Prehospital management and outcomes of patients calling with chest pain as the main complaint

Prehospital management and outcomes of patients calling with chest pain as the main complaint | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prehospital management and outcomes of patients calling with chest pain as the main complaint Sughra Ahmed, Filip Gnesin, Helle Collatz Christensen, Stig Nikolaj Blomberg, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4607638/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Oct, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted 8 You are reading this latest preprint version Abstract Background Chest pain is a frequent cause of health care contacts. We examined the prehospital management, in-hospital discharge diagnoses, and mortality of patients calling a non-emergency and emergency medical service with chest pain. Methods We included all calls to a non-emergency medical helpline (calls to 1813) and emergency medical service (1-1-2 calls) with a primary complaint of chest pain from 2014–2018 in Copenhagen, Denmark. The outcomes were: emergency response (ambulance dispatch, other transports/self-transport/home visits, self-care, and unknown/cancelled response), in-hospital diagnosis within 7 days after the call (cardiovascular, pulmonary, or other non-cardiovascular/pulmonary) and 30-day mortality. Results Among 4,838,232 calls, 91,671 were registered with chest pain by medical dispatchers. The first call for each patient was kept for analysis (n = 66,672). In total, 91.4% were referred to the hospital, 75.8% (n = 50,627) received an ambulance and 15.6% (n = 10,383) received other transport/self-transport/home visits. In total, 26.9% (n = 17,937) were diagnosed with a cardiovascular disease (Acute Coronary Syndrome (ACS): 11.1%), 5.2% (n = 3,490) a pulmonary disease, 52.8% (n = 35.242) other non-cardiovascular/pulmonary disease, and 15.1% (n = 10,093) received no diagnosis. Among ambulance-transported patients, the prevalence of cardiovascular discharge diagnoses was higher (32.1%) and fewer received no diagnosis (11.0%). Cardiovascular disease was rare among patients not transported by ambulance and patients who were not referred to hospital at all (2-13.4%) and in patients ≤ 40 years of age (< 10%). The 30-day mortality was low regardless of the diagnosis (0.6-4%), and 65,704 were still alive 30 days later. Conclusion Nearly all patients calling with chest pain were referred to treatment and among ambulance-transported patients, one-third received a cardiovascular diagnosis. While current practices appear reasonable, improved differentiation of chest pain in telephone consultations could potentially reduce burden of non-acute chest pain consultations. Chest pain ischemic heart disease emergency medical services Figures Figure 1 Figure 2 Figure 3 Introduction Globally, chest pain is considered one of the most prevalent causes of patient contacts to the health care system. Roughly 7 million patients in the United States contact the emergency departments (ED) each year due to chest pain, and chest pain is the second most frequent condition in the ED [ 1 ]. Chest pain is a common symptom of cardiovascular disease [ 2 ] and raises concern among patients as well as health care professionals. Referral to urgent diagnosis and treatment is broadly recommended for acute chest pain to rule out severe conditions and improve patients’ chance of surviving and recovering if chest pain is of cardiac origin [ 3 ]. However, chest pain can also be less severe, such as in the case of gastrointestinal complaints, musculoskeletal pain, depression, or anxiety where urgent hospital treatment is often unnecessary [ 4 ]. Among patients contacting ED in the United States, more than half appear to have chest pain with a non-cardiac cause [ 5 ]. In many cases, the first contact with health services is a telephone call making the initial medical assessment challenging. Referring patients to healthcare institutions for evaluation is costly [ 6 ]. Over triaging of chest pain patients during the first medical contact can therefore lead to a considerable overuse of resources and unnecessary financial pressure on the healthcare system. In a previous Danish study of calls to the 1-1-2 emergency number, 11% of calls were related to chest pain [ 7 ]. Similarly, chest pain has been found to be the primary symptom in 16% of all ambulance transports [ 8 ]. Chest pain is the most frequent medical complaint in contacts to the emergency medical services, and the large number of calls and ambulance transports related to this single dominating complaint emphasizes the need to evaluate how such calls are managed and assess patients’ outcomes.[ 9 ] The aim of this study was to evaluate the prehospital emergency response, in-hospital diagnosis, and 30-day mortality for patients who had called a non-emergency or emergency medical service due to chest pain. Methods Study design and setting This register-based study included all calls registered at the Copenhagen Emergency Medical Services (EMS) in the Capital Region of Denmark in a 5-year period from 1st of January 2014 till the 31st of December 2018. The Capital Region has a population of 1.8 million people with an area of 2.561 km 2 [ 10 ]. The Copenhagen EMS consist of two medical services, an out-of-hours general practitioner service (reached by dialling 1813), and the 1-1-2 emergency number [ 11 ]. Apart from these medical services inhabitants of the Capital Region can seek medical help or advice at their general practitioner who typically are available between 8 am and 4 pm. In case of a life-threatening medical condition, patients are advised to call the 1-1-2 emergency number, where nurses and paramedics evaluate the urgency of the call and dispatch ambulances and other vehicles accordingly. Moreover, the 1813-medical helpline is a medical helpline, intended as an out-of-hours service, for non-emergencies, that is medical conditions requiring immediate attention but not presumed to be life-threatening. The 1813-medical helpline is predominantly staffed by nurses, but also medical doctors. They provide medical guidance to patients, refer to hospital emergency department, and dispatch ambulances [ 12 ]. One software system is used by both the 1813 medical helpline and the 1-1-2 emergency number, which enables health care professionals to transfer calls between the two services but also to use services linked to any of the two services. However, two different protocols are used. While the 1813-medical helpline uses an electronic decision support system that is locally developed, the 1-1-2 emergency number uses the Danish Index, a criteria-based dispatch decision support tool [ 13 ]. Data collection and processing The data used in this study originates from the Danish National Patient Registry [ 14 ], the Danish Civil Registration System [ 15 ] and the Copenhagen EMS. At the Copenhagen EMS information of the calls, including the primary complaint and the immediate response provided to the patient is registered. In this study, we linked this information to diagnosis registered for emergency department visits and hospital admission available from the Danish National Patients Registry and deaths registered in the Danish Civil Registration System using the civil registration number, a unique ID assigned to all Danish citizens[ 15 , 16 ]. Patient characteristics such as age, gender and ethnicity were also collected from the Danish Civil Registration System [ 15 ]. Selection of participants We included patients who had called the 1813-medical helpline or 1-1-2 emergency number and were recorded with a primary complaint of chest pain. Only patients that could be identified in the Danish Civil Registration System were included. Further, only the first of possibly several calls during the 5-year time interval for each patient was included for analysis. Outcomes The following outcomes were considered; prehospital emergency response, in-hospital diagnosis following the call, and all-cause mortality. The prehospital emergency response is the immediate response initiated by the call-taker at the Copenhagen EMS and were divided into four categories: ambulance dispatch, other transports/self-transport/home visits (this category included almost exclusively self-transport), self-care, and unknown or cancelled response. Patients who were advised to wait and call again in case of worsening of their condition or asked to call their general practitioner the following day was categorized as self-care. Ambulance dispatch includes all patients who were dispatched with an ambulance of type A, B and C urgency, with A being potentially life-threatening conditions, B representing urgent but not life-threatening condition and C consisting of conditions where transportation and observation are necessary but not urgent. Details of the type of ambulances and other vehicles are described elsewhere [ 11 , 17 ]. Only hospitalized patients received an in-hospital diagnosis at discharge, defined as primary diagnosis by using International Classification of Diseases 10th Revision (ICD-10) codes registered within 7 days of their first contact. However, patients not initially hospitalized but who had a hospital contact within 7 days of their call were also registered as having received an in-hospital diagnosis based on their subsequent contact. ICD-10 codes registered at any hospital department including the emergency department and out-patient clinics were considered. We used one primary diagnosis for each patient according to a prioritized ranking. Cardiovascular diagnoses were ranked highest followed by pulmonary diagnosis and lastly other diagnosis were listed. For example, if a patient had a myocardial infarction (MI) diagnosis and diagnosis of Type 2 diabetes, only the MI diagnosis was considered. A prioritized ranking list of the primary diagnoses and the belonging ICD-10 codes can be seen in Table S3. Patients, who received primary diagnosis of ICD-10 I00-I99 were classified with cardiovascular disease. Pulmonary diseases included J00-J99. Other non-cardiac disease was defined as the rest of the ICD-10 codes. Finally, we defined 30-day mortality as deaths from any cause registered between time of call and 30 days after. Statistical methods We assessed the prevalence of all three outcomes (emergency response, in-hospital diagnosis, and 30-day mortality) among all chest pain patients and in subgroups of choice of medical service (1813-medical helpline and 1-1-2 emergency number). A comparison between 30-day mortality among patients with a cardiovascular or pulmonary diagnosis and patients with other diagnosis was conducted. Categorical variables were described with absolute numbers and percentages. Ethnicity was divided into three categories: ethnic Danes, immigrants, and 2nd generation immigrants. Continuous variables such as age were presented as medians with interquartile range. Additionally, we assessed the in-hospital diagnosis and 30-day mortality according to the emergency response, the distribution of in-hospital diagnosis according to sex and age groups (> 30, 30–39, 40–49, 50–59, 60–69, 70–79, ≥ 80), and patient characteristics and outcomes for survivors and non-survivors at 30-day follow-up. We calculated 95% confidence intervals for the 30-day mortality according to primary diagnosis and compared the mortality of the primary diagnosis groups using chi-square test. We used R version 4.2.1 for the data management and analyses.[ 18 ] Results A total of 4,834,071 calls were registered at the Copenhagen EMS during the study period, and 98,849 calls were regarding patients with a primary symptom of chest pain. Among these, 91,671 patients existed in the Danish Civil Registration system. We included the first of the chest pain calls for each patient resulting in a study population of 66,762 calls (1813-medical helpline: 34,904 calls, 1-1-2 emergency number: 31,858 calls) (Fig. 1 ). In Table 1 the distribution of age, sex and ethnicity of patients calling with chest pain according to their choice of medical service (1-1-2 emergency number and 1813-medical helpline). The median age for the total study population was 55.3 (38-71.6). For patients calling the 1813-medical helpline, the median age (49.3 (32.5–66.2)) and the proportion of males (47.0%) were lower compared to 1-1-2 emergency number (Median age: 62.1 (45.8–75.3); Males: 52.6%). Table 1 Patient characteristics, response, diagnosis and 30-day mortality for chest pain patients calling Copenhagen EMS (2014–2018) Variable Level 1-1-2 emergency number (n = 31,858) 1813-medical helpline (n = 34,904) Total (n = 66,762) Ethnicity Ethnic Danes 24,920 (78.4) 26,299 (75.5) 51,219 (76.9) Immigrants 5,979 (18.8) 6,670 (19.1) 12,649 (19.0) 2nd gen. Immigrants 874 (2.8) 1,881 (5.4) 2,755 (4.1) Unknown ethnicity 85 54 139 Sex Male 16,749 (52.6) 16,404 (47.0) 33,153 (49.7) Age Median (IQR) 62.1 (45.8–75.3) 49.3 (32.5–66.2) 55.3 (38-71.6) Response category Ambulance dispatch 30,684 (96.3) 19,943 (57.1) 50,627 (75.8) Other transports/Self-transport/Home visits 297 (0.9) 10,086 (28.9) 10,383 (15.6) Self-care 33 (0.1) 3,906 (11.2) 3,939 (5.9) Unknown or cancelled response 844 (2.6) 969 (2.8) 1,813 (2.7) In-hospital diagnostic categories received within 7 days Cardiovascular diseases 10,835 (34.0) 7,102 (20.3) 17,937 (26.9) Pulmonary diseases 1,693 (5.3) 1,797 (5.1) 3,490 (5.2) Other non-cardiac/pulmonary diseases 15,531 (48.8) 19,711 (56.5) 35,242 (52.8) No diagnosis 3,799 (11.9) 6,294 (18.0) 10,093 (15.1) 30-day mortality Mortality 799 (2.5) 259 (0.7) 1,058 (1.6) The response provided to the patients is also shown in Table 1 . In total, 91.4% of the patients were referred to a hospital while only 5.9% (n = 3,939) were suggested to perform self-care and 2.7% (n = 1,813) were not registered with a response or had the dispatched vehicle cancelled. However, patients who contacted the 1-1-2 emergency number were more likely to get an ambulance dispatched (96.3%) compared to those who called the 1813-medical helpline (57.1%). Types of ambulances can be seen in Table S1. However, the total number of patients referred to hospital or other medical assessment did not differ much according to the choice of medical service, as 97.2% of the patients who called 1-1-2 emergency number were transported to the hospital by an ambulance, other transport, or received a home visit, while the same response was provided to 86% of the patients, who called the 1813-medical helpline. The proportion of patients who were diagnosed with a cardiac disease was highest among patients who had called the 1-1-2 emergency number versus 1813-medical helpline (34.0% versus 20.3%) (Table 1 ). Table 2 shows in-hospital diagnosis of chest pain patients obtained within 7 days from their call according to the emergency response provided by the Copenhagen EMS. The median age was higher among patients transported by an ambulance (60.4 (44.9–74.1)) compared to patients receiving other forms of response or guidance (other transports/self-transport/home visits: 40.7 (27.1–55.4); self-care: 29.3 (22.3–45.5)). Most of the patients suffered from a non-cardiac/pulmonary disease regardless of which emergency response they received from the Copenhagen EMS. Hence, 51.3% of ambulance transported patients and 77.1% of patients, who were seen at the hospital but not transported by an ambulance, were diagnosed with a non-cardiac/pulmonary disease. Despite this, among patients who received an ambulance, 32.1% had a cardiac disease (ACS: 13.4%) and 5.5% had a pulmonary disease. Among patients provided with other transport, self-transport, or visit 13.4% had a cardiac disease (ACS: 5.2%), while cardiac diseases were found among 2% (ACS: 0.6%) of the patients referred to self-care. Among patients referred to self-care, 81.2% did not get a diagnosis, indicating that these patients had no hospital contacts during the first 7 days after the call. The distribution within response category of each sub-diagnosis included in the diagnosis categories (cardiovascular diseases, pulmonary diseases, and other non-cardiac/pulmonary diseases) are available in Table 2 . The prevalence of ACS including AMI and unstable angina pectoris was highest amongst patients who received an ambulance (13.4%) compared to other categories (0.6–5.2%). Only 1.6% of the patients died within 7 days. Moreover, the 30-day mortality for patients receiving an ambulance dispatch was 2.0% and 0.3% for the patients belonging to the two other categories (other transports/self-transport/home visits and self-care) (Table 2 ). Table 2 Diagnosis category, sub-diagnosis, and 30-day mortality according to emergency response for chest pain patients Variable Level Ambulance dispatch (n = 50,627) Other transports/Self-transport/Home visits (n = 10,383) Self-care (n = 3,939) Unknown or cancelled response (n = 1,813) Sex Male 25,047 (49.5) 5,284 (50.9) 1,897 (48.2) 925 (51.0) Age Median (IQR) 60.4 (44.9–74.1) 40.7 (27.1–55.4) 29.3 (22.3–45.5) 41.1 (25.9–62.1) Diagnosis' categories Cardiovascular diseases 16,272 (32.1) 1,389 (13.4) 79 (2.0) 197 (10.9) Pulmonary diseases 2,791 (5.5) 594 (5.7) 65 (1.7) 40 (2.2) Other non-cardiac/pulmonary diseases 25,978 (51.3) 8,004 (77.1) 598 (15.2) 662 (36.5) No diagnosis 5,586 (11.0) 396 (3.8) 3,197 (81.2) 914 (50.4) Primary diagnosis Cardiovascular diseases Cardiac arrest 163 (0.3) ≤ 3 ≤ 3 ≤ 3 Acute myocardial infarction 4,626 (9.1) 272 (2.6) 13 (0.3) 39 (2.2) Unstable angina pectoris 2,172 (4.3) 269 (2.6) 11 (0.3) 30 (1.7) Heart failure 1,389 (2.7) 58–61 9–12 12 (0.7) Ischemic heart disease 1,237 (2.4) 136 (1.3) 7 (0.2) 13–16 Atrial fibrillation 2,315 (4.6) 132 (1.3) 7 (0.2) 26 (1.4) Other cardiovascular diseases 4,370 (8.6) 519 (5.0) 30 (0.8) 74 (4.1) Pulmonary diseases Pneumothorax 121 (0.2) 49 (0.5) 8–11 ≤ 3 Chronic obstructive pulmonary disease 694 (1.4) 33 (0.3) ≤ 3 4–7 Other respiratory diseases 1,976 (3.9) 512 (4.9) 54 (1.4) 32 (1.8) Other non-cardiac/pulmonary diseases Diabetes Mellitus 301 (0.6) 39 (0.4) 4 (0.1) 6 (0.3) Stroke – TCI 59 (0.1) ≤ 3 0 (0.0) 0 (0.0) Bleeding 161 (0.3) 13 (0.1) 5 (0.1) 6 (0.3) Diseases of the nervous system 397 (0.8) 59 (0.6) 9 (0.2) 4 (0.2) Neoplasms 269 (0.5) 20 (0.2) 5 (0.1) ≤ 3 Certain infectious and parasitic diseases 503 (1.0) 148 (1.4) 19 (0.5) 18 (1.0) Diseases of the blood 151 (0.3) 16 (0.2) ≤ 3 5 (0.3) Endocrine, nutritional, and metabolic diseases 571 (1.1) 66 (0.6) ≤ 3 13 (0.7) Diseases of the eye and adnexa 55 (0.1) 4 (0.0) ≤ 3 ≤ 3 Diseases of the ear and mastoid process 116 (0.2) 13 (0.1) ≤ 3 0 (0.0) Diseases of the digestive system 1,710 (3.4) 408 (3.9) 28 (0.7) 34 (1.9) Diseases of the musculoskeletal system and connective tissue 1,827 (3.6) 1,198 (11.5) 68 (1.7) 79 (4.4) Diseases of the skin and subcutaneous tissue 55 (0.1) 13 (0.1) ≤ 3 0 (0.0) Diseases of the genitourinary system 423 (0.8) 44 (0.4) 11 (0.3) 7 (0.4) Pregnancy, childbirth, and the puerperium 25–28 13 (0.1) 5 (0.1) 0 (0.0) Mental and behavioural disorders 834 (1.6) 115 (1.1) 8 (0.2) 21 (1.2) Certain conditions originating in the perinatal period ≤ 3 ≤ 3 0 (0.0) 0 (0.0) Congenital malformations, deformations, and chromosomal abnormalities 36 (0.1) ≤ 3 0 (0.0) ≤ 3 Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified 12,496 (24.7) 4,317 (41.6) 239 (6.1) 298 (16.4) External causes of morbidity and mortality 572 (1.1) 132 (1.3) 29 (0.7) 22 (1.2) Unspecific diagnosis 5,414 (10.7) 1,383 (13.3) 156 (4.0) 141 (7.8) Unknown or no diagnosis - 5,586 (11.0) 396 (3.8) 3,197 (81.2) 914 (50.4) 30-day mortality Mortality 1,007 (2.0) 28 (0.3) 12 (0.3) 11 (0.6) The prevalence of the diagnosis categories according to patients’ age and gender is illustrated in Fig. 2 . We found a higher prevalence of patients diagnosed with cardiovascular disease with increasing age. The increase in pulmonary diagnosis with increasing age were modest, whereas the share of patients receiving no diagnosis, or a non-cardiac/pulmonary diagnosis decreased rapidly with increasing age. Generally, the prevalence of cardiovascular disease was lower among females than males, whereas the prevalence of non-cardiac/pulmonary diagnoses was higher. The prevalence of pulmonary diagnoses was similar across sex and females were only slightly more likely to not receiving a diagnosis compared to males. Cardiovascular disease was generally rare among chest pain patients younger than 40 (3–10%) (Fig. 2 ). Additionally, the primary diagnoses for the different age groups are listed in Table S2, where a very low prevalence of ACS among patients younger than 40 is observed (0.4–2.5%) in comparison with patients who were 40 and above (7.9–18.2%). The 30-day mortality was low regardless of the diagnosis of the patient, but patients subsequently diagnosed with a cardiovascular disease or a pulmonary disease, had a significantly higher 30-day mortality (3.3 95% CI[3.1;3.6] to 4% 95% CI[3.4;4.7]) compared to patients who suffered from non-cardiovascular/pulmonary diseases (0.6 95% CI[0.5;0.7] to 1% 95% CI[0.8;1.2]) (Fig. 3 ). Table 3 shows an overview of the patients (n = 1,058) who died within 30 days after their first contact to the Copenhagen EMS. The mean age of these patients was 78.3 years (Table 3 ). Most of the patients who died within 30 days had called 1-1-2 emergency number (75.5%) and were diagnosed with a cardiovascular diagnosis (54.6%) while 13.3% had received a pulmonary diagnosis. Table 3 Characteristics of chest pain patients according to whether they were alive at 30-day follow-up. Variable Level Alive after 30 days (n = 65,704) Dead after 30 days (n = 1,058) Total (n = 66,762) Ethnicity Ethnic Danes 50,267 (76.7) 952 (90.0) 51,219 (76.9) Immigrants 12,546 (19.1) 102–105 12649 (19.0) 2nd gen. Immigrants 2752 (4.2) ≤ 3 2755 (4.1) Sex Male 32,541 (49.5) 612 (57.8) 33,153 (49.7) Age Median (IQR) 54.8 (37.6–71.1) 80.1 (70.9–87.5) 55.3 (38-71.6) Type of emergency service 1-1-2 emergency number 31,059 (47.3) 799 (75.5) 31,858 (47.7) 1813-medical helpline 34,645 (52.7) 259 (24.5) 34,904 (52.3) Response category Ambulance dispatch 49,620 (75.5) 1,007 (95.2) 50,627 (75.8) Other transports/Self-transport/Home visits 10,355 (15.8) 28 (2.6) 10,383 (15.6) Self-care 3,927 (6.0) 12 (1.1) 3,939 (5.9) Unknown or cancelled response 1,802 (2.7) 11 (1.0) 1,813 (2.7) Diagnosis' categories Cardiovascular diseases 17,338 (26.4) 599 (56.6) 17,937 (26.9) Pulmonary diseases 3,349 (5.1) 141 (13.3) 3,490 (5.2) Other non-cardiac/pulmonary diseases 35,026 (53.3) 216 (20.4) 35,242 (52.8) No diagnosis 9,991 (15.2) 102 (9.6) 10,093 (15.1) Discussion Main findings The main findings from this study were that a call to Copenhagen EMS regarding chest pain nearly invariably resulted in hospital referral, and around 35% of these patients received a cardiovascular or pulmonary diagnosis. The proportion of patients who received a cardiovascular diagnosis was very low among patients younger than 40, and regardless of the diagnosis, the 30-day mortality was low for chest pain patients. Diagnostic patterns In our study, almost all patients were referred to hospital care either by an ambulance (more than 75%) or by other transportation (around 15%). Approximately, more than half of the admitted patients were discharged without receiving a specific cardiovascular or pulmonary diagnosis, which aligns with previous findings [ 8 , 19 ]. In a Danish study, 50% of ambulance transported chest pain patients were discharged without any diagnosis of disease [ 8 ]. Similarly, the proportion of non-cardiac chest pain cases in the ED was found to be 60% in another Dutch study [ 19 ]. A South African study found that respiratory diseases were the cause of chest pain in 46% of hospital admissions following an emergency call by patients with chest pain, while cardiovascular diseases were the second most common cause (43%) [ 20 ]. However, direct comparison between our and the South African study’s findings are limited due to dissimilarities between the study populations, emergency helpline, EMS, and hospital systems. Prevalence of cardiovascular diseases among chest pain patients Chest pain is acknowledged as a cardinal symptom of acute onset of ischemic heart diseases; thus, protocols recommend dispatch of high priority. Since approximately 97% of the patients with chest pain were hospitalized following their contact with the Copenhagen EMS, the results suggest that patients are managed according to protocol. However, more than 55% of chest pain patients who contacted Copenhagen EMS were not registered with cardiovascular or pulmonary diseases at discharge and cardiovascular disease were very infrequent among patients younger than 40 (ACS: 0.4–2.5%). The low risk of cardiovascular disease, but also hospitalization in general, among young chest pain patients have been documented previously [ 21 ]. Risk stratification in young patients could be improved by using cardiovascular disease history [ 21 ], however determining the history of cardiac and pulmonary disease is already included in the chest pain protocols at the Copenhagen EMS [ 13 ]. Pain intensity and location and size of the area affected by pain have also been found to predict high-risk or low-risk chest pain patients [ 22 ]. Although protocols advice clarifying the timing and activity of pain onset and type or sensation of pain, questions of size of the area or intensity could possibly be included in protocols, specifically. Research on how to improve protocols is warranted to improve the ability of differentiating cardiovascular and pulmonary induced chest pain from benign chest pain during the first medical contact especially for telephone consultations where physical examinations and diagnostic procedures are not possible. Information that can be collected by ambulance personnel, including electrocardiography (ECG), oxygen saturation, and fever have also been found to predict high versus low-risk chest pain, and might enable early diagnosis [ 22 ]. An early POC-troponin measurement has also shown to be useful to rule-in AMI [ 23 ]. Collecting these data is already considered standard practice for chest pain patients in the ambulance. A recent Scandinavian study found that the ECG and vital signs were registered for almost all ambulance transported chest pain patients [ 24 ]. Thus, it is uncertain whether additional emphasis on these predictors would in fact improve the risk stratification further. Limitations Patients not registered with a Danish civil registration number were excluded, as we are not able to track their subsequent diagnoses or 30-day mortality. However, this was a very low proportion of patients in our study. Another limitation is that we do not know which condition patients not referred for treatment suffered from. However, if they were hospitalized during the following 7 days of a call, we would include information of their in-hospital diagnosis regardless of whether they were referred to the hospital during the initial call. Conclusion Nearly all patients calling the non-emergency medical helpline or emergency medical service with chest pain were referred directly to hospital care. Cardiovascular disease was frequent among the ambulance transported chest pain patients, but low among patients younger than 40 and patients not dispatched to ambulance transport. Regardless of the diagnosis, the 30-days mortality for chest pain patients was low (0.6-4%). While current practices appear reasonable, improved differentiation of chest pain patient in telephone consultations could potentially reduce in-hospital burden of non-acute chest pain consultations. Declarations Ethics approval and consent to participate Ethical approval is not required for retrospective register-based studies in Denmark. However, this study was approved by the Danish Patient Safety Authority (Case number:3-3013-2795/1, reference EMGW) and The Capital Region of Denmark (Region Hovedstaden), the institution responsible for the data, (Approval number: P-2019-191). All authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent is not required for this study. Consent for publication Not applicable. Availability of data and materials Due to restrictions related to Danish law and patient privacy, the data used in the present study can only be made available through a trusted third party, in this case Statistics Denmark. Examination of data is only possible in collaboration with an authorized Danish investigator. Request for access can be send to Professor Christian Torp-Pedersen, [email protected] Competing interests All the following reported grants have been received outside the submitted work and are without relevance to the current study. CTP, FF and FG reports grant from Novo Nordisk Foundation. CTP has received grants for studies from Bayer. FF has received research grant from TrygFonden. FG has received a grant from Danish Cardiovascular Academy. SA, ALM, HCC, SNB, KK, HB and FL, have no competing interests to report. Funding The study was supported by a grant from the Danish Heart Foundation (grant number: R122-A8403). The Danish Heart Foundation had no role in designing the study, the data collection, the analyses, the decision to publish, or preparation of the manuscript. Authors' contributions All authors contributed to the conception and interpretation of the study. ALM, CTP, and SA performed the data management and analyses. CTP, KK, FF, and FL were involved in the funding acquisition. SA wrote the frst draft of the manuscript. All authors commented and contributed to previous versions of the manuscript and approved the fnal version for submission. Acknowledgements Not applicable. References Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2019 Emergency Department Summary Tables . National Center for Health Statistics (U.S.), 2022. Brieger D, Eagle KA, Goodman SG et al. Acute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group. Chest 2004; 126 :461–9. Beygui F, Castren M, Brunetti ND et al. Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. Eur Heart J Acute Cardiovasc Care 2020; 9 :59–81. Eslick GD, Jones MP, Talley NJ. Non-cardiac chest pain: prevalence, risk factors, impact and consulting - a population-based study: NON-CARDIAC CHEST PAIN - A POPULATION-BASED STUDY. Aliment Pharmacol Ther 2003; 17 :1115–24. Januzzi JL, McCarthy CP. Evaluating Chest Pain in the Emergency Department. J Am Coll Cardiol 2018; 71 :617–9. Brian J. Moore, Ph.D., and Lan Liang, Ph.D. Costs of Emergency Department Visits in the United States, 2017. HCUP (HEALTHCARE COST AND UTILIZATION PROJECT) 2020:14. Møller TP, Ersbøll AK, Tolstrup JS et al. Why and when citizens call for emergency help: an observational study of 211,193 medical emergency calls. Scand J Trauma Resusc Emerg Med 2015; 23 :88. Pedersen CK, Stengaard C, Friesgaard K et al. Chest pain in the ambulance; prevalence, causes and outcome - a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019; 27 :84. Bøtker MT, Terkelsen CJ, Sørensen JN et al. Long-Term Mortality of Emergency Medical Services Patients. Ann Emerg Med 2017; 70 :366-373.e3. Centre of communication, Capital Region of Denmark. Capitial Region of Denmark – Growth and quality of life. 2017. Zinger ND, Blomberg SN, Lippert F et al. Impact of integrating out-of-hours services into Emergency Medical Services Copenhagen: a descriptive study of transformational years. Int J Emerg Med 2022; 15 :40. Lindskou TA, Mikkelsen S, Christensen EF et al. The Danish prehospital emergency healthcare system and research possibilities. Scand J Trauma Resusc Emerg Med 2019; 27 :100. Danske Regioner, Laerdal. Dansk Index for Akuthjælp - AMK-vagtcentralernes værktøj for visitation til præhospitale ressourcer Landsudgaven, version 1.8. 2017. Schmidt M, Schmidt SAJ, Sandegaard JL et al. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol 2015:449. Pedersen CB. The Danish Civil Registration System. Scand J Public Health 2011; 39 :22–5. Lynge E, Sandegaard JL, Rebolj M. The Danish National Patient Register. Scand J Public Health 2011; 39 :30–3. Møller AL, Mills EHA, Gnesin F et al. Impact of myocardial infarction symptom presentation on emergency response and survival. Eur Heart J Acute Cardiovasc Care 2021; 10 :1150–9. R Core Team. R: A Language and Environment for Statistical Computing. 2021. Mol KA, Smoczynska A, Rahel BM et al. Non-cardiac chest pain: prognosis and secondary healthcare utilisation. Open Heart 2018; 5 :e000859. Geyser M, Smith S. Chest pain prevalence, causes, and disposition in the emergency department of a regional hospital in Pretoria. Afr J Prim Health Care Fam Med 2016; 8 , DOI: 10.4102/phcfm.v8i1.1048. Walker NJ, Sites FD, Shofer FS et al. Characteristics and Outcomes of Young Adults Who Present to the Emergency Department with Chest Pain. Acad Emerg Med 2001; 8 :703–8. Wibring K, Lingman M, Herlitz J et al. Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study. BMJ Open 2021; 11 :e044938. Stopyra JP, Snavely AC, Scheidler JF et al. Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction. 2020; 24 :10. Wibring K, Lingman M, Herlitz J et al. Guideline adherence among prehospital emergency nurses when caring for patients with chest pain: a prospective cohort study. Scand J Trauma Resusc Emerg Med 2021; 29 :157. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 18 Oct, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted Reviews received at journal 30 Jul, 2024 Reviews received at journal 28 Jul, 2024 Reviewers agreed at journal 18 Jul, 2024 Reviewers agreed at journal 12 Jul, 2024 Reviewers invited by journal 10 Jul, 2024 Editor assigned by journal 09 Jul, 2024 Submission checks completed at journal 09 Jul, 2024 First submitted to journal 19 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4607638","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":333739151,"identity":"42ca9019-58b1-4279-9cfa-522369e5b5a1","order_by":0,"name":"Sughra Ahmed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYHACNjBpAMQSDAZsciDOgQfEa6ngMwZrSSBeyxm5xAYQD58W+Rnp1x5X1DDIm4sdPniDsc0sfX7Y4YdAW+zkdBuwazG4kVNueOYYg+HO2WnJFoxtabkbb6cZALUkG5sdwKFFIidNsoGNgXHD7RwzCca2Y7kbZyeAtBxI3IZDi/wMkJZ/DPYbbud/A2r5n244O/0DXi0MN9KPSTa2MSQCbWEDep8tQV46B78tBmfesEk29kkkb7idZmyRUMFmuEE6p+BAggFuv8i3pz+TbPhmY7vhdvLDGx8M2OTlZ6dv/vChwk4OlxYGBh5IjIBBAshesEoDXMpBgP0Bmr0N+FSPglEwCkbBSAQAySZhygxxh90AAAAASUVORK5CYII=","orcid":"","institution":"Nordsjaellands Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sughra","middleName":"","lastName":"Ahmed","suffix":""},{"id":333739152,"identity":"5fbd6a07-59cc-4765-85da-e05ea9f8a88f","order_by":1,"name":"Filip Gnesin","email":"","orcid":"","institution":"Nordsjaellands Hospital","correspondingAuthor":false,"prefix":"","firstName":"Filip","middleName":"","lastName":"Gnesin","suffix":""},{"id":333739154,"identity":"98eaef1d-55bd-4fd9-9986-138b1ce0a0fd","order_by":2,"name":"Helle Collatz Christensen","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Helle","middleName":"Collatz","lastName":"Christensen","suffix":""},{"id":333739156,"identity":"75a7de54-37cf-47a3-aa9c-a21f431e0b1c","order_by":3,"name":"Stig Nikolaj Blomberg","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Stig","middleName":"Nikolaj","lastName":"Blomberg","suffix":""},{"id":333739158,"identity":"8472312e-71d7-41a8-8a60-2de0a1157731","order_by":4,"name":"Fredrik Folke","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Fredrik","middleName":"","lastName":"Folke","suffix":""},{"id":333739159,"identity":"782f6356-9f2d-42e3-b3bd-920656625fe1","order_by":5,"name":"Kristian Kragholm","email":"","orcid":"","institution":"Aalborg University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kristian","middleName":"","lastName":"Kragholm","suffix":""},{"id":333739160,"identity":"b0c6523c-7dad-4ca1-b771-90c061e7dfa6","order_by":6,"name":"Henrik Bøggild","email":"","orcid":"","institution":"Aalborg University","correspondingAuthor":false,"prefix":"","firstName":"Henrik","middleName":"","lastName":"Bøggild","suffix":""},{"id":333739161,"identity":"f7717511-4396-4f1d-8652-71691e2f2c4e","order_by":7,"name":"Freddy Lippert","email":"","orcid":"","institution":"Copenhagen Emergency Medical Services","correspondingAuthor":false,"prefix":"","firstName":"Freddy","middleName":"","lastName":"Lippert","suffix":""},{"id":333739162,"identity":"61651468-5a1f-493f-8f14-1ff0ed11b00b","order_by":8,"name":"Christian Torp-Pedersen","email":"","orcid":"","institution":"Nordsjaellands Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Torp-Pedersen","suffix":""},{"id":333739163,"identity":"6b7f3299-4f86-4725-8097-b5770470faae","order_by":9,"name":"Amalie Lykkemark Møller","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Amalie","middleName":"Lykkemark","lastName":"Møller","suffix":""}],"badges":[],"createdAt":"2024-06-19 18:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4607638/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4607638/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-024-00745-8","type":"published","date":"2024-10-18T15:57:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62183265,"identity":"41c9d666-a0d9-4b00-9549-6c09773a86ac","added_by":"auto","created_at":"2024-08-10 11:34:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61977,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart illustrating selection of participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4607638/v1/6675cccf307b4657057d9829.png"},{"id":62183263,"identity":"04bcb216-9c1f-44c0-bbdc-6340b6a65ea8","added_by":"auto","created_at":"2024-08-10 11:34:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101603,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of diagnoses according to sex and age groups for chest pain patients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegend: The figure illustrates the diagnoses the patients received within 7 days from their call to the Copenhagen Emergency Medical Services in the study period (2014-2018). The size of the box illustrates the proportion of that diagnosis in the specific sex and age stratum.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4607638/v1/8266ac87b8cf55d0555ada49.png"},{"id":62184420,"identity":"2cf719f2-de77-4d34-a7f5-c574a2123c24","added_by":"auto","created_at":"2024-08-10 11:42:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":68073,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe 30-day mortality among chest pain patients according to primary diagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegend: The figure shows the 30-day mortality according to primary diagnosis with 95% confidence intervals. The 30-day mortality for those diagnosed with cardiovascular diseases was significantly higher compared to those not receiving a diagnosis (p\u0026lt;0.001) and those with Other non-cardiac/pulmonary diseases (p\u0026lt;0.001). Similarly, the 30-day mortality for those with pulmonary diseases was significantly higher compared to those not receiving a diagnosis (p\u0026lt;0.001) and those with Other non-cardiac/pulmonary diseases (p\u0026lt;0.001).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4607638/v1/adfbd20ff8f525777571d2b4.png"},{"id":67149011,"identity":"ce8a94cf-116e-4090-b7d0-17c26fd9089d","added_by":"auto","created_at":"2024-10-21 16:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1166803,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4607638/v1/d1d6026c-cfae-4008-8677-9790e67e15ac.pdf"},{"id":62183262,"identity":"449aa6c6-90cd-48f3-a90e-e2ce2fbf54fb","added_by":"auto","created_at":"2024-08-10 11:34:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":35497,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4607638/v1/9e4a149125d12bf9fc31c9d0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prehospital management and outcomes of patients calling with chest pain as the main complaint","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGlobally, chest pain is considered one of the most prevalent causes of patient contacts to the health care system. Roughly 7\u0026nbsp;million patients in the United States contact the emergency departments (ED) each year due to chest pain, and chest pain is the second most frequent condition in the ED [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChest pain is a common symptom of cardiovascular disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and raises concern among patients as well as health care professionals. Referral to urgent diagnosis and treatment is broadly recommended for acute chest pain to rule out severe conditions and improve patients\u0026rsquo; chance of surviving and recovering if chest pain is of cardiac origin [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, chest pain can also be less severe, such as in the case of gastrointestinal complaints, musculoskeletal pain, depression, or anxiety where urgent hospital treatment is often unnecessary [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Among patients contacting ED in the United States, more than half appear to have chest pain with a non-cardiac cause [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In many cases, the first contact with health services is a telephone call making the initial medical assessment challenging. Referring patients to healthcare institutions for evaluation is costly [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Over triaging of chest pain patients during the first medical contact can therefore lead to a considerable overuse of resources and unnecessary financial pressure on the healthcare system.\u003c/p\u003e \u003cp\u003eIn a previous Danish study of calls to the 1-1-2 emergency number, 11% of calls were related to chest pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, chest pain has been found to be the primary symptom in 16% of all ambulance transports [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Chest pain is the most frequent medical complaint in contacts to the emergency medical services, and the large number of calls and ambulance transports related to this single dominating complaint emphasizes the need to evaluate how such calls are managed and assess patients\u0026rsquo; outcomes.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate the prehospital emergency response, in-hospital diagnosis, and 30-day mortality for patients who had called a non-emergency or emergency medical service due to chest pain.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis register-based study included all calls registered at the Copenhagen Emergency Medical Services (EMS) in the Capital Region of Denmark in a 5-year period from 1st of January 2014 till the 31st of December 2018. The Capital Region has a population of 1.8\u0026nbsp;million people with an area of 2.561 km\u003csup\u003e2\u003c/sup\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The Copenhagen EMS consist of two medical services, an out-of-hours general practitioner service (reached by dialling 1813), and the 1-1-2 emergency number [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Apart from these medical services inhabitants of the Capital Region can seek medical help or advice at their general practitioner who typically are available between 8 am and 4 pm. In case of a life-threatening medical condition, patients are advised to call the 1-1-2 emergency number, where nurses and paramedics evaluate the urgency of the call and dispatch ambulances and other vehicles accordingly. Moreover, the 1813-medical helpline is a medical helpline, intended as an out-of-hours service, for non-emergencies, that is medical conditions requiring immediate attention but not presumed to be life-threatening. The 1813-medical helpline is predominantly staffed by nurses, but also medical doctors. They provide medical guidance to patients, refer to hospital emergency department, and dispatch ambulances [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. One software system is used by both the 1813 medical helpline and the 1-1-2 emergency number, which enables health care professionals to transfer calls between the two services but also to use services linked to any of the two services. However, two different protocols are used. While the 1813-medical helpline uses an electronic decision support system that is locally developed, the 1-1-2 emergency number uses the Danish Index, a criteria-based dispatch decision support tool [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection and processing\u003c/h2\u003e \u003cp\u003eThe data used in this study originates from the Danish National Patient Registry [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], the Danish Civil Registration System [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and the Copenhagen EMS.\u003c/p\u003e \u003cp\u003eAt the Copenhagen EMS information of the calls, including the primary complaint and the immediate response provided to the patient is registered. In this study, we linked this information to diagnosis registered for emergency department visits and hospital admission available from the Danish National Patients Registry and deaths registered in the Danish Civil Registration System using the civil registration number, a unique ID assigned to all Danish citizens[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Patient characteristics such as age, gender and ethnicity were also collected from the Danish Civil Registration System [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSelection of participants\u003c/h2\u003e \u003cp\u003eWe included patients who had called the 1813-medical helpline or 1-1-2 emergency number and were recorded with a primary complaint of chest pain. Only patients that could be identified in the Danish Civil Registration System were included. Further, only the first of possibly several calls during the 5-year time interval for each patient was included for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes\u003c/h2\u003e \u003cp\u003eThe following outcomes were considered; prehospital emergency response, in-hospital diagnosis following the call, and all-cause mortality.\u003c/p\u003e \u003cp\u003eThe prehospital emergency response is the immediate response initiated by the call-taker at the Copenhagen EMS and were divided into four categories: ambulance dispatch, other transports/self-transport/home visits (this category included almost exclusively self-transport), self-care, and unknown or cancelled response. Patients who were advised to wait and call again in case of worsening of their condition or asked to call their general practitioner the following day was categorized as self-care. Ambulance dispatch includes all patients who were dispatched with an ambulance of type A, B and C urgency, with A being potentially life-threatening conditions, B representing urgent but not life-threatening condition and C consisting of conditions where transportation and observation are necessary but not urgent. Details of the type of ambulances and other vehicles are described elsewhere [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOnly hospitalized patients received an in-hospital diagnosis at discharge, defined as primary diagnosis by using International Classification of Diseases 10th Revision (ICD-10) codes registered within 7 days of their first contact. However, patients not initially hospitalized but who had a hospital contact within 7 days of their call were also registered as having received an in-hospital diagnosis based on their subsequent contact. ICD-10 codes registered at any hospital department including the emergency department and out-patient clinics were considered.\u003c/p\u003e \u003cp\u003e We used one primary diagnosis for each patient according to a prioritized ranking. Cardiovascular diagnoses were ranked highest followed by pulmonary diagnosis and lastly other diagnosis were listed. For example, if a patient had a myocardial infarction (MI) diagnosis and diagnosis of Type 2 diabetes, only the MI diagnosis was considered. A prioritized ranking list of the primary diagnoses and the belonging ICD-10 codes can be seen in Table S3.\u003c/p\u003e \u003cp\u003ePatients, who received primary diagnosis of ICD-10 I00-I99 were classified with cardiovascular disease. Pulmonary diseases included J00-J99. Other non-cardiac disease was defined as the rest of the ICD-10 codes. Finally, we defined 30-day mortality as deaths from any cause registered between time of call and 30 days after.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eWe assessed the prevalence of all three outcomes (emergency response, in-hospital diagnosis, and 30-day mortality) among all chest pain patients and in subgroups of choice of medical service (1813-medical helpline and 1-1-2 emergency number). A comparison between 30-day mortality among patients with a cardiovascular or pulmonary diagnosis and patients with other diagnosis was conducted.\u003c/p\u003e \u003cp\u003eCategorical variables were described with absolute numbers and percentages. Ethnicity was divided into three categories: ethnic Danes, immigrants, and 2nd generation immigrants.\u003c/p\u003e \u003cp\u003eContinuous variables such as age were presented as medians with interquartile range. Additionally, we assessed the in-hospital diagnosis and 30-day mortality according to the emergency response, the distribution of in-hospital diagnosis according to sex and age groups (\u0026gt;\u0026thinsp;30, 30\u0026ndash;39, 40\u0026ndash;49, 50\u0026ndash;59, 60\u0026ndash;69, 70\u0026ndash;79, \u0026ge;\u0026thinsp;80), and patient characteristics and outcomes for survivors and non-survivors at 30-day follow-up. We calculated 95% confidence intervals for the 30-day mortality according to primary diagnosis and compared the mortality of the primary diagnosis groups using chi-square test.\u003c/p\u003e \u003cp\u003eWe used R version 4.2.1 for the data management and analyses.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 4,834,071 calls were registered at the Copenhagen EMS during the study period, and 98,849 calls were regarding patients with a primary symptom of chest pain. Among these, 91,671 patients existed in the Danish Civil Registration system. We included the first of the chest pain calls for each patient resulting in a study population of 66,762 calls (1813-medical helpline: 34,904 calls, 1-1-2 emergency number: 31,858 calls) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e the distribution of age, sex and ethnicity of patients calling with chest pain according to their choice of medical service (1-1-2 emergency number and 1813-medical helpline). The median age for the total study population was 55.3 (38-71.6). For patients calling the 1813-medical helpline, the median age (49.3 (32.5\u0026ndash;66.2)) and the proportion of males (47.0%) were lower compared to 1-1-2 emergency number (Median age: 62.1 (45.8\u0026ndash;75.3); Males: 52.6%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics, response, diagnosis and 30-day mortality for chest pain patients calling Copenhagen EMS (2014\u0026ndash;2018)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1-1-2 emergency number (n\u0026thinsp;=\u0026thinsp;31,858)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1813-medical helpline (n\u0026thinsp;=\u0026thinsp;34,904)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;66,762)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthnic Danes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24,920 (78.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26,299 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51,219 (76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmigrants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,979 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,670 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12,649 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd gen. Immigrants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e874 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,881 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2,755 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown ethnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e139\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16,749 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16,404 (47.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33,153 (49.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.1 (45.8\u0026ndash;75.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.3 (32.5\u0026ndash;66.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55.3 (38-71.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse category\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmbulance dispatch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30,684 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19,943 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50,627 (75.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther transports/Self-transport/Home visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e297 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10,086 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10,383 (15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3,906 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,939 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown or cancelled response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e844 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e969 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,813 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital diagnostic categories received within 7 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10,835 (34.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,102 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17,937 (26.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,693 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,797 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,490 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther non-cardiac/pulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15,531 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19,711 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35,242 (52.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,799 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6,294 (18.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10,093 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e799 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e259 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,058 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe response provided to the patients is also shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In total, 91.4% of the patients were referred to a hospital while only 5.9% (n\u0026thinsp;=\u0026thinsp;3,939) were suggested to perform self-care and 2.7% (n\u0026thinsp;=\u0026thinsp;1,813) were not registered with a response or had the dispatched vehicle cancelled. However, patients who contacted the 1-1-2 emergency number were more likely to get an ambulance dispatched (96.3%) compared to those who called the 1813-medical helpline (57.1%). Types of ambulances can be seen in Table S1. However, the total number of patients referred to hospital or other medical assessment did not differ much according to the choice of medical service, as 97.2% of the patients who called 1-1-2 emergency number were transported to the hospital by an ambulance, other transport, or received a home visit, while the same response was provided to 86% of the patients, who called the 1813-medical helpline.\u003c/p\u003e \u003cp\u003eThe proportion of patients who were diagnosed with a cardiac disease was highest among patients who had called the 1-1-2 emergency number versus 1813-medical helpline (34.0% versus 20.3%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows in-hospital diagnosis of chest pain patients obtained within 7 days from their call according to the emergency response provided by the Copenhagen EMS. The median age was higher among patients transported by an ambulance (60.4 (44.9\u0026ndash;74.1)) compared to patients receiving other forms of response or guidance (other transports/self-transport/home visits: 40.7 (27.1\u0026ndash;55.4); self-care: 29.3 (22.3\u0026ndash;45.5)). Most of the patients suffered from a non-cardiac/pulmonary disease regardless of which emergency response they received from the Copenhagen EMS. Hence, 51.3% of ambulance transported patients and 77.1% of patients, who were seen at the hospital but not transported by an ambulance, were diagnosed with a non-cardiac/pulmonary disease. Despite this, among patients who received an ambulance, 32.1% had a cardiac disease (ACS: 13.4%) and 5.5% had a pulmonary disease. Among patients provided with other transport, self-transport, or visit 13.4% had a cardiac disease (ACS: 5.2%), while cardiac diseases were found among 2% (ACS: 0.6%) of the patients referred to self-care. Among patients referred to self-care, 81.2% did not get a diagnosis, indicating that these patients had no hospital contacts during the first 7 days after the call. The distribution within response category of each sub-diagnosis included in the diagnosis categories (cardiovascular diseases, pulmonary diseases, and other non-cardiac/pulmonary diseases) are available in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The prevalence of ACS including AMI and unstable angina pectoris was highest amongst patients who received an ambulance (13.4%) compared to other categories (0.6\u0026ndash;5.2%). Only 1.6% of the patients died within 7 days. Moreover, the 30-day mortality for patients receiving an ambulance dispatch was 2.0% and 0.3% for the patients belonging to the two other categories (other transports/self-transport/home visits and self-care) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnosis category, sub-diagnosis, and 30-day mortality according to emergency response for chest pain patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAmbulance dispatch (n\u0026thinsp;=\u0026thinsp;50,627)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOther transports/Self-transport/Home visits (n\u0026thinsp;=\u0026thinsp;10,383)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelf-care (n\u0026thinsp;=\u0026thinsp;3,939)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnknown or cancelled response (n\u0026thinsp;=\u0026thinsp;1,813)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25,047 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5,284 (50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,897 (48.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e925 (51.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.4 (44.9\u0026ndash;74.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.7 (27.1\u0026ndash;55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29.3 (22.3\u0026ndash;45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.1 (25.9\u0026ndash;62.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis' categories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16,272 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,389 (13.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e197 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,791 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e594 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther non-cardiac/pulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25,978 (51.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,004 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e598 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e662 (36.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,586 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e396 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,197 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e914 (50.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiac arrest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e163 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcute myocardial infarction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,626 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e272 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnstable angina pectoris\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,172 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e269 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 (1.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,389 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58\u0026ndash;61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIschemic heart disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,237 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e136 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u0026ndash;16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,315 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther cardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,370 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e519 (5.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronic obstructive pulmonary disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e694 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther respiratory diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,976 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e512 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther non-cardiac/pulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e301 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStroke \u0026ndash; TCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the nervous system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e397 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeoplasms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e269 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertain infectious and parasitic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e503 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e148 (1.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (0.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the blood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEndocrine, nutritional, and metabolic diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e571 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the eye and adnexa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the ear and mastoid process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the digestive system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,710 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e408 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the musculoskeletal system and connective tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,827 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,198 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the skin and subcutaneous tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiseases of the genitourinary system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e423 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePregnancy, childbirth, and the puerperium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental and behavioural disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e834 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (0.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertain conditions originating in the perinatal period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCongenital malformations, deformations, and chromosomal abnormalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSymptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12,496 (24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,317 (41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e239 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e298 (16.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExternal causes of morbidity and mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e572 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e132 (1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnspecific diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,414 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,383 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e156 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e141 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown or no diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5,586 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e396 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3,197 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e914 (50.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30-day mortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,007 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (0.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe prevalence of the diagnosis categories according to patients\u0026rsquo; age and gender is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. We found a higher prevalence of patients diagnosed with cardiovascular disease with increasing age. The increase in pulmonary diagnosis with increasing age were modest, whereas the share of patients receiving no diagnosis, or a non-cardiac/pulmonary diagnosis decreased rapidly with increasing age. Generally, the prevalence of cardiovascular disease was lower among females than males, whereas the prevalence of non-cardiac/pulmonary diagnoses was higher. The prevalence of pulmonary diagnoses was similar across sex and females were only slightly more likely to not receiving a diagnosis compared to males. Cardiovascular disease was generally rare among chest pain patients younger than 40 (3\u0026ndash;10%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, the primary diagnoses for the different age groups are listed in Table S2, where a very low prevalence of ACS among patients younger than 40 is observed (0.4\u0026ndash;2.5%) in comparison with patients who were 40 and above (7.9\u0026ndash;18.2%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe 30-day mortality was low regardless of the diagnosis of the patient, but patients subsequently diagnosed with a cardiovascular disease or a pulmonary disease, had a significantly higher 30-day mortality (3.3 95% CI[3.1;3.6] to 4% 95% CI[3.4;4.7]) compared to patients who suffered from non-cardiovascular/pulmonary diseases (0.6 95% CI[0.5;0.7] to 1% 95% CI[0.8;1.2]) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows an overview of the patients (n\u0026thinsp;=\u0026thinsp;1,058) who died within 30 days after their first contact to the Copenhagen EMS. The mean age of these patients was 78.3 years (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Most of the patients who died within 30 days had called 1-1-2 emergency number (75.5%) and were diagnosed with a cardiovascular diagnosis (54.6%) while 13.3% had received a pulmonary diagnosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of chest pain patients according to whether they were alive at 30-day follow-up.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlive after 30 days (n\u0026thinsp;=\u0026thinsp;65,704)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDead after 30 days (n\u0026thinsp;=\u0026thinsp;1,058)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;66,762)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthnic Danes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50,267 (76.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e952 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51,219 (76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImmigrants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12,546 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102\u0026ndash;105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12649 (19.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd gen. Immigrants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2752 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2755 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32,541 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e612 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33,153 (49.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.8 (37.6\u0026ndash;71.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80.1 (70.9\u0026ndash;87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55.3 (38-71.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType of emergency service\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1-1-2 emergency number\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31,059 (47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e799 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31,858 (47.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1813-medical helpline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34,645 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e259 (24.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34,904 (52.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponse category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmbulance dispatch\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49,620 (75.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1,007 (95.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50,627 (75.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther transports/Self-transport/Home visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10,355 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10,383 (15.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf-care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,927 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,939 (5.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown or cancelled response\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,802 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,813 (2.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiagnosis' categories\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCardiovascular diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17,338 (26.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e599 (56.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17,937 (26.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,349 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3,490 (5.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther non-cardiac/pulmonary diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35,026 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e216 (20.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35,242 (52.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,991 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102 (9.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10,093 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eMain findings\u003c/h2\u003e \u003cp\u003eThe main findings from this study were that a call to Copenhagen EMS regarding chest pain nearly invariably resulted in hospital referral, and around 35% of these patients received a cardiovascular or pulmonary diagnosis. The proportion of patients who received a cardiovascular diagnosis was very low among patients younger than 40, and regardless of the diagnosis, the 30-day mortality was low for chest pain patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDiagnostic patterns\u003c/h2\u003e \u003cp\u003eIn our study, almost all patients were referred to hospital care either by an ambulance (more than 75%) or by other transportation (around 15%). Approximately, more than half of the admitted patients were discharged without receiving a specific cardiovascular or pulmonary diagnosis, which aligns with previous findings [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In a Danish study, 50% of ambulance transported chest pain patients were discharged without any diagnosis of disease [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, the proportion of non-cardiac chest pain cases in the ED was found to be 60% in another Dutch study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A South African study found that respiratory diseases were the cause of chest pain in 46% of hospital admissions following an emergency call by patients with chest pain, while cardiovascular diseases were the second most common cause (43%) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. However, direct comparison between our and the South African study\u0026rsquo;s findings are limited due to dissimilarities between the study populations, emergency helpline, EMS, and hospital systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of cardiovascular diseases among chest pain patients\u003c/h2\u003e \u003cp\u003eChest pain is acknowledged as a cardinal symptom of acute onset of ischemic heart diseases; thus, protocols recommend dispatch of high priority. Since approximately 97% of the patients with chest pain were hospitalized following their contact with the Copenhagen EMS, the results suggest that patients are managed according to protocol. However, more than 55% of chest pain patients who contacted Copenhagen EMS were not registered with cardiovascular or pulmonary diseases at discharge and cardiovascular disease were very infrequent among patients younger than 40 (ACS: 0.4\u0026ndash;2.5%). The low risk of cardiovascular disease, but also hospitalization in general, among young chest pain patients have been documented previously [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Risk stratification in young patients could be improved by using cardiovascular disease history [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], however determining the history of cardiac and pulmonary disease is already included in the chest pain protocols at the Copenhagen EMS [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Pain intensity and location and size of the area affected by pain have also been found to predict high-risk or low-risk chest pain patients [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although protocols advice clarifying the timing and activity of pain onset and type or sensation of pain, questions of size of the area or intensity could possibly be included in protocols, specifically. Research on how to improve protocols is warranted to improve the ability of differentiating cardiovascular and pulmonary induced chest pain from benign chest pain during the first medical contact especially for telephone consultations where physical examinations and diagnostic procedures are not possible. Information that can be collected by ambulance personnel, including electrocardiography (ECG), oxygen saturation, and fever have also been found to predict high versus low-risk chest pain, and might enable early diagnosis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. An early POC-troponin measurement has also shown to be useful to rule-in AMI [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Collecting these data is already considered standard practice for chest pain patients in the ambulance. A recent Scandinavian study found that the ECG and vital signs were registered for almost all ambulance transported chest pain patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Thus, it is uncertain whether additional emphasis on these predictors would in fact improve the risk stratification further.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003ePatients not registered with a Danish civil registration number were excluded, as we are not able to track their subsequent diagnoses or 30-day mortality. However, this was a very low proportion of patients in our study.\u003c/p\u003e \u003cp\u003eAnother limitation is that we do not know which condition patients not referred for treatment suffered from. However, if they were hospitalized during the following 7 days of a call, we would include information of their in-hospital diagnosis regardless of whether they were referred to the hospital during the initial call.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eNearly all patients calling the non-emergency medical helpline or emergency medical service with chest pain were referred directly to hospital care. Cardiovascular disease was frequent among the ambulance transported chest pain patients, but low among patients younger than 40 and patients not dispatched to ambulance transport. Regardless of the diagnosis, the 30-days mortality for chest pain patients was low (0.6-4%). While current practices appear reasonable, improved differentiation of chest pain patient in telephone consultations could potentially reduce in-hospital burden of non-acute chest pain consultations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval is not required for retrospective register-based studies in Denmark. However, this study was approved by the Danish Patient Safety Authority (Case number:3-3013-2795/1, reference EMGW) and The Capital Region of Denmark (Region Hovedstaden), the institution responsible for the data, (Approval number: P-2019-191).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent is not required for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to restrictions related to Danish law and patient privacy, the data used in the present study can only be made available through a trusted third party, in this case Statistics Denmark. Examination of data is only possible in collaboration with an authorized Danish investigator. Request for access can be send to Professor Christian Torp-Pedersen, [email protected]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the following reported grants have been received outside the submitted work and are without relevance to the current study. CTP, FF and FG reports grant from Novo Nordisk Foundation. CTP has received grants for studies from Bayer. FF has received research grant from TrygFonden. FG has received a grant from Danish Cardiovascular Academy.\u003c/p\u003e\n\u003cp\u003eSA, ALM, HCC, SNB, KK, HB and FL, have no competing interests to report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by a grant from the Danish Heart Foundation\u0026nbsp;(grant number: R122-A8403). The Danish Heart Foundation had no role in designing the study, the data collection, the analyses, the decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and interpretation of the study. ALM, CTP, and SA performed the data management and analyses. CTP, KK, FF, and FL were involved in the funding acquisition. SA wrote the frst draft of the manuscript. All authors commented and contributed to previous versions of the manuscript and approved the fnal version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCairns C, Kang K. \u003cem\u003eNational Hospital Ambulatory Medical Care Survey: 2019 Emergency Department Summary Tables\u003c/em\u003e. National Center for Health Statistics (U.S.), 2022.\u003c/li\u003e\n\u003cli\u003eBrieger D, Eagle KA, Goodman SG \u003cem\u003eet al.\u003c/em\u003e Acute Coronary Syndromes Without Chest Pain, An Underdiagnosed and Undertreated High-Risk Group. \u003cem\u003eChest\u003c/em\u003e 2004;\u003cstrong\u003e126\u003c/strong\u003e:461\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBeygui F, Castren M, Brunetti ND \u003cem\u003eet al.\u003c/em\u003e Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC. \u003cem\u003eEur Heart J Acute Cardiovasc Care\u003c/em\u003e 2020;\u003cstrong\u003e9\u003c/strong\u003e:59\u0026ndash;81.\u003c/li\u003e\n\u003cli\u003eEslick GD, Jones MP, Talley NJ. Non-cardiac chest pain: prevalence, risk factors, impact and consulting - a population-based study: NON-CARDIAC CHEST PAIN - A POPULATION-BASED STUDY. \u003cem\u003eAliment Pharmacol Ther\u003c/em\u003e 2003;\u003cstrong\u003e17\u003c/strong\u003e:1115\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eJanuzzi JL, McCarthy CP. Evaluating Chest Pain in the Emergency Department. \u003cem\u003eJ Am Coll Cardiol\u003c/em\u003e 2018;\u003cstrong\u003e71\u003c/strong\u003e:617\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eBrian J. Moore, Ph.D., and Lan Liang, Ph.D. Costs of Emergency Department Visits in the United States, 2017. \u003cem\u003eHCUP (HEALTHCARE COST AND UTILIZATION PROJECT)\u003c/em\u003e 2020:14.\u003c/li\u003e\n\u003cli\u003eM\u0026oslash;ller TP, Ersb\u0026oslash;ll AK, Tolstrup JS \u003cem\u003eet al.\u003c/em\u003e Why and when citizens call for emergency help: an observational study of 211,193 medical emergency calls. \u003cem\u003eScand J Trauma Resusc Emerg Med\u003c/em\u003e 2015;\u003cstrong\u003e23\u003c/strong\u003e:88.\u003c/li\u003e\n\u003cli\u003ePedersen CK, Stengaard C, Friesgaard K \u003cem\u003eet al.\u003c/em\u003e Chest pain in the ambulance; prevalence, causes and outcome - a retrospective cohort study. \u003cem\u003eScand J Trauma Resusc Emerg Med\u003c/em\u003e 2019;\u003cstrong\u003e27\u003c/strong\u003e:84.\u003c/li\u003e\n\u003cli\u003eB\u0026oslash;tker MT, Terkelsen CJ, S\u0026oslash;rensen JN \u003cem\u003eet al.\u003c/em\u003e Long-Term Mortality of Emergency Medical Services Patients. \u003cem\u003eAnn Emerg Med\u003c/em\u003e 2017;\u003cstrong\u003e70\u003c/strong\u003e:366-373.e3.\u003c/li\u003e\n\u003cli\u003eCentre of communication, Capital Region of Denmark. Capitial Region of Denmark \u0026ndash; Growth and quality of life. 2017.\u003c/li\u003e\n\u003cli\u003eZinger ND, Blomberg SN, Lippert F \u003cem\u003eet al.\u003c/em\u003e Impact of integrating out-of-hours services into Emergency Medical Services Copenhagen: a descriptive study of transformational years. \u003cem\u003eInt J Emerg Med\u003c/em\u003e 2022;\u003cstrong\u003e15\u003c/strong\u003e:40.\u003c/li\u003e\n\u003cli\u003eLindskou TA, Mikkelsen S, Christensen EF \u003cem\u003eet al.\u003c/em\u003e The Danish prehospital emergency healthcare system and research possibilities. \u003cem\u003eScand J Trauma Resusc Emerg Med\u003c/em\u003e 2019;\u003cstrong\u003e27\u003c/strong\u003e:100.\u003c/li\u003e\n\u003cli\u003eDanske Regioner, Laerdal. Dansk Index for Akuthj\u0026aelig;lp - AMK-vagtcentralernes v\u0026aelig;rkt\u0026oslash;j for visitation til pr\u0026aelig;hospitale ressourcer Landsudgaven, version 1.8. 2017.\u003c/li\u003e\n\u003cli\u003eSchmidt M, Schmidt SAJ, Sandegaard JL \u003cem\u003eet al.\u003c/em\u003e The Danish National Patient Registry: a review of content, data quality, and research potential. \u003cem\u003eClin Epidemiol\u003c/em\u003e 2015:449.\u003c/li\u003e\n\u003cli\u003ePedersen CB. The Danish Civil Registration System. \u003cem\u003eScand J Public Health\u003c/em\u003e 2011;\u003cstrong\u003e39\u003c/strong\u003e:22\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eLynge E, Sandegaard JL, Rebolj M. The Danish National Patient Register. \u003cem\u003eScand J Public Health\u003c/em\u003e 2011;\u003cstrong\u003e39\u003c/strong\u003e:30\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eM\u0026oslash;ller AL, Mills EHA, Gnesin F \u003cem\u003eet al.\u003c/em\u003e Impact of myocardial infarction symptom presentation on emergency response and survival. \u003cem\u003eEur Heart J Acute Cardiovasc Care\u003c/em\u003e 2021;\u003cstrong\u003e10\u003c/strong\u003e:1150\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eR Core Team. R: A Language and Environment for Statistical Computing. 2021.\u003c/li\u003e\n\u003cli\u003eMol KA, Smoczynska A, Rahel BM \u003cem\u003eet al.\u003c/em\u003e Non-cardiac chest pain: prognosis and secondary healthcare utilisation. \u003cem\u003eOpen Heart\u003c/em\u003e 2018;\u003cstrong\u003e5\u003c/strong\u003e:e000859.\u003c/li\u003e\n\u003cli\u003eGeyser M, Smith S. Chest pain prevalence, causes, and disposition in the emergency department of a regional hospital in Pretoria. \u003cem\u003eAfr J Prim Health Care Fam Med\u003c/em\u003e 2016;\u003cstrong\u003e8\u003c/strong\u003e, DOI: 10.4102/phcfm.v8i1.1048.\u003c/li\u003e\n\u003cli\u003eWalker NJ, Sites FD, Shofer FS \u003cem\u003eet al.\u003c/em\u003e Characteristics and Outcomes of Young Adults Who Present to the Emergency Department with Chest Pain. \u003cem\u003eAcad Emerg Med\u003c/em\u003e 2001;\u003cstrong\u003e8\u003c/strong\u003e:703\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eWibring K, Lingman M, Herlitz J \u003cem\u003eet al.\u003c/em\u003e Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study. \u003cem\u003eBMJ Open\u003c/em\u003e 2021;\u003cstrong\u003e11\u003c/strong\u003e:e044938.\u003c/li\u003e\n\u003cli\u003eStopyra JP, Snavely AC, Scheidler JF \u003cem\u003eet al.\u003c/em\u003e Point-of-Care Troponin Testing during Ambulance Transport to Detect Acute Myocardial Infarction. 2020;\u003cstrong\u003e24\u003c/strong\u003e:10.\u003c/li\u003e\n\u003cli\u003eWibring K, Lingman M, Herlitz J \u003cem\u003eet al.\u003c/em\u003e Guideline adherence among prehospital emergency nurses when caring for patients with chest pain: a prospective cohort study. \u003cem\u003eScand J Trauma Resusc Emerg Med\u003c/em\u003e 2021;\u003cstrong\u003e29\u003c/strong\u003e:157.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chest pain, ischemic heart disease, emergency medical services","lastPublishedDoi":"10.21203/rs.3.rs-4607638/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4607638/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChest pain is a frequent cause of health care contacts. We examined the prehospital management, in-hospital discharge diagnoses, and mortality of patients calling a non-emergency and emergency medical service with chest pain.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe included all calls to a non-emergency medical helpline (calls to 1813) and emergency medical service (1-1-2 calls) with a primary complaint of chest pain from 2014\u0026ndash;2018 in Copenhagen, Denmark. The outcomes were: emergency response (ambulance dispatch, other transports/self-transport/home visits, self-care, and unknown/cancelled response), in-hospital diagnosis within 7 days after the call (cardiovascular, pulmonary, or other non-cardiovascular/pulmonary) and 30-day mortality.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 4,838,232 calls, 91,671 were registered with chest pain by medical dispatchers. The first call for each patient was kept for analysis (n\u0026thinsp;=\u0026thinsp;66,672). In total, 91.4% were referred to the hospital, 75.8% (n\u0026thinsp;=\u0026thinsp;50,627) received an ambulance and 15.6% (n\u0026thinsp;=\u0026thinsp;10,383) received other transport/self-transport/home visits. In total, 26.9% (n\u0026thinsp;=\u0026thinsp;17,937) were diagnosed with a cardiovascular disease (Acute Coronary Syndrome (ACS): 11.1%), 5.2% (n\u0026thinsp;=\u0026thinsp;3,490) a pulmonary disease, 52.8% (n\u0026thinsp;=\u0026thinsp;35.242) other non-cardiovascular/pulmonary disease, and 15.1% (n\u0026thinsp;=\u0026thinsp;10,093) received no diagnosis. Among ambulance-transported patients, the prevalence of cardiovascular discharge diagnoses was higher (32.1%) and fewer received no diagnosis (11.0%). Cardiovascular disease was rare among patients not transported by ambulance and patients who were not referred to hospital at all (2-13.4%) and in patients\u0026thinsp;\u0026le;\u0026thinsp;40 years of age (\u0026lt;\u0026thinsp;10%). The 30-day mortality was low regardless of the diagnosis (0.6-4%), and 65,704 were still alive 30 days later.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eNearly all patients calling with chest pain were referred to treatment and among ambulance-transported patients, one-third received a cardiovascular diagnosis. While current practices appear reasonable, improved differentiation of chest pain in telephone consultations could potentially reduce burden of non-acute chest pain consultations.\u003c/p\u003e","manuscriptTitle":"Prehospital management and outcomes of patients calling with chest pain as the main complaint","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-10 11:34:28","doi":"10.21203/rs.3.rs-4607638/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-07-30T12:26:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-28T21:24:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309897490331408060182094543415440248502","date":"2024-07-18T13:51:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114818511221806529952157970078983579785","date":"2024-07-12T17:56:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-10T17:26:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-10T00:40:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-10T00:38:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2024-06-19T18:42:55+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"06ad3d1e-647b-4b29-87b7-b3315038ddd2","owner":[],"postedDate":"August 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:03:00+00:00","versionOfRecord":{"articleIdentity":"rs-4607638","link":"https://doi.org/10.1186/s12245-024-00745-8","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2024-10-18 15:57:51","publishedOnDateReadable":"October 18th, 2024"},"versionCreatedAt":"2024-08-10 11:34:28","video":"","vorDoi":"10.1186/s12245-024-00745-8","vorDoiUrl":"https://doi.org/10.1186/s12245-024-00745-8","workflowStages":[]},"version":"v1","identity":"rs-4607638","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4607638","identity":"rs-4607638","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}