in the early stages of acute coronary syndrome symptom onset. The findings from our study suggest that a public education drive is necessary to promote ambulance usage during an acute coronary syndrome event.

A Description of the Prehospital Phase of Aortic Dissection in Terms of Early Suspicion and Treatment

Purpose

Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.

Basic Procedures

All patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age < 18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.

Main findings

Of 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).

Conclusion

Among patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.

AxelssonC, KarlssonT, PandeK, WigertzK, ÖrtenwallP, NordanstigJ, HerlitzJ. A description of the prehospital phase of aortic dissection in terms of early suspicion and treatment. Prehosp Disaster Med. 2015;30(2):1-8.

Comparison of outcomes of ambulance users and nonusers in ST elevation myocardial infarction

In a systematic province-wide evaluation of care and outcomes of ST elevation myocardial infarction (STEMI), we sought to examine whether a previously documented association between ambulance use and outcome remains after control for clinical risk factors. All 82 acute care hospitals in Quebec (Canada) that treated at least 30 acute myocardial infarctions annually participated in a 6-month evaluation in 2008 to 2009. Medical record librarians abstracted hospital chart data for consecutive patients with a discharge diagnosis of myocardial infarction who presented with characteristic symptoms and met a priori study criteria for STEMI. Linkage to administrative databases provided outcome data (to 1 year) and co-morbidities. Of 1,956 patients, 1,222 (62.5%) arrived by ambulance. Compared with nonusers of an ambulance, users were older, more often women, and more likely to have co-morbidities, low systolic pressure, abnormal heart rate, and a higher Thrombolysis In Myocardial Infarction risk index at presentation. Ambulance users were less likely to receive fibrinolysis or to be sent for primary angioplasty (78.5% vs 83.2% for nonusers, p = 0.01), although if they did, treatment delays were shorter (p <0.001). The 1-year mortality rate was 18.7% versus 7.1% for nonusers (p <0.001). Greater mortality persisted after adjusting for presenting risk factors, co-morbidities, reperfusion treatment, and symptom duration (hazard ratio 1.56, 95% confidence interval 1.30 to 1.87). In conclusion, ambulance users with STEMI were older and sicker than nonusers. Mortality of users was substantially greater after adjustment for clinical risk factors, although they received faster reperfusion treatment overall.

Delay and inequality in treatment of the elderly with suspected acute coronary syndrome

BACKGROUND/OBJECTIVES

The aim of this study is to determine differences between elderly patients (≥80 years) and younger patients with suspected acute coronary syndrome (ACS) regarding delay times before diagnostic tests and treatments.

METHODS

All patients with chest pain who were admitted to a hospital in the Gothenburg area were included consecutively over a 3-month period. They were divided into an elderly group (≥80 years) and a reference group (<80 years). Previous medical history, ECG findings, treatments, diagnostic tests, and delay times were registered.

RESULTS

Altogether, 2588 patients were included (478 elderly and 2110 reference). There were no significant differences in delay time to hospital ward admission, to first medical therapy with aspirin, or to investigation with coronary angiography (CA) between the two groups. The elderly patients had a significantly shorter median time from first medical contact to first ECG (12 vs. 14 min, p=0.002) but after adjustment for confounding factors, especially mode of transport, the opposite was found to be the case (p=0.002). Elderly hospitalized patients with ACS were less often investigated with CA (44% vs. 89%, p<0.0001) and received less medical treatment with P2Y12 antagonists and lipid lowering drugs.

CONCLUSIONS

Elderly individuals with chest pain could not be shown to have a delay to hospital admission compared to their younger counterparts. Nevertheless, higher age was associated with a longer time to first ECG. The elderly patients received less active therapy, and fear of age-related side effects might explain this difference.

Improving knowledge, attitudes and beliefs about acute coronary syndrome through an individualized educational intervention: a randomized controlled trial

OBJECTIVE

To test the effectiveness of an individualized educational intervention on knowledge, attitudes and beliefs about acute coronary syndrome (ACS).

METHODS

This multi-site, randomized controlled trial was conducted on 1947 patients with a diagnosis of ACS. Both groups received usual in-hospital education. Participants randomized to the intervention group received a 40-min one to one individualized education session, delivered using motivational interviewing techniques. The intervention was reinforced 1 month and 6 months later. Knowledge, attitudes and beliefs were measured using the ACS Response Index. A total of 1136 patients (control, n=551; intervention, n=585) completed the questionnaire at baseline, 3 and 12 months. Data were analyzed using repeated measures analysis of variance. Ethical approval was obtained.

RESULTS

There was a significant effect of the intervention on mean knowledge (p<0.001), attitude (p=0.003) and belief (p<0.001) scores at 3 and 12 months.

CONCLUSION

Ensuring patients retain information post education has always been difficult to attain. This study demonstrated that patient education using motivational interviewing techniques and an individualized approach has the potential to alter knowledge, attitudes and beliefs about ACS among a high risk population.

PRACTICE IMPLICATIONS

This relatively short, simple and effective educational intervention could be delivered by nurses in multiple settings.

The basic social medical insurance is associated with clinical outcomes in the patients with ST-elevation myocardial infarction: a retrospective study from Shanghai, China

OBJECTIVE

Several social economic factors play important roles in treatments of ST-elevation myocardial infarction (STEMI) and finally influence the clinical outcomes. The basic social medical insurance (BSMI) is an important economic factor in China's medical system. However, the impact of BSMI on clinical outcomes in STEMI patients has not been explored yet. The aim of this study is to investigate whether BSMI is a predictor of clinical outcomes in the patients with STEMI in Shanghai, China.

MATERIAL AND METHODS

In this retrospective study, 681 STEMI patients from different areas in Shanghai were classified into four groups: new rural cooperative medical scheme (NCMS) group, urban resident basic medical insurance scheme (URBMI) group, urban employee basic medical insurance scheme (UEBMI) group and UNINSURED group, major adverse events (cardiac death, nonfatal reinfarction, clinically driven target lesion revascularization/target vessel revascularization, stroke, heart failure) were regarded as study endpoints to determine whether BSMI was a prognostic factor.

RESULTS

During a mean follow-up of 36 months, the incidence of major adverse events was significantly higher in NCMS patients (64; 38.8%) compared with the other groups: URBMI (47; 24.6%); UEBMI (28; 15.6%); UNISURED (40; 27.6%). Similarly, cardiac mortality was also higher in NCMS group (19; 11.5%). A Kaplan-Meier survival analysis revealed significantly lower event-free survival rate for major adverse events (p < 0.001) and cardiac mortality (p = 0.01) in NCMS group. Multivariate Cox regression analysis revealed that BSMI was an important prognostic factor in STEMI patients.

CONCLUSION

These results demonstrate that BSMI is closely associated with the major adverse events-free survival rate at 36-month follow-up in the STEMI patients under the current policies in Shanghai, China.

Gender differences in calls to 9-1-1 during an acute coronary syndrome

Calling 911 during acute coronary syndromes (ACS) decreases time to treatment and may improve prognosis. Women may have more atypical ACS symptoms compared to men, but few data are available on differences in gender and ACS symptoms in calling 911. In this study, patient interviews and structured chart reviews were conducted to determine gender differences in calling 911. Calls to 911 were assessed by self-report and validated by medical chart review. Of the 476 patients studied, 292 (61%) were diagnosed with unstable angina and 184 (39%) with myocardial infarctions (MIs). Overall, only 23% of patients called 911. Similar percentages of women and men with unstable angina called 911 (15% and 13%, respectively, p = 0.59). In contrast, women with MIs were significantly more likely to call 911 than men (57% vs 28%, p <0.001). After adjustment for sociodemographic factors, health insurance status, history of MI, the left ventricular ejection fraction, Global Registry of Acute Coronary Events (GRACE) score, and ACS symptoms, women were 1.79 times more likely to call 911 during an MI than men (prevalence ratio 1.79, 95% confidence interval 1.22 to 2.64, p <0.01). In conclusion, the findings of the present study suggest that initiatives to increase calls to 911 are needed for women and men.

Predictors of ambulance transport in patients with ST-elevation myocardial infarction

INTRODUCTION

Despite intense public awareness campaigns, many patients with ST-elevation myocardial infarction (STEMI) do not utilize Emergency Medical Services (EMS) transportation to the Emergency Department (ED). Predictors for mode of transport by EMS versus private vehicle in patients with an acute STEMI were investigated. Hypothesis It was hypothesized that patient characteristics, specifically older age, male sex, and a history of a prior cardiac intervention, would be associated with a higher likelihood of EMS utilization.

METHODS

A retrospective, observational cohort study was performed for all STEMI patients treated from April 1, 2007 through June 30, 2010 at an urban, academic ED with 24-hour cardiac catheterization available. Multivariable analyses with predetermined predictors (age, sex, prior cardiac intervention, weekend/evening arrival) were performed to investigate associations with mode of transport. Door-to-balloon (D2B) times were calculated.

RESULTS

Of the 209 STEMI patients, 11 were excluded, leaving 198 for analysis. Median age was 60 years (IQR: 53-70), 138 (70%) arrived by private vehicle, and 60 (30%) by EMS. The primary analysis did not identify significant predictors for EMS, but a post-hoc model found that private insurance (OR 0.18; 95% CI, 0.07-0.45) was associated with fewer EMS transports. Although not statistically significant due to the great variability in time of arrival for STEMI patients transported by private vehicle, EMS transports had shorter D2B times. During business hours and weekend/evenings, EMS had D2B times of 50 (IQR: 42-61) and 58 minutes (IQR: 47-63), respectively, while private vehicle transports had median D2B times of 62 (IQR: 50-74) and 78 minutes (IQR: 66-106). Conclusion No associations between mode of transport and patient age, sex, weekend/evening presentation and history of a prior cardiac intervention were identified. Privately insured patients were less likely to use EMS when experiencing a STEMI. More effective ways are needed to educate the public on the importance of EMS activation when one is concerned for acute coronary syndrome.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

Utilisation of emergency medical service among Singapore patients presenting with ST-segment elevation myocardial infarction: prevalence and impact on ischaemic time

BACKGROUND

Previous studies in Western countries found that the emergency medical service (EMS) was under-used in patients with myocardial infarction.

AIM

We sought to determine the prevalence of immediate EMS utilisation among Singapore patients presenting with ST-segment elevation myocardial infarction (STEMI), and correlated the use of the EMS with the symptom-to-balloon and door-to-balloon times.

METHODS

We studied 252 patients admitted with STEMI to our institution from August 2008 to September 2009. Information regarding demographic characteristics, whether EMS was used, reperfusion procedural details and mortality rates were collected prospectively.

RESULTS

Among the recruited patients, 89 (35.3%) used the EMS (EMS group) and 163 (64.7%) did not use the EMS (non-EMS group). In the latter group, 98 (60.1%) arrived at our institution through their own transport, 56 (34.4%) first consulted general practitioners, and 9 (5.5%) initially consulted another hospital without acute medical services. Among the 245 (out of 252, 97.2%) patients who received percutaneous coronary intervention (PCI), the EMS group was more likely to undergo primary PCI (P= 0.003) while the non-EMS group was more likely to undergo non-urgent PCI (P= 0.002). In patients who underwent primary PCI, the EMS group had a shorter symptom-to-balloon time (average difference 81.6 min, P= 0.002). The door-to-balloon time was similar for both groups.

CONCLUSION

Despite the availability of a centralised EMS, 64.7% of patients with STEMI did not contact EMS at presentation. These patients were less likely to receive primary PCI and had a significantly longer symptom-to-balloon time.