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Diurnal, weekly and seasonal variations of chest pain in patients transported by emergency medical services
  1. Ziad Faramand1,2,
  2. Stephanie O Frisch1,2,
  3. Christian Martin-Gill2,3,
  4. Parker Landis1,
  5. Mohammad Alrawashdeh4,5,
  6. Khaled A Al-Robaidi6,
  7. Clifton W Callaway2,3,
  8. Salah S Al-Zaiti1,3
  1. 1 Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pittsburgh, PA, United States
  2. 2 University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
  3. 3 Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
  4. 4 Department of Population Medicine, Harvard Medical School, Boston, MA, United States
  5. 5 Jordan University of Science and Technology, Irbid, Jordan
  6. 6 Department of Neurology, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, United States
  1. Correspondence to Dr Salah S Al-Zaiti, University of Pittsburgh School of Nursing Department of Acute and Tertiary Care, Pittsburgh PA 15261, USA; ssa33{at}


Objectives Chest pain is among the leading causes for emergency medical services (EMS) activation. Acute myocardial infarction (MI) is not only one of the most critical aetiologies of chest pain, but also one of few conditions encountered by EMS that has been shown to follow a circadian pattern. Understanding the diurnal relationship between the inflow of chest pain patients and the likelihood of acute MI may inform prehospital and emergency department (ED) healthcare providers regarding the prediction, and hence prevention, of dire outcomes.

Methods This was a secondary analysis of previously collected data from an observational prospective study that enrolled consecutive chest pain patients transported by a large metropolitan EMS system in the USA. We used the time of EMS call to determine the time-of-day of the indexed encounter. Two independent reviewers examined available medical data to determine our primary outcome, the presence of MI, and our secondary outcomes, infarct size and 30-day major adverse cardiac events (MACE). We estimated infarct size using peak troponin level.

Results We enrolled 2065 patients (age 56±17, 53% males, 7.5% with MI). Chest pain encounters increased from 9:00 AM to 2:00 PM, with a peak at 1:00 PM and a nadir at 6:00 AM. Acute MI had a bimodal distribution with two peaks: 10 AM in ST-elevation MI, and 10 PM in non-ST-elevation MI. ST-elevation MI with afternoon onset was an independent predictor of infarct size. Acute MI with winter and early spring presentation was an independent predictor of 30-day MACE.

Conclusions EMS-attended chest pain calls follow a diurnal pattern, with the most vulnerable patients encountered during afternoons and winter/spring seasons. These data can inform prehospital and ED healthcare providers regarding the time of presentation where patients are more likely to have an underlying MI and subsequently worse outcomes.

  • chest - non trauma
  • emergency ambulance systems
  • pre-hospital
  • acute coronary syndrome
  • acute myocardial infarct

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  • Contributors We attest to the fact that all authors listed on the title page have contributed significantly to the work, have read the manuscript, attest to the validity and legitimacy of the data and its interpretation and agree to its submission to EMJ.

  • Funding Supported by the National Institutes of Health (R01 HL-137761). The authors have no disclosures regarding interests in business or industry related to the planning, execution and/or publication of this study. This study was funded by a grant from NIH/NHLBI R01 HL 137761.

  • Competing interests None declared.

  • Ethics approval The University of Pittsburgh Institutional Review Board granted the ethics approval for this study and deemed this a low-risk study due to it’s the non-interventional nature.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.