Dyspnea, a high-risk symptom in patients suspected of myocardial infarction in the ambulance? A population-based follow-up study.

BACKGROUND: Systematic management of patients suffering high-risk symptoms is essential in emergency medical services. Patients with chest pain receive algorithm-based work-up and treatment. Though dyspnea is recognized as an independent predictor of mortality, no generally accepted prehospital treatment algorithm exists and this may affect outcome. The objective of this study was to compare mortality in patients suspected of myocardial infarction (MI) presenting with dyspnea versus chest pain in the ambulance. METHODS: Follow-up study in patients undergoing electrocardiogram-based telemedical triage because of suspected MI in an ambulance in the Central Denmark Region from 1 June 2008 to 1 January 2013. Primary outcome was 30-day mortality. Secondary outcomes were 4-year mortality and mortality rates in subgroups of patients with and without a confirmed MI. Absolute risk differences adjusted for comorbidity, age, systolic blood pressure and heart rate were calculated by a generalized linear regression model. RESULTS: Of 17,398 patients, 12,230 (70%) suffered from chest pain, 1464 (8%) from dyspnea, 3540 (20%) from other symptoms and 164 (1%) from cardiac arrest. Among patients with dyspnea, 30-day mortality was 13% (CI 12-15) and 4-year mortality was 50% (CI 47-54) compared to 2.9% (CI 2.6-3.2) and 20% (CI 19-21) in patients with chest pain. MI was confirmed in 121 (8.3%) patients with dyspnea and in 2319 (19%) with chest pain. Patients with dyspnea and confirmed MI had a 30-day and 4-year mortality of 21 % (CI 15-30) and 60% (CI 50-70) compared to 5.0% (CI 4.2-5.8) and 23% (CI 21-25) in patients with chest pain and confirmed MI. Adjusting for age, comorbidity, systolic blood pressure and heart rate did not change these patterns. CONCLUSION: Patients suspected of MI presenting with dyspnea have significantly higher short- and long-term mortality than patients with chest pain irrespective of a confirmed MI diagnosis. Future studies should examine if supplementary prehospital diagnostics can improve triage, facilitate early therapy and improve outcome in patients presenting with dyspnea.

Bypassing primary stroke centre reduces delay and improves outcomes for patients with large vessel occlusion.

OBJECTIVE: In large-vessel occlusion, endovascular therapy is superior to medical management alone in achieving recanalisation. Reducing time delays to revascularisation in patients with large-vessel occlusion is important to improving outcome. PATIENTS AND METHODS: A campaign was implemented in the Central Denmark Region targeting the identification of patients with large-vessel occlusion for direct transport to a comprehensive stroke centre. Time delays and outcomes before and after the intervention were assessed. RESULTS: A total of 476 patients (153 pre-intervention and 323 post-intervention) were included. They were treated with either intravenous tissue plasminogen activator or endovascular treatment (alone or in combination with intravenous tissue plasminogen activator). Endovascular therapy patients' median system delay was reduced from 234 to 185 min (adjusted relative risk delay 0.79 (95% confidence interval: 0.67-0.93)). The in-hospital delay was the main driver with an adjusted relative risk delay of 0.76 (confidence interval: 0.62-0.94), while pre-hospital delay was almost significantly reduced with an adjusted relative delay of 0.86 (confidence interval: 0.71-1.04). This was achieved without increasing the intravenous tissue plasminogen activator-treated patients' delay. Significantly more patients treated with endovascular therapy in the post-interventional period achieved functional independence (62% versus 43%), corresponding to an adjusted odds ratio of 3.08 (95% confidence interval: 1.08-8.78). CONCLUSION: Direct transfer of patients with suspected large-vessel occlusion to a comprehensive stroke centre leads to shorter treatment times for endovascular therapy patients and is, in turn, associated with an increase in functional independence. We recorded no adverse effects on intravenous tissue plasminogen activator treatment times or outcome.

Criteria-based emergency medical dispatch of ambulances fulfils goals.

INTRODUCTION: In Denmark, Alarm 112 (112) calls and emergency medical dispatch (EMD) are two separate institutions. 112 calls are mainly answered by the police. In Aarhus, a new EMD centre for the Region of Central Jutland (1.2 million people) opened on 1 December 2009. It was the first to employ health-care professionals and to use a new tool for criteria-based dispatch called Danish Index. The aim of the present paper is, for the first time in Denmark, to describe the level of urgency of patients transported by ambulance based on the Danish Index categories A-E and to determine if ambulance response time target values were reached. MATERIAL AND METHODS: The present paper is an observational cohort study based on consecutive, electronically collected data from the initial six months of operation (1 December 2009 to 31 May 2010) of the new EMD centre in Aarhus. RESULTS: A total of 73,484 patients were included. The distribution according to level of urgency was as follows: A 28.7% (n = 21,104), B 13.5% (n = 9,890), C 21.0% (n = 15,418), D 35.1% (n = 25,818), E 1.7% (n = 1,254). The median ambulance response time intervals for levels A and B were 6.5 and 11.9 min., respectively. Comparison of level A response time intervals with the equivalent target values showed that the 75, 92 and 98 percentiles were 10.0/10 min., 14.6/15 min., 18.6/20 min., respectively. CONCLUSION: In a cohort of 73,484 patients, the highest level of urgency (A) was found in 28.7% of cases, while the largest group, 35.1% of patients, were level D cases - these patients had a need for transport, but not by ambulance. The level A target response time requested by 112 was achieved. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.