Saleh Fares, Mohammad Zubaid, Wael Al-Mahmeed, Gregory Ciottone, Assaad Sayah, Jassim Al Suwaidi, Haitham Amin, Farid Al-Atawna, Mustafa Ridha, Kadhim Sulaiman, Alawi A Alsheikh-Ali

Background:
Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.

Objective:
To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE).

Methods:
Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).

Results:
Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03-1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48-2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34-1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02-1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09-1.51), and current smoking (OR 1.30; 95% CI 1.13-1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30 min of arrival at the ED.

Conclusion:
Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.