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ACS presentations via emergency services at ED increased after warning signs campaign

8th November 2021

ACS presentations via emergency services at ED increased significantly after the introduction of a public health warning signs campaign.

Acute coronary syndrome (ACS) presentations using emergency medical services increased after the introduction of a public health ‘warning signs’ campaign. This was the finding of a retrospective study by researchers from the department of  Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.

Any delay in ACS presentations has a major impact on outcomes for patients, despite major advances in the care of such patients yet few fully understand the importance of early treatment. For example, a focus group study revealed a general ignorance of ACS symptoms and this has arisen in part, due to the perceptions derived from films and TV in which heart attack symptoms were displayed as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. The study also highlighted a lack of awareness of the benefits of rapid action and using emergency service transport (EST) to hospital over alternative methods for reaching hospital. In fact, other work has shown that only 60% of patients used EST when experiencing ST-segment–elevation myocardial infarction.

The National Heart Foundation of Australia (NHFA) in recognising the importance of EST for patients with suspected ACS, launched a mass media campaign to improve Australian’s ACS symptom knowledge and address barriers to emergency transport use. Nevertheless, despite the media campaign, in a subsequent survey of 100 patients hospitalised with an acute myocardial infarction (AMI) only 26%  recognised that they were having an AMI and only 34% had called an ambulance. This led the researchers from Monash University to examine the impact of the NHFA warning signs campaign on ACS EST use and to explore any pre- and post-campaign changes on ED presentations via general practitioners for those with unspecified chest pain (U-CP). The team used the Victorian Department of Health and Human Services administrative database to collect information of ED admissions, patient characteristics, mode of arrival and referral sources. The primary outcomes of interest were ACS arrivals via ETS and ED presentations. Data were collected from 2003 to 2015, that included the period of the campaign which ran from 2009 to 2013. In their analysis, the researchers adjusted for factors such as age, gender, ethnicity, residential status (i.e., living alone etc) and location.


Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 612,758 with U-CP. There was an 11% increase in ED presentations for ACS (incidence rate ratio, IRR = 1.11, 95% CI 1.07 – 1.15) during the campaign compared to the pre-campaign period. Similarly, there was an 8% increase (IRR = 1.08, 95% CI 1.05 – 1.12) for U-CP compared to the pre-campaign period.

For patients with ACS, 58% had arrived using emergency transport and compared with the pre-campaign period there was a slight increase in the adjusted odds of direct arrival via emergency transport (odds ratio, OR = 1.10, 95% CI 1.05 – 1.17) and a significant decrease in the adjusted odds of a GP referral (OR = 0.77, 95% CI 0.70 to 0.86). For U-CP, there was a modest increase during the campaign period of emergency transport arrivals (OR = 1.03, p = 0.019) but a more substantial reduction in GP referral compared to pre-campaign levels (OR = 0.79, 96% CI 0.75 – 0.82, p < 0.0001).

The authors concluded that the NHFA’s warning signs campaign was associated with an increase in ACS presentations and use of emergency transport and a reduction in GP referrals to ED.


Eastwood K et al. Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome. BMJ Open heart 2021