International Emergency Nursing 33 (2017) 43–47

Contents lists available at ScienceDirect

International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

Acute coronary syndrome in relation to the occurrence of associated

symptoms: A quantitative study in prehospital emergency care
Henrik Andersson a,b,⇑, Andreas Ullgren b,c, Mats Holmberg a,e, Thomas Karlsson d, Johan Herlitz a,b,
Birgitta Wireklint Sundström a,b
a
PreHospen – Centre for Prehospital Research, University of Borås, Sweden
b
Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
c
Emergency Medical Service System, Skaraborg Hospital, Skövde, Sweden
d
Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
e
School of Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Acute chest pain is a common symptom among prehospital emergency care patients.
Received 7 September 2016 Therefore, it is crucial that ambulance nurses (ANs) have the ability to identify symptoms and assess
Received in revised form 25 October 2016 patients suffering from acute coronary syndrome (ACS). The aim of this study is to explore the occurrence
Accepted 13 December 2016
of dyspnoea and nausea and/or vomiting in the prehospital phase of a suspected ACS and the associations
with patients’ outcome.
Methods: This study has a quantitative design based on data from hospital records and from a previous
interventional study (randomised controlled trial) including five Emergency Medical Service (EMS) sys-
tems in western Sweden in the years 2008–2010.
Results: In all, 1836 patients were included in the interventional study. Dyspnoea was reported in 38%
and nausea and/or vomiting in 26% of patients. The risk of death within one year increased with the pres-
ence of dyspnoea. The presence of nausea and/or vomiting increased the likelihood of a final diagnosis of
acute myocardial infarction (AMI).
Conclusion: This study shows that dyspnoea, nausea and/or vomiting increase the risk of death and seri-
ous diagnosis among ACS patients. This means that dyspnoea, nausea and/or vomiting should influence
the ANs’ assessment and that special education in cardiovascular nursing is required.
Ó 2016 Elsevier Ltd. All rights reserved.

1. Introduction symptoms, here called associated symptoms. In this paper, associ-

Acute chest pain is a common symptom among people contact-
ing prehospital emergency care [1,2]. However, chest pain can be a
challenge to assess [3]. It is essential to be prepared for an open
and flexible encounter with the patient in order to avoid being
influenced by preconceived ideas [4]. In a patient suffering from
acute coronary syndrome (ACS), for example, it is important to
identify and assess her/his symptoms to determine the degree of
severity, to consider a number of different diagnoses and to carry
out relevant interventions. This is crucial, because mistakes in
the assessment of the patient are a significant threat to patient
safety in prehospital emergency care [5].
The most typical symptom in ACS is pain or discomfort in the
chest [6]. However, this symptom is often accompanied by other
⇑ Corresponding author at: PreHospen – Centre for Prehospital Research,
University of Borås, Sweden.
E-mail address: henrik.andersson@hb.se (H. Andersson).
ated symptoms consist of symptoms as experienced by the
patients that can also be signs of ACS [7]. Examples of these symp-
toms are dyspnoea and nausea and/or vomiting [8]. Sometimes,
patients with ACS react with these symptoms but without pain
or discomfort in the chest [9–11]. At the same time, patients with-
out sudden, continuous and severe chest pain are more likely to
have longer prehospital delays [12]. The mechanism behind the
development of associated symptoms is not always clear, particu-
larly with regard to nausea and/or vomiting. With regard to dysp-
noea, complicating factors such as heart failure and pulmonary
disease may coexist [13,14]. Furthermore, it has been suggested
that these associated symptoms are gender related, as they are
more frequent in women than in men [15–17]. This means that
associated symptoms appear together with typical ones, which
influences the assessment of the patient.
Patient history and physical examination are essential in the
care and treatment of patients with chest pain. One example is
the electrocardiogram (ECG), which is essential to provide for

http://dx.doi.org/10.1016/j.ienj.2016.12.001
1755-599X/Ó 2016 Elsevier Ltd. All rights reserved.
44 H. Andersson et al. / International Emergency Nursing 33 (2017) 43–47
optimal reperfusion strategy [18]. However, the assessment also
includes questions on how patients experience their symptoms
and signs. This highlights the need for the ambulance nurses
(ANs) to be involved in and understand the patient’s story [4].
For this reason, knowledge relating to medicine and knowledge
relating to caring sciences are complementary [4,19]. Knowledge
relating to the association of these symptoms with various types
of complication among patients with ACS is less well described
in the literature. This is a clinically relevant question, as it is possi-
ble to argue that these symptoms should increase the priority early
in the prehospital setting. The aim of this study has been to explore
the occurrence of dyspnoea and nausea and/or vomiting in the pre-
hospital phase of cases with suspected ACS and their connection
with the patients’ outcomes. Our hypothesis has been that the
presence of associated symptoms among patients with chest pain
raising suspicion of ACS indicates an increased risk of an adverse
outcome. This study is part of a larger research project, whose
overall aim is to increase ANs ability to assess and relieve chest
pain and anxiety among patients seeking prehospital emergency
care.
2. Methods
2.1. Study design and setting
This study is a quantitative study. Data was obtained in two
ways: 1) clinical measurements obtained in an interventional
study (randomised controlled trial) to facilitate the description of
the associated symptoms of patients with chest pain (for further
information, see www.clinicaltrials.gov, registration number
NCT00792181), 2) data about previous medical history, complica-
tions that required treatment, final diagnosis, mortality and length
of hospitalisation was obtained from hospital records. Ethical
approval was obtained from the Regional Ethics Committee in
Gothenburg (Ref. 022-08). For further information on the study
design, intervention, inclusion and exclusion criteria, see Wireklint
Sundström and colleagues [20].
The study took place in western Sweden (1.5 million inhabi-
tants) and included hospital records and five Emergency Medical
Services (EMS) systems in western Sweden in the years 2008–
2010. The ambulances in all the EMS systems participating in the
study were staffed by at least one AN who was a registered nurse
(RN), although not all RNs were prehospital emergency nurses
(PENs) i.e. nurses with specialist education in prehospital emer-
gency care. In this study, both RNs and PENs were included in
the group of ANs.
2.2. Clinical measures
In the interventional study the presence of dyspnoea, nausea
and/or vomiting (yes/no) was assessed by ANs on three occasions:
on the arrival of the ambulance team, 15 min later and on arrival in
hospital. In this study, we focused on the first occasion. Patients
were therefore divided into two groups in relation to whether or
not symptoms were present on the arrival of the EMS.
2.3. Hospital records and clinical endpoints
The primary endpoints were one-year mortality and the devel-
opment of an acute myocardial infarction (AMI) during hospitalisa-
tion. The secondary endpoints were complications prior to and
after arrival in hospital, defined as heart failure, hypotension, AV
block, bradyarrhythmia, supraventricular and ventricular arrhyth-
mias requiring treatment. Further secondary endpoints were anx-
iety and pain requiring treatment after hospital admission; the
duration of hospitalisation; and 30-day mortality.
2.4. Data analysis
Fisher’s exact test was used to test for associations with
dichotomous variables and the Mann-Whitney U test was used
for associations with continuous variables. The Kaplan-Meier
method was used for estimations of 30-day and one-year mortality
and the log rank test was used to test for associations with the
presence of symptoms. Individuals with multiple inclusions in
the study were only used once (the first time) in the analysis of
30-day and one-year mortality. All tests were two-sided and p-
values below 0.01 were considered statistically significant. All
analyses were performed using SAS for Windows v9.3.
3. Results
In all, 1836 patients were included in the intervention study. Of
these, 1705 (93%) had information recorded in the study protocol
(i.e. yes/no) on the arrival of the EMS regarding the presence of
dyspnoea symptoms and 1702 (93%) regarding nausea and/or
vomiting. These 1705 and 1702 cases respectively were included
in the analyses.
3.1. Dyspnoea
In 646 (38%) cases, dyspnoea was reported on the arrival of the
EMS.
3.2. Age, gender, previous history
The presence of dyspnoea was significantly associated with a
previous history of heart failure and with a previous history of
chronic obstructive pulmonary disease (Table 1).
3.3. Complications before and after hospital admission
There was a significant association between the presence of
dyspnoea and heart failure requiring treatment before and after
hospital admission (Tables 2 and 3).
3.4. Anxiety, pain, final diagnosis, mortality and length of
hospitalisation
The presence of dyspnoea was significantly associated with
anxiety requiring treatment in hospital, as well as with mortality
during the course of one year after hospital admission and with a
prolonged duration of hospitalisation (Table 4).
3.5. Nausea and/or vomiting
Nausea and/or vomiting was reported in 449 (26%) cases.
3.6. Age, gender, previous history
There was a significant association between female gender and
the presence of nausea and/or vomiting. The absence of a history of
heart failure was significantly associated with the presence of nau-
sea and/or vomiting (Table 1).
3.7. Complications before and after hospital admission
There was no association between the presence of symptoms
of nausea and/or vomiting and any complication prior to arrival
 H. Andersson et al. / International Emergency Nursing 33 (2017) 43–47 45

Table 1
Age, gender and previous history.

Dyspnoea p Nausea and/or vomiting p

No Yes No Yes
(n = 1059) (n = 646) (n = 1253) (n = 449)
Age (median) 71 73 0.04 72 70 0.012
Women (%) (1/1) * 44 45 0.62 42 50 0.005
Previous history (%)
Myocardial infarction (49/49) * 37 36 0.67 38 34 0.15
Angina pectoris (62/62) 28 32 0.07 29 28 0.66
Heart failure (67/68) 13 18 0.004 16 10 0.0008
Diabetes (40/40) 18 23 0.03 20 19 0.63
Hypertension (50/49) 42 43 0.61 44 38 0.05
COPD (43/43) 7 13 <0.0001 9 9 0.92
Stroke (41/41) 10 9 0.61 10 8 0.11
Peripheral artery disease (49/49) 3 3 0.56 3 3 0.75
Renal disease (43/43) 6 7 0.36 7 5 0.09
Cancer (41/41) 9 12 0.18 11 10 0.65
Current smoker (390/390)* 19 20 0.52 18 21 0.24
*
Number of patients with missing information regarding dyspnoea and nausea and/or vomiting in study groups, respectively.

Table 2
Complications before hospital admission.

Dyspnoea p Nausea and/or vomiting p

No Yes Yes No
(n = 1059) (n = 646) (n = 1253) (n = 449)
Heart failure (%) (12/12) * 0.5 3.0 <0.0001 1.4 1.1 0.81
Hypotension (%) (13/13) 1.4 1.6 0.84 1.2 2.2 0.17
AV block/bradyarrhythmia (%) (12/12) 0.4 0.6 0.49 0.4 0.7 0.44
Supraventricular tachyarrhythmia (%) (15/15) 0.8 1.1 0.59 0.8 1.1 0.56
Ventricular tachyarrhythmia (%) (15/15) 0.4 0.0 0.30 0.2 0.2 1.00
*
Number of patients with missing information regarding dyspnoea and nausea and/or vomiting in study groups, respectively.

Table 3
Complications after hospital admission.

Dyspnoea p Nausea and/or vomiting p

No Yes No Yes
(n = 1059) (n = 646) (n = 1253) (n = 449)
Heart failure (%) (47/47) * 9 17 <0.0001 12 12 0.73
Hypotension (%) (47/47) 5 4 0.53 4 6 0.09
AV block/bradyarrhythmia (%) (47/47) 2 2 0.48 1 4 0.008
Supraventricular tachyarrhythmia (%) (45/45) 5 7 0.05 5 7 0.11
Ventricular tachyarrhythmia (%) (49/49) 2 1 0.68 <1 3 0.002
*
Number of patients with missing information regarding dyspnoea and nausea and/or vomiting in study groups, respectively.

Table 4
Anxiety, pain, final diagnosis, mortality and length of hospitalisation.

Dyspnoea p Nausea and/or vomiting p

No Yes No Yes
(n = 1059) (n = 646) (n = 1253) (n = 449)
Anxiety requiring treatment (%) (58/58) * 9 14 0.0009 10 12 0.47
Pain requiring treatment (%) (63/63) 37 39 0.64 38 35 0.30
Final diagnosis (%) (101/100)
Myocardial infarction 28 23 0.04 24 32 0.001
Angina pectoris 9 11 0.31 11 6 0.002
Myocardial infarction or angina pectoris 37 34 0.22 35 38 0.29
30-day mortality** (%) (4/4) 2.2 3.9 0.04 2.6 3.4 0.44
1-year mortality** (%) (6/6) 7.3 15.0 <0.0001 10.5 8.9 0.37
Length of hospitalisation (46/46) 3 3 0.006# 3 3 0.35#
*
Number of patients with missing information regarding dyspnoea and nausea and/or vomiting in study groups, respectively.
**
Only first time if included more than once in the study (n = 1564/1562).
#
Longer hospitalisation if symptoms.
46 H. Andersson et al. / International Emergency Nursing 33 (2017) 43–47
in hospital. After arrival in hospital, AV blocks/bradyarrhythmia
and ventricular arrhythmia requiring treatment were significantly
associated with the presence of nausea and/or vomiting (Tables 2
and 3).
3.8. Anxiety, pain, final diagnosis, mortality and duration of
hospitalisation
The presence of symptoms of nausea and/or vomiting was sig-
nificantly associated with the final diagnosis, i.e. more AMIs and
less angina pectoris. However, there was no significant association
between the presence of nausea and/or vomiting and mortality
(Table 4).
4. Discussion
The main finding in this study is that when it came to the occur-
rence of associated symptoms among patients with suspected ACS
transported by ambulance, approximately one in three patients
had symptoms of dyspnoea and one in four had symptoms of nausea
and/or vomiting, which increased the suspicion of ACS. The risk of
death within one year increased with the presence of symptoms
of dyspnoea. However, no increased risk of AMI was found. Further-
more, there is an increased risk of heart failure requiring treatment
either before or after hospital admission. On the other hand, the
presence of symptoms such as nausea and/or vomiting increased
the likelihood of a final diagnosis of AMI, but no significant associa-
tion with death was found. In addition, the risk of arrhythmias and
hypotension while the patient was hospitalised increased with the
presence of nausea and/or vomiting symptoms.
The results show the occurrence of the associated symptom of
dyspnoea before hospitalisation in patients with ACS. In many
cases, the mechanism behind dyspnoea is well known [21–23].
For instance, heart failure is associated with impaired myocardial
function, which is a strong risk marker of death [24,25]. Our find-
ings of an association between the occurrence of dyspnoea and an
increased risk of death is consistent with previous studies [26,27].
A possible explanation for this association of the degree of severity
is that patients with dyspnoea are expected to have anamneses of
heart and lung diseases, which of course may influence the result.
The results also show that dyspnoea was associated with more
anxiety after hospital admission. It is only possible to speculate
about the causes of this finding. Anxiety can be seen from an exis-
tential perspective. Suffering from heart disease alters the patient’s
life and the risk of death becomes a part of everyday life. Knowing
that life may end quickly also creates anxiety [28]. At the same
time, studies show that anxiety is a common symptom in patients
in prehospital emergency care, regardless of etiology [29,30].
The mechanism involved in the development of the associated
symptoms of nausea and/or vomiting in suspected ACS is not well
described. The results also show an association between nausea or
vomiting and gender, as these symptoms are more common in
women. This is consistent with previous studies [15–17].
Our results suggest that, among patients suffering from nausea
and/or vomiting, there is an increased likelihood of an underlying
AMI. This may well explain the increased risk of arrhythmias. On
the other hand, our results may be seen in the light of a previous
study by Goodacre and colleagues [31]. In their study, more than
800 patients were included and the presence of chest pain, nausea,
or vomiting could not be shown to predict AMI. However, all their
patients had a non-diagnostic ECG.
It was surprising that no significant association between the
symptom of nausea and/or vomiting and death could be found in
our study. One possible cause of the absence of association could
be that data is insufficient, i.e. the study was underpowered to
detect an association between symptoms of nausea and/or vomit-
ing and the risk of death. At the same time, other studies have
shown that the presence of associated symptoms tends to be asso-
ciated with a negative outcome [32] and that the combination of
anxiolytics and analgesics reduces the frequency of anxiety, nausea
and/or vomiting compared with adding only analgesics [20].
Any assessment of a patient’s symptoms should be based on a
holistic approach, which takes account of both the medical and
caring aspects. The encounter with prehospital emergency care
takes place mainly in a context where the patient may experience
helplessness, limited autonomy and loss of control over her/his life
situation [33]. ANs need to understand and reflect on the patient’s
perceived or expressed discomfort, but they also need to possess
the ability to address this, no matter how explicit the care need
is. This means that it is necessary for ANs to adapt both to the
patient’s care needs and to the resources available to meet these
individual needs. Furthermore, it is important that ANs involve
the patients when it comes to decisions relating to their health
and the care that is given [34]. For this reason, knowledge of med-
icine and knowledge of caring sciences are both important in the
profession of AN [35–37], to enable them to assess and manage
patients’ medical conditions as well as their suffering [19].
Identifying and assessing the symptoms experienced by
patients and the signs of disease as expressed, as well as being
observant of patients’ general health status, all constitute the basis
of prioritisation [38]. Based on the quality of care, patient safety
and the use of resources, it is important that patients are cate-
gorised into the correct priority levels according to their health
conditions [39,40]. One challenge in the assessment of patients
with chest pain is that their pain or discomfort may be caused by
conditions other than cardiac conditions [3]. This means that ANs
never know with certainty the kind of care the patient needs [4].
This uncertainty about the patient’s care can contribute to an inad-
equate assessment, which is in turn a threat to patient safety [5].
In stressful situations or situations where the patient exhibits no
obvious symptoms or signs of illness, a protocol for the assessment
of patients may be beneficial [41]. At the same time, there is
research that shows that assessments of patients do not always
appear to be in accordance with what is expected. In a study by
Jönsson and Fridlund [42], the results showed that approximately
60 per cent of the assessments made were not properly docu-
mented, even though the protocol for the assessment was available.
Although these results reflect documentation, it indicates that there
is a risk that assessments are not always carried out in accordance
with patient safety. This means that there is the risk of excessively
exaggerated confidence in protocol-based assessments. Andersson
and colleagues [43] showed that knowledge, experience and the
ability to make decisions are key success factors when it comes to
assessing the severity of the patients’ symptoms and, during a lim-
ited time, determining the patients’ need for healthcare. Even if this
study was conducted in the context of an emergency department, it
is a reasonable assumption that the results can be transferred to
prehospital emergency care and the encounter with patients with
suspected ACS. Our present results thus stress the importance of
prehospital triage and taking the associated symptoms of dyspnoea,
nausea and/or vomiting when suspecting ACS as seriously as the
most typical ones, i.e. pain or discomfort in the chest.
4.1. Study limitation
The study cohort is not entirely representative for several rea-
sons. 1) Only patients transported by the EMS are included in the
analyses. 2) All patients participated in an intervention study and
gave their informed consent. There is therefore an obvious risk of
selection bias, as patients in the worst clinical condition were most
probably often not asked by ANs to participate in the study. 3) The
 H. Andersson et al. / International Emergency Nursing 33 (2017) 43–47
inclusion criterion for participation was a pain score of >3 [20],
which meant that patients with less severe pain were not included
in the analyses. 4) Patients with dyspnoea might be a sicker group
with more comorbid conditions that may explain the adverse
outcome.
5. Conclusion
In the prehospital setting of a suspected ACS, about one in three
patients had symptoms of dyspnoea and one in four had symptoms
of nausea and/or vomiting. The most important findings were that
the presence of the associated symptom of dyspnoea was associated
with an increased risk of death, but that no such association was
found for the development of an AMI and the opposite was found
for the associated symptoms of nausea or vomiting, i.e. a significant
association with the development of an AMI but not with death.
Among patients in the prehospital setting with pain raising suspi-
cion of ACS, the simultaneous presence of associated symptoms
such as dyspnoea and nausea or vomiting should trigger a warning
signal for the ANs. Whereas both highlight an increased risk of com-
plications after hospital admission, the former is associated with an
increased risk of death and the latter with an increased risk of devel-
oping an AMI. As a result, the presence of any of these symptoms
should influence the triage decision towards direct admission to
more intensive care directly from the prehospital setting.
Accurately assessing associated symptoms is important, as they
may have a devastating effect on the patient. However, ANs must
sometimes assess the patient’s symptoms without knowledge of
past medical history. An increased awareness of associated symp-
toms may reduce delays to treatment for patients with ACS.
Preparing ANs so that they know what to do requires special edu-
cation in cardiovascular nursing. ANs perform an important func-
tion in identifying and assessing changes in patients’ conditions
and they should therefore be encouraged to take advantage of
and participate in these educational opportunities. It is therefore
essential that the EMS system considers, implements and evaluates
educational strategies of this kind.
References
[1] Forslund K, Kihlgren M, Sørlie V. Patients with acute chest pain-experiences of
emergency calls and pre-hospital care. J Telemed Telecare 2005;11:361–7.
[2] Burman RA, Zakariassen E, Hunskaar S. Acute chest pain – a prospective
population based study of contacts to Norwegian emergency medical
communication centres. BMC Emerg Med 2011;11:9.
[3] Cayler WE. Diagnosing the cause of chest pain. Am Fam Phys
2005;72:2012–21.
[4] Wireklint Sundström B, Dahlberg K. Being prepared for the unprepared: a
phenomenology field study of Swedish prehospital care. J Emerg Nurs
2011;38:571–7.
[5] Andersson Hagiwara M. Development and evaluation of computerised decision
support system for use in pre-hospital care (Dissertation). Jönköping: Jönköping
University; 2014.
[6] Kumar A, Cannon C. Acute coronary syndromes: diagnosis and management,
Part I. Mayo Clin Proc 2009;84:917–38.
[7] Ekman I, Cleland J, Andersson B, Swedberg K. Exploring symptoms in chronic
heart failure. Eur J Heart Fail 2005;7:699–703.
[8] Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway K. The value
of symptoms and signs in the emergent diagnosis of acute coronary
syndromes. Resuscitation 2010;81:281–6.
[9] Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, Fredrick PD, Lambrew CT, et al.
Prevalence, clinical characteristics, and mortality among patients with
myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9.
[10] Stern S. Angina pectoris without chest pain: Clinical implications of silent
ischemia. Circulation 2002;106:1906–8.
[11] Zdzienicka J, Siudak Z, Zawislak B, Dziewierz A, Rakowski T, Dubiel J, et al.
Patients with non-ST-elevation myocardial infarction and without chest pain
are treated less aggressively and experience higher in-hospital mortality.
Kardiol Pol 2007;65:7.
[12] O’Donnell S, McKee G, Mooney M, O’Brien F, Moser DK. Slow-onset and fast-
onset symptom presentations in acute coronary syndrome (ACS): new
perspectives on prehospital delay in patients with ACS. J Emerg Med
2014;46(4):507–15.
47
[13] Ramasamy R, Hildebrandt T, O’Hea E, Patel M, Clemow L, Freudenberger R,
et al. Psychological and social factors that correlate with dyspnea in heart
failure. Psychosomatics 2006;47:430–4.
[14] Burki NK, Lee L-Y. Mechanisms of dyspnea. Chest 2010;138:1196–201.
[15] Berg J, Bjorck L, Dudas K, Lappas G, Rosengren A. Symptoms of a first acute
myocardial infarction in women and men. Gend Med 2009;6:454–62.
[16] Arslanian-Engoren C, Engoren M. Physiological and anatomical bases for sex
differences in pain and nausea as presenting symptoms of acute coronary
syndromes. Heart Lung 2010;39:386–93.
[17] Coventry LL, Finn J, Bremner AP. Sex differences in symptom presentation in
acute myocardial infarction: a systematic review and meta-analysis. Heart
Lung 2011;40:477–91.
[18] Fitchett DH, Theroux P, Brophy JM, Cantor WJ, Cox JL, Gupta M, et al.
Assessment and management of acute coronary syndromes (ACS): a Canadian
perspective on current guideline-recommended treatment – Part 2: ST-
segment elevation myocardial infarction. Can J Cardiol 2011;27:S402–12.
[19] Wireklint Sundström B, Dahlberg K. Caring assessment in the Swedish
ambulance services relieves suffering and enables safe decisions. Int Emerg
Nurs 2010;19:113–9.
[20] Wireklint Sundström B, Bång A, Karlsson T, Winge K, Lundberg C, Herlitz J.
Anxiolytics in patients suffering a suspected acute coronary syndrome: multi-
centre randomised controlled trial in emergency medical service. Int J Cardiol
2013;168:3580–7.
[21] McMurray JJV, Pfeffer MA. Heart failure. Lancet 2005;365:1877–89.
[22] West RL, Hernandez AF, O’Connor CM, Starling RC, Califf RM. A review of
dyspnea in acute heart failure syndromes. Am Heart J 2010;160:209–14.
[23] Peters SP. When the chief complaints is (or should be) dyspnea in adults. J
Allergy Clin Immunol Pract 2013;1:129–36.
[24] McMurray JJV. Systolic heart failure. N Engl J Med 2010;362:228–38.
[25] Stewart S, Ekman I, Ekman T, Odén A, Rosengren A. Population impact of heart
failure and the most common forms of cancer. Circ Cardiovasc Qual Outcomes
2010;3:573–80.
[26] Goldstein RE, Boccuzzi SJ, Cruess D. Prognosis after hospitalization for acute
myocardial infarction not accompanied by typical ischemic chest pain. Am J
Med 1995;99:123–31.
[27] Kirchberger I, Heier M, Kuch B, von Scheidt W, Meisinger C. Presenting
symptoms of myocardial infarction predict short- and long-term mortality:
the MONICA/KORA myocardial infarction registry. Am Heart J
2012;164:856–61.
[28] Johansson A, Dahlberg K, Ekeberg M. Living with experiences following a
myocardial infarction. Eur J Cardiovasc Nurs 2003;2:229–36.
[29] Ahl C, Nyström M, Jansson L. Making up one’s mind: – patients’ experiences of
calling an ambulance. Accid Emerg Nurs 2006;14:11–9.
[30] Holmberg M, Forslund K, Wahlberg AC, Fagerberg I. To surrender in
dependence of another: the relationship with the ambulance clinicians
experienced by patients. Scand J Caring Sci 2014;28:544–51.
[31] Goodacre S, Locker T, Campbell S. How useful are clinical features in the
diagnosis of acute, undifferentiated chest pain? Acad Emerg Med.
2002;9:203–8.
[32] Herlitz J, Bång A, Isaksson L, Karlsson T. Ambulance despatchers’ estimation of
intensity of pain and presence of associated symptoms in relation to outcome
in patients who call for an ambulance because of acute chest pain. Eur Heart J
1995;16:1789–94.
[33] Elmqvist C, Fridlund B, Ekeberg M. More than medical treatment: the patient’s
first encounter with prehospital emergency care. Int Emerg Nurs; 2008. p.
185–92.
[34] Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al.
Shared decision making: a model for clinical practice. J Gen Intern Med
2012;27:1361–7.
[35] Svensson A, Fridlund B. Experiences of and actions towards worries among
ambulance nurses in their professional life: a critical incident study. Int Emerg
Nurs 2008;16:35–42.
[36] Gunnarsson B-M, Warrén Stomberg M. Factors influencing decision making
among ambulance nurses in emergency care situations. Int Emerg Nurs
2009;17:83–9.
[37] Wihlborg J, Edgren G, Johansson A, Sivberg B. The desired competence of
Swedish ambulance nurse according to the professionals – a Delphi study. Int
Emerg Nurs 2014;22:127–33.
[38] Grossman V. Quick Reference to Triage. second ed. Philadelphia: Lippincott
Williams & Wilkins; 2003.
[39] Widgren BR, Jourak M. Medical emergency triage and treatment system
(METTS): a new protocol in primary triage and secondary priority decision in
emergency medicine. J Emerg Med 2011;40:623–8.
[40] Ek B, Edström P, Toutin A, Svedlund M. Reliability of a Swedish pre-hospital
dispatch system in prioritizing patients. Int Emerg Nurs 2013;21:143–9.
[41] Andersson Hagiwara M, Suserud B-O, Jonsson A, Henricson M. Exclusion of
context knowledge in the development of prehospital guidelines: results
produced by realistic evaluation. Scand J Trauma Resusc Emerg Med
2013;21:46.
[42] Jönsson K, Fridlund B. A comparison of adherence to correctly documented
triage level of critically ill patients between emergency department and the
ambulance service nurses. Int Emerg Nurs 2013;21:204–9.
[43] Andersson A-K, Omberg M, Svedlund M. Triage in the emergency department –
a qualitative study of the factors which nurses consider when making
decisions. Nurs Crit Care 2006;11:136–45.