Outcomes of Patients Calling Emergency Medical Services for Suspected Acute Cardiovascular Disease
2014; Elsevier BV; Volume: 115; Issue: 1 Linguagem: Inglês
10.1016/j.amjcard.2014.09.042
ISSN1879-1913
AutoresMikkel Malby Schoos, Maria Sejersten, Usman Baber, Philip Michael Treschow, Mette Madsen, Anders Hvelplund, Henning Kelbæk, Roxana Mehran, Peter Clemmensen,
Tópico(s)Emergency and Acute Care Studies
ResumoAdequate health care is increasingly dependent on prehospital systems and cardiovascular (CV) disease remains the most common cause for hospital admission. However the prevalence of CV dispatches of emergency medical services (EMS) is not well reported and survival data described in clinical trials and registries are subject to selection biases. We aimed to describe the prevalence and prognosis of acute CV disease and the effect of invasive treatment, in an unselected and consecutive prehospital cohort of 3,410 patients calling the national emergency telephone number from 2005 to 2008 with follow-up in 2013. Individual-level data from national registries were linked to the dedicated EMS database of primary ambulance dispatches supported by physician-manned emergency units. Outcome data were obtained from the Central Population Registry, the National Patient Registry, and the National Registry of Causes of Death. In patients calling the national emergency telephone number, a CV related ambulance alarm code was given in 2,541 patients of 3,410 patients (74.5%) resulting in 2,056 of 3,410 primary CV discharge diagnoses (60.3%) with a 30-day and 5-year all-cause mortality of 24.5% and 46.4%, respectively. Stroke, acute heart failure, and ST-segment elevation myocardial infarction (STEMI) carried a 25- to 50-fold adjusted mortality hazard during the first 4 days. In patients with suspected STEMI, 90.5% had an acute angiography performed. Nontransferred, nonreperfused patients with STEMI (9.1%) carried 80% short-term mortality. Noninvasive management of non–ST-segment elevation myocardial infarction was common (37.9%) and associated with an increased adjusted long-term mortality hazard (hazard ratio 4.17 [2.51 to 8.08], p <0.001). Survival in 447 out-of-hospital cardiac arrest patients (13.1%) was 11.6% at 30 days. In conclusion, patients with a CV ambulance alarm call code and a final CV discharge diagnosis constitute most patients handled by EMS with an extremely elevated short-term mortality hazard and a poor long-term prognosis. Although co-morbidities and frailty may influence triage, this study emphasizes the need for an efficient prehospital phase with focus on CV disease and proper triage of patients suitable for invasive evaluation if the outcomes of acute heart disease are to be improved further in the current international context of hospitals merging into highly specialized entities resulting in longer patient transfers. Adequate health care is increasingly dependent on prehospital systems and cardiovascular (CV) disease remains the most common cause for hospital admission. However the prevalence of CV dispatches of emergency medical services (EMS) is not well reported and survival data described in clinical trials and registries are subject to selection biases. We aimed to describe the prevalence and prognosis of acute CV disease and the effect of invasive treatment, in an unselected and consecutive prehospital cohort of 3,410 patients calling the national emergency telephone number from 2005 to 2008 with follow-up in 2013. Individual-level data from national registries were linked to the dedicated EMS database of primary ambulance dispatches supported by physician-manned emergency units. Outcome data were obtained from the Central Population Registry, the National Patient Registry, and the National Registry of Causes of Death. In patients calling the national emergency telephone number, a CV related ambulance alarm code was given in 2,541 patients of 3,410 patients (74.5%) resulting in 2,056 of 3,410 primary CV discharge diagnoses (60.3%) with a 30-day and 5-year all-cause mortality of 24.5% and 46.4%, respectively. Stroke, acute heart failure, and ST-segment elevation myocardial infarction (STEMI) carried a 25- to 50-fold adjusted mortality hazard during the first 4 days. In patients with suspected STEMI, 90.5% had an acute angiography performed. Nontransferred, nonreperfused patients with STEMI (9.1%) carried 80% short-term mortality. Noninvasive management of non–ST-segment elevation myocardial infarction was common (37.9%) and associated with an increased adjusted long-term mortality hazard (hazard ratio 4.17 [2.51 to 8.08], p <0.001). Survival in 447 out-of-hospital cardiac arrest patients (13.1%) was 11.6% at 30 days. In conclusion, patients with a CV ambulance alarm call code and a final CV discharge diagnosis constitute most patients handled by EMS with an extremely elevated short-term mortality hazard and a poor long-term prognosis. Although co-morbidities and frailty may influence triage, this study emphasizes the need for an efficient prehospital phase with focus on CV disease and proper triage of patients suitable for invasive evaluation if the outcomes of acute heart disease are to be improved further in the current international context of hospitals merging into highly specialized entities resulting in longer patient transfers. An uncovered need remains for investigating the true underlying mortality rates in acute cardiovascular (CV) disease. Recently, a national Danish survey based on the National Patient Registry, in which all hospitalized patients are coded according to the International Classification of Diseases (ICD-10), showed a 14.8% (confidence interval 14.5% to 15.2%) 30-day mortality rate from 2004 to 2008 for all myocardial infarctions diagnoses (ICD I21 diagnoses: ST-segment elevation myocardial infarction [STEMI], non–ST-segment elevation myocardial infarction [NSTEMI], and unspecified myocardial infarction [MI]),1Schmidt M. Jacobsen J.B. Lash T.L. Bøtker H.E. Sørensen H.T. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study.BMJ. 2012; 344: e356Crossref PubMed Scopus (373) Google Scholar an incidence that is considerably higher than those reported in randomized clinical trials2Stone G.W. Witzenbichler B. Guagliumi G. Peruga J.Z. Brodie B.R. Dudek D. Kornowski R. Hartmann F. Gersh B.J. Pocock S.J. Dangas G. Wong S.C. Kirtane A.J. Parise H. Mehran R. Bivalirudin during primary PCI in acute myocardial infarction.N Engl J Med. 2008; 358: 2218-2230Crossref PubMed Scopus (1653) Google Scholar, 3Stone G.W. McLaurin B.T. Cox D.A. Bertrand M.E. Lincoff A.M. Moses J.W. White H.D. Pocock S.J. Ware J.H. Feit F. Colombo A. Aylward P.E. Cequier A.R. Darius H. Desmet W. Ebrahimi R. Hamon M. Rasmussen L.H. Rupprecht H.J. Hoekstra J. Mehran R. Ohman E.M. Bivalirudin for patients with acute coronary syndromes.N Engl J Med. 2006; 355: 2203-2216Crossref PubMed Scopus (1360) Google Scholar and registries.4Fox K.A. Anderson Jr., F.A. Goodman S.G. Steg P.G. Pieper K. Quill A. Gore J.M. Time course of events in acute coronary syndromes: implications for clinical practice from the GRACE registry.Nat Clin Pract Cardiovasc Med. 2008; 5: 580-589Crossref PubMed Scopus (73) Google Scholar, 5Puymirat E. Simon T. Steg P.G. Schiele F. Guéret P. Blanchard D. Khalife K. Goldstein P. Cattan S. Vaur L. Cambou J.P. Ferrières J. Danchin N. USIK USIC 2000 InvestigatorsFAST MI InvestigatorsAssociation of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction.JAMA. 2012; 308: 998-1006Crossref PubMed Scopus (376) Google Scholar Because of this mortality discrepancy between randomized clinical trials, registries, and national data, we relied on a prehospital register of patients with a potential upstream acute CV diagnosis, enabling us to follow primary discharge diagnoses of patients calling emergency medical services (EMS) for suspected CV disease, rather than relying on acute coronary syndrome (ACS) discharge diagnoses obtained after admission at the invasive center in a consequently selected patient population. To describe the burden of CV disease in an EMS setting is important, as adequate health care is increasingly dependent on elaborate prehospital systems because hospitals condensate into fewer and highly specialized entities, conjoining smaller or rural hospitals and thereby enhancing catchment areas and transfer distances. We aimed to describe the prevalence and prognosis of CV disease in an upstream unselected prehospital cohort of patients calling the national emergency telephone number, for example 112 or 911. We investigated a consecutive Danish cohort of 4,083 patient contacts with EMS in Storstrøm County in the southern part of Zealand (262,781 inhabitants and 3,398 km2). The former Storstrøm county is a nonurban region of small cities with 75 years of age is higher than the national average. Population increase, educational level, employment rate, and self-assessed health are lower than the national average, whereas the average alcohol and cigarette consumption and the incidence of long-term sick leave are above national average.6Illemann Christensen A. Ekholm O. Davidsen M. Juel K. Health and Morbidity in Denmark in 2010- and the Trend since 1987. National Institute of Public Health, University of Southern Denmark, 2014www.si-folkesundhed.dk/upload/sundhed_og_sygelighed_2010,_med_sidetal.pdfGoogle Scholar The prehospital organization in this study has been previously described.7Clemmensen P. Schoos M.M. Lindholm M.G. Rasmussen L.S. Steinmetz J. Hesselfeldt R. Pedersen F. Jørgensen E. Holmvang L. Sejersten M. Pre-hospital diagnosis and transfer of patients with acute myocardial infarction: a decade long experience from one of Europe's largest STEMI networks.J Electrocardiol. 2013; 46: 546-552Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Usually the first EMS to arrive at scene is the primary ambulance staffed by emergency medical technicians or paramedics. These primary ambulances are supported by emergency medical units manned with physicians. A patient contact was registered every time a patient called the national emergency telephone number, activating a primary ambulance and physician-manned unit. Calls that did not result in an ambulance dispatch were not registered. Patients were entered, regardless of vital status at the arrival of EMS and regardless of being permanent residents in Storstrøm county. We only considered the first admission of every patient and excluded 641 (15.7%) register entries of patients repeatedly admitted by EMS (Figure 1). The physician-manned units are fast vehicles without the space to transport patients, but are dispatched simultaneously with the primary ambulance to the injury site for a so-called "rendezvous" with the primary ambulance at the injury site or on the way, to triage and initiate advanced treatment for stabilization before transport. Patients were transferred to 2 around the clock invasive centers in Copenhagen and 4 noninvasive hospitals within the county. We linked individual-level data from national registries to the dedicated prehospital EMS database, using the personal registration number provided to all Danish residents. The inclusion period was May 1, 2005, to January 31, 2008, with follow-up from May 6, 2013, to May 14, 2013. The EMS database contained data entries based on ambulance charts reporting time information on alarm call, arrival at scene, departure from scene and hospital arrival, vital parameters, and the tentative prehospital diagnosis. Outcome data were obtained from the Central Population Registry, the National Patient Registry, and the National Registry of Causes of Death, enabling follow-up of all patients who had not emigrated. Long-term follow-up was at least 5 years in all patients, maximum follow-up was 8 years, and median follow-up was 5 years and 6 months. Patients were categorized according to their primary discharge diagnosis based on the ICD-10 codes. STEMI was defined by the ICD-10 codes I210B, I211B, and I213, and NSTEMI was defined by the codes I210A, I211A, and I214. The diagnosis of MI has been validated in the National Patient Registry.8Madsen M. Davidsen M. Rasmussen S. Abildstrom S.Z. Osler M. The validity of the diagnosis of acute myocardial infarction in routine statistics: a comparison of mortality and hospital discharge data with the Danish MONICA registry.J Clin Epidemiol. 2003; 56: 124-130Abstract Full Text Full Text PDF PubMed Scopus (438) Google Scholar Patients treated invasively with diagnostic coronary angiography, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) were also registered in the eastern Denmark PCI database. Non specified MI was defined by I219. In these patients, we applied all available data from the registries, as well as the eastern Denmark PCI database and individual discharge letter reviews, to allocate I219 to either the STEMI or NSTEMI group. Unstable angina pectoris (UAP) was defined by I200 and also by I208, I209 and I259, as patients in this population called 112 for chest pain due to acute onset or aggravation of known angina pectoris. ACS rule-out diagnosis was defined by a discharge diagnosis Z034, Z035, and R072-74. Heart failure was defined by I420, I500-509, and R570; atrial fibrillation by I48-I489; and out-of-hospital cardiac arrest (OHCA) by ambulance charts and I46-I469 at emergency room arrival. The term OHCA covers both patients with community cardiac arrest and cardiac arrest during ambulance transfer. Chronic kidney disease was defined by N17-19. The study was approved by the Danish Data Protection Agency (2011-41-5849) and the National Board of Health (7-505-29-1710/1/FSE). Continuous variables are presented as mean ± SD. The independent samples t test was used for comparison. Discrete data are presented as frequencies and percentages. The chi-square test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test were used for comparison of categorical and continuous variables as appropriate. Mortality hazards were adjusted for age and gender in multivariate Cox regression analysis. Hazard ratios are presented according to time interval after admission by EMS with patients discharged with an ACS rule-out diagnosis as the reference group. Independent predictors of all-cause 30-day to 5-year mortality in non–ST-segment elevation (NSTE)-ACS were identified using Cox proportional hazard regression analysis. We excluded patients with STEMI from the prediction analysis of invasive management, as patients with STEMI per definition are invasively managed because of the Danish national reperfusion strategy with primary percutaneous coronary intervention (pPCI).9Terkelsen C.J. Jensen L.O. Tilsted H.H. Thaysen P. Ravkilde J. Johnsen S.P. Trautner S. Andersen H.R. Thuesen L. Lassen J.F. Primary percutaneous coronary intervention as a national reperfusion strategy in patients with ST-segment elevation myocardial infarction.Circ Cardiovasc Interv. 2011; 4: 361-367Crossref Scopus (40) Google Scholar Also the survival benefit of invasive management in patients with STEMI is well established.10Boersma E. The Primary Coronary Angioplasty vs. Thrombolysis GroupDoes time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients.Eur Heart J. 2006; 27: 779-788Crossref PubMed Scopus (573) Google Scholar The statistical significance level was p <0.05 (2-sided test). Data were analyzed using the PASW Statistics 18 software package (SPSS Inc., Chicago, Illinois). In 3,442 consecutive patient contacts calling the national emergency telephone number, follow-up was 99.2% complete; thus, we included 3,410 patients. A CV related diagnosis by ambulance call alarm code was given in 2,541 (74.5%) of patients and a CV related final primary discharge diagnosis in 2,056 (60.3%) of patients (Figure 1). Of these, 1,294 (38%) patients were discharged with an ischemic heart disease–related diagnosis. Baseline characteristics and crude mortality rates according to discharge diagnosis are listed in Tables 1 and 2, respectively.Table 1Baseline variablesSTEMINSTEMIUAPACS rule outVariable(n=275)(n=211)(n=321)(n=497)Men198 (72%)133 (63%)216 (67.3%)290 (58.4%)Age (years)65.0 ± 13.171.2 ± 13.168.5± 13.362.9 ± 15.7Diabetes mellitus41 (14.9%)37 (17.5%)63 (19.6%)72 (14.5%)Chronic kidney disease9 (3.3%)21 (10%)20 (6.2%)15 (3%)Prior myocardial infarction35 (12.7%)58 (27.5%)98 (30.5%)50 (10.1%)Prior percutaneous coronary intervention19 (6.9%)25 (11.8%)78 (24.3%)33 (6.6%)Prior coronary artery bypass3 (1.1%)9 (4.3%)41 (12.8%)9 (1.8%)Prior stroke9 (3.3%)17 (8.1%)24 (7.5%)33 (6.6%)Invasive management (Total of CAG without PCI, PCI, CABG)249 (90.5%)131 (62.1%)56 (17.4%)0 (0%)ACS = acute coronary syndrome; NSTEMI = non-ST segment elevation myocardial infarction; STEMI = ST segment elevation myocardial infarction; UAP = unstable angina pectoris. Open table in a new tab Table 2All-cause mortality rates n (%) for each diagnosis category. Patients with out of hospital cardiac arrest are included in each respective category in case they were resuscitated and obtained a specific diagnosis. Nonresuscitated OHCA patients (n = 338) are included in the total cardiovascular categoryN30 day1 year3 year5 yearSTEMI27540 (14.5%)49 (17.8%)63 (22.9%)82 (29.8%)NSTEMI21121 (10%)52 (24.6%)75 (35.5%)94 (44.5%)UAP32112 (3.7%)34 (10.6%)72 (22.4%)105 (32.7%)ACS rule out4977 (1.4%)45 (9.1%)86 (17.3%)114 (22.9%)Heart failure10634 (32.1%)54 (50.9%)71 (67%)78 (73.6%)Atrial fibrillation964 (4.2%)18 (18.8%)34 (35.5%)41 (42.7%)Stroke9533 (34.7%)41 (43.2%)54 (56.8%)62 (65.3%)OtherCardiovascular11716 (13.7%)26 (22.2%)33 (28.2%)39 (33.3%)TotalCardiovascular2056503 (24.5%)656 (31.9%)826 (40.2%)953 (46.4%)NonCardiovascular1264138 (10.9%)261 (20.6%)417 (33%)521 (41.2%)Trauma906 (6.7%)11 (12.2%)19 (21.1%)22 (24.4%)Total emergency medical services population647 (19%)928 (27.2%)1250(36.7%)1496(43.9%)ACS = acute coronary syndrom; NSTEMI = non-ST segment elevation myocardial infarction; STEMI = ST segment elevation myocardial infarction; UAP = unstable angina pectoris. Open table in a new tab ACS = acute coronary syndrome; NSTEMI = non-ST segment elevation myocardial infarction; STEMI = ST segment elevation myocardial infarction; UAP = unstable angina pectoris. ACS = acute coronary syndrom; NSTEMI = non-ST segment elevation myocardial infarction; STEMI = ST segment elevation myocardial infarction; UAP = unstable angina pectoris. Patients with a primary STEMI discharge diagnosis were invasively investigated in 90.5% of cases. Those treated with pPCI within 12 hours had a 30-day mortality of 6.3%, whereas patients who did not undergo any attempt of reperfusion had a 30-day mortality rate of 80% (Table 3). The reasons for nonreperfusion were death at the local hospital before transfer in 17 cases (68%) and 4 patients (16%) were judged too frail. Three patients (12%) were not accepted by the attending cardiologist at the pPCI center, and 1 patient (4%) refused transfer. Nonreperfused patients were significantly older (median 81 years [interquartile range 70 to 87] vs 64 [interquartile range 55 to 73], p <0.001), more often women (48% vs 26%, p = 0.019), had higher incidence of previous stroke (16% vs 2%, p 12 hours11 (4%)1 (9.1%)3 (27.6%)3 (27.6%)7 (63.6%)Acute coronary artery bypass graft8 (2.9%)0 (0%)0 (0%)0 (0%)0 (0%)Acute coronary angiography, no percutaneous coronary intervention8 (2.9%)4 (50%)4 (50%)7 (87.5%)7 (87.5%)Transferred, no coronary angiography1 (0.4%)1 (100%)1 (100%)1 (100%)1 (100%)Not transferred25 (9.1%)20 (80%)22 (88%)22 (88%)22 (88%) Open table in a new tab In patients with NSTEMI, an angiography was performed in 62.1% of the cases. Of these, 34.6% were treated by PCI within 30 days and 9% by CABG within 90 days, and 37.9% were noninvasively managed. In patients with UAP, 17.4% of patients had an angiography performed, whereas 4.7% were treated by PCI within 30 days and 3.4% by CABG within 90 days, and 82.6% were noninvasively managed. The mortality rates according to treatment for patients with NSTE-ACS are listed in Table 4. Noninvasively treated patients with NSTE-ACS had higher all-cause mortality in the period from 30 days to 5 years (41.5% vs 18.6%, p <0.001) compared with invasively handled patients with a coronary angiography (CAG) <30 days. Patients without invasive management were older (71.6 ± 13.1 vs 65.7 ± 12.8, p 100; 54.3% vs 28.4%. p <0.001) was more frequent in patients without invasive management. There were no differences for gender, known chronic kidney disease, previous stroke, and diabetes.Table 4Mortality in NSTE-ACS (NSTEMI and UAP) patients according to treatment. Only invasive treatment within the first 30 days after index admission was consideredN30 day1 year3 year5 yearPercutaneous coronary intervention88 (16.5%)1 (1.1%)2 (2.3%)6 (6.8%)13 (14.8%)Coronary artery bypass graft30 (5.6%)2 (6.7%)5 (16.7%)6 (20%)9 (30%)Coronary angiography, no revasc.69 (13%)1 (1.4%)10 (14.5%)11 (15.9%)16 (23.2%)Non-invasive treatment345 (64.8%)29 (8.4%)69 (20%)124 (35.9%)161(46.7%) Open table in a new tab Medical management without subacute CAG performed within 30 days was independently associated with 30-day and 5-year all-cause mortality. Other independent long-term predictors were age, gender, diabetes, chronic kidney disease, prehospital tachycardia, and an NSTEMI diagnosis (Table 5). Age and gender adjusted hazard ratios are shown in Figure 2. All CV diagnoses had substantially elevated risk of all-cause mortality during the first 4 days after admission, which mitigated to nonsignificant hazard levels after 30 days from EMS admission, except for patients with NSTEMI, heart failure and stroke, where mortality risk remained significantly elevated during the 5-year follow-up.Table 5Predictors of all-cause 30-day to 5-year mortality by Cox proportional hazard in 532 NSTE-ACS patients (NSTEMI, UAP). All baseline variables from Table 1 were tested, and only univariable predictors (P <0.1) and gender were entered in the multivariable modelUnivariableMultivariableHR (95 % CI)PHR (95 % CI)PAge1.08 (1.06 - 1.09)<0.0011.08 (1.06 - 1.10) 1002.62 (1.88 - 3.64)<0.0012.05 (1.43 - 2.94)<0.001Prehospital SBP <1001.69 (0.99 - 2.88)0.054Prior Stroke1.53 (0.92 – 2.52)0.0991.68 (0.95 - 2.98)0.075Chronic Kidney Disease3.47 (2.28 – 5.28)<0.0011.99 (1.21 - 3.27)0.007Non-invasively managed∗Hazard ratio (HR) compared to CAG ≤30 days. CABG within 90 days did not carry any additional risk. Non-invasively managed patients had no coronary angiography performed within 30 days.3.69 (2.04 – 6.67)<0.0014.17 (2.51- 8.08)<0.001NSTEMI vs. UAP1.39 (1.01 – 1.87)0.0411.87 (1.28 - 2.73)<0.001MI = myocardial infarction.∗ Hazard ratio (HR) compared to CAG ≤30 days. CABG within 90 days did not carry any additional risk. Non-invasively managed patients had no coronary angiography performed within 30 days. Open table in a new tab MI = myocardial infarction. Mortality rates for 447 (13.1%) patients with OHCA according to resuscitation and initial retrievable rhythm are listed in Table 6. Thirty-three (12%) patients with STEMI had OHCA; of those, 19 patients (57.6%) were EMS witnessed during ambulance transfer and 14 (43.4%) were bystander witnessed before ambulance arrival. Patients with STEMI with OHCA had a significantly elevated 30-day mortality compared with all patients with STEMI without OHCA (30.3 vs 12.4%, p = 0.004). However, the excess mortality was confined to patients who suffered community-based OHCA (57.1 vs 12.4% p = 0.004), as patients with STEMI who experienced EMS-witnessed OHCA had no excess mortality (10.5 vs 12.4%, p = 0.84), in comparison to patients with STEMI without OHCA.Table 6Survival in patients with out-of-hospital cardiac arrest (OHCA)NReturn of spontaneous circulation30 day1 year3 year5 yearOut-of-hospital cardiac arrest447113 (25.3%)395 (88.4%)403 (90.2%)410 (91.7%)414 (92.6%)Return of spontaneous circulation113 (25.3%)NA63 (55.8%)69 (61.1%)76 (67.3%)80 (70.8%)Initial rhythm retrievable231 1. Ventricular fibrillation/Ventricular tachycardia58 (25.1%)49 (84.5%)20 (34.5%)23 (39.7%)27 (46.6%)29 (50%) 2. Asystole/Pulsless electric activity173 (74.9%)21 (12.1%)170 (98.3)170 (98.3%)171 (98.8%)171 (98.8%) Open table in a new tab Seventeen (3.2%) patients with NSTE-ACS had OHCA with significantly higher 30-day mortality (41.2% vs 5%, p <0.001) and 5-year mortality (70.6% vs 36.3%, p <0.001) than patients with NSTE-ACS without OHCA. None of the baseline variables were associated with OHCA in patients with NSTE-ACS, but patients with OHCA tended to be younger (65.3 ± 12.5 vs 69.7 ± 12.3, p = 0.186). In this large unselected cohort of patients dialing for EMS, most patients (75%) handled in the prehospital phase by physician-manned EMS received a CV alarm call code, and 6 of 10 admitted patients received a final primary CV hospital discharge diagnosis. These CV patients carried a poor long-term prognosis with a very elevated acute 4-day mortality hazard. The 30-day mortality rates in this unselected prehospital population including nontransferred and nonreperfused patients with ACS with nonspecific MI diagnoses were 14.5% for patients with STEMI and 10% for patients with NSTEMI. These incidences suggest considerably higher actual population rates than reported in randomized clinical trials (2% to 5% for STEMI2Stone G.W. Witzenbichler B. Guagliumi G. Peruga J.Z. Brodie B.R. Dudek D. Kornowski R. Hartmann F. Gersh B.J. Pocock S.J. Dangas G. Wong S.C. Kirtane A.J. Parise H. Mehran R. Bivalirudin during primary PCI in acute myocardial infarction.N Engl J Med. 2008; 358: 2218-2230Crossref PubMed Scopus (1653) Google Scholar, 11Armstrong P.W. Gershlick A.H. Goldstein P. Wilcox R. Danays T. Lambert Y. Sulimov V. Ortiz F.R. Ostojic M. Welsh R.C. Carvalho A.C. Nanas J. Arntz H.R. Halvorsen S. Huber K. Grajek S. Fresco C. Bluhmki E. Regelin A. Vandenberghe K. Bogaerts K. Van de Werf F. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.N Engl J Med. 2013; 368: 1379-1387Crossref PubMed Scopus (558) Google Scholar and 1.5% for NSTEMI3Stone G.W. McLaurin B.T. Cox D.A. Bertrand M.E. Lincoff A.M. Moses J.W. White H.D. Pocock S.J. Ware J.H. Feit F. Colombo A. Aylward P.E. Cequier A.R. Darius H. Desmet W. Ebrahimi R. Hamon M. Rasmussen L.H. Rupprecht H.J. Hoekstra J. Mehran R. Ohman E.M. Bivalirudin for patients with acute coronary syndromes.N Engl J Med. 2006; 355: 2203-2216Crossref PubMed Scopus (1360) Google Scholar) or registries (5% to 8% for STEMI4Fox K.A. Anderson Jr., F.A. Goodman S.G. Steg P.G. Pieper K. Quill A. Gore J.M. Time course of events in acute coronary syndromes: implications for clinical practice from the GRACE registry.Nat Clin Pract Cardiovasc Med. 2008; 5: 580-589Crossref PubMed Scopus (73) Google Scholar, 5Puymirat E. Simon T. Steg P.G. Schiele F. Guéret P. Blanchard D. Khalife K. Goldstein P. Cattan S. Vaur L. Cambou J.P. Ferrières J. Danchin N. USIK USIC 2000 InvestigatorsFAST MI InvestigatorsAssociation of changes in clinical characteristics and management with improvement in survival among patients with ST-elevation myocardial infarction.JAMA. 2012; 308: 998-1006Crossref PubMed Scopus (376) Google Scholar and 4% for NSTEMI4Fox K.A. Anderson Jr., F.A. Goodman S.G. Steg P.G. Pieper K. Quill A. Gore J.M. Time course of events in acute coronary syndromes: implications for clinical practice from the GRACE registry.Nat Clin Pract Cardiovasc Med. 2008; 5: 580-589Crossref PubMed Scopus (73) Google Scholar). Clinical trial populations of acute MI only account for 10% of the underlying population, with a lower mortality risk than nonincluded patients.12Steg P. López-Sendón J. Lopez de Sa E. Goodman S.G. Gore J.M. Anderson Jr., F.A. Himbert D. Allegrone J. Van de Werf F. GRACE InvestigatorsExternal validity of clinical trials in acute myocardial infarction.Arch Intern Med. 2007; 167: 68-73Crossref PubMed Scopus (237) Google Scholar By including upstream patients evaluated by EMS, we are privy to the adverse outcomes of CV disease without the selection bias of making it to the hospital. Despite our dire mortality results, the findings are quite actionable. This is elucidated by the substantially better survival of patients with STEMI with EMS-witnessed cardiac arrest, compared with community based cardiac arrest in patients with STEMI and the very differential rates of return of spontaneous circulation in patients with ventricular fibrillation or tachycardia compared with asystole/pulseless electric activity.13Sund B. Developing an analytical tool for evaluating EMS system design changes and their impact on cardiac arrest outcomes: combining geographic information systems with register data on s
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