acute myocardial infarction ( ami ) is a leading cause of morbidity and mortality worldwide with approximately one - half of deaths occurring in the prehospital setting . in
the united arab emirates , mortality statistics from 2008 to 2010 showed that cardiovascular disease was the leading cause of death among both the united arab emirates nationals and expatriates . in the emirate of abu dhabi , early diagnosis and care by emergency medical services ( ems )
can play a crucial role in improving the management and ultimate outcome of patients with ami .
use of ems may result in the faster initiation of reperfusion therapies , and facilitate quicker and more efficient treatment decisions .
of particular importance is the role of ems in caring for patients with st - segment elevation myocardial infarction ( stemi ) , the most serious and time - sensitive type of ami .
stemi is potentially reversible provided that revascularization is initiated rapidly , as evidence has shown increased mortality associated longer culprit vessel occlusion times .
while several international studies have emphasized the need for early activation of ems in patients with ami , ems use is generally low in patients with stemi .
these low ems use rates were also found in the first gulf registry of acute coronary events ( gulf race ) and again in the second gulf race-2 , which reported ems use rates of 17% and 25% , respectively , as well as in other studies of middle eastern countries .
several studies have examined the issue of ems transport to the hospital versus self - transport and found that patient characteristics , american community survey ( acs ) characteristics , and patient 's knowledge of acs symptoms , influence the use of ems as well .
patient perception and knowledge of ems care is critical to proper utilization of such services .
the purpose of this study was to estimate the utilization , knowledge , and perceptions of prehospital ems among patients with stemi in the emirate of abu dhabi to determine if demographic and background variables or event characteristics were related to these factors .
cardiac catheterization services are provided at five government operated hospitals , four of which are under the abu dhabi health services company ( seha ) and one operated by the united arab emirates armed forces .
ems is operated by the abu dhabi police emergency and public safety department , in conjunction with national ambulance company llc , which provides emergency technicians and paramedics .
the ems is able to provide advanced cardiac life support and early stemi recognition by means of 12 lead ecg acquisition and paramedic interpretation .
this was an 18-month , multicenter , prospective study of consecutive patients admitted with stemi to four government hospitals in the emirates of abu dhabi .
the united arab emirates armed forces hospital , zayed military hospital , was excluded from our research due to ems not transporting to this hospital .
we performed telephonic or face - to - face semi - structured interviews , to assess their rationale for choosing their prehospital mode of transport and their knowledge of ems contact details .
mode of transport was ascertained by the way of both ems and hospital electronic medical record data and confirmed with the patient at interview .
the following questions were asked of all patients regardless of mode of transport utilized : 
 do you know what the emergency number is to call an ambulance?when you decided to go to the hospital , how did you get there , by ambulance or did you use private transport ? 
 
when you decided to go to the hospital , how did you get there , by ambulance or did you use private transport ? patients who made the use of private transport instead of ems were asked the following additional question : 
 what made you not call for an ambulance , but instead make use of private transport ? what made you not call for an ambulance , but instead make use of private transport ?
these questions were asked in the patient 's native language with the assistance of staff in the hospital or with the assistance of follow - up investigators if the patient was discharged before interview .
descriptive statistics were computed for all the study variables including the demographic and background variables as well as the reasons for using private transportation .
inferential analyses were performed to determine if relationships existed between the demographic and background variables , on the one hand , and the reasons for taking private transportation on the other .
most of the demographic and background variables were also categorical , and therefore , a series of chi - square tests of independence were performed .
one demographic variable , age , was continuous , and therefore , a one - way anova was performed to determine if the participants ' reasons for using private transportation differed according to their age .
analyses were performed using spss version 22.0 ( ibm corporation , armonk , ny , usa ) and a p  0.05 was considered to be statistically significant .
the study protocol was approved by the research ethics committees of sheikh khalifa medical city , mafraq , al ain , and tawam hospitals as well as the university of cape town human research ethics committee ( hrec 286/2013 ) .
written consent to follow - up was obtained from patients before discharge , and an explanation of the research was provided in the patient 's native language .
ems and in - hospital electronic medical records were also utilized for patients ' data collection .
cardiac catheterization services are provided at five government operated hospitals , four of which are under the abu dhabi health services company ( seha ) and one operated by the united arab emirates armed forces .
ems is operated by the abu dhabi police emergency and public safety department , in conjunction with national ambulance company llc , which provides emergency technicians and paramedics .
the ems is able to provide advanced cardiac life support and early stemi recognition by means of 12 lead ecg acquisition and paramedic interpretation .
this was an 18-month , multicenter , prospective study of consecutive patients admitted with stemi to four government hospitals in the emirates of abu dhabi .
the united arab emirates armed forces hospital , zayed military hospital , was excluded from our research due to ems not transporting to this hospital .
we performed telephonic or face - to - face semi - structured interviews , to assess their rationale for choosing their prehospital mode of transport and their knowledge of ems contact details .
mode of transport was ascertained by the way of both ems and hospital electronic medical record data and confirmed with the patient at interview .
the following questions were asked of all patients regardless of mode of transport utilized : 
 do you know what the emergency number is to call an ambulance?when you decided to go to the hospital , how did you get there , by ambulance or did you use private transport ? 
 
when you decided to go to the hospital , how did you get there , by ambulance or did you use private transport ?
patients who made the use of private transport instead of ems were asked the following additional question : 
 what made you not call for an ambulance , but instead make use of private transport ? what made you not call for an ambulance , but instead make use of private transport ?
these questions were asked in the patient 's native language with the assistance of staff in the hospital or with the assistance of follow - up investigators if the patient was discharged before interview .
descriptive statistics were computed for all the study variables including the demographic and background variables as well as the reasons for using private transportation .
inferential analyses were performed to determine if relationships existed between the demographic and background variables , on the one hand , and the reasons for taking private transportation on the other .
most of the demographic and background variables were also categorical , and therefore , a series of chi - square tests of independence were performed .
one demographic variable , age , was continuous , and therefore , a one - way anova was performed to determine if the participants ' reasons for using private transportation differed according to their age .
analyses were performed using spss version 22.0 ( ibm corporation , armonk , ny , usa ) and a p  0.05 was considered to be statistically significant .
the study protocol was approved by the research ethics committees of sheikh khalifa medical city , mafraq , al ain , and tawam hospitals as well as the university of cape town human research ethics committee ( hrec 286/2013 ) .
written consent to follow - up was obtained from patients before discharge , and an explanation of the research was provided in the patient 's native language . ems and in - hospital electronic medical records were also utilized for patients ' data collection .
most participants ( n = 557 , 94.9% ) were male , and the average age was 51 ( 11 ) years . however , this finding is not surprising considering that the united arab emirates has a large expatriate workforce which is predominately male .
the most common countries of origin were the india subcontinent ( n = 421 , 71.7% ) .
arabic was the most common language ( n = 183 , 31.2% ) , with substantial percentages of these participants being able to comprehend basic english ( n = 96 , 16.4% ) , hindi ( n = 104 , 17.7% ) , and urdu ( n = 100 , 17.0% ) .
english was the first language of only 23.7% ( n = 139 ) of the participants [ table 1 ] .
most participants ( n = 501 , 85.3% ) used private transportation to get to the hospital , and only a small percentage ( n = 86 , 14.7% ) used ems .
descriptive statistics for reasons for mode of transport ( n=587 ) the reasons for using private transportation are shown in table 2 .
the most common responses were that it was quicker ( 232 , 46.3% ) and easier ( 67 , 13.4% ) to go through private means .
a smaller percentage of participants stated that they had not called ems because they did not think their symptoms were cardiac - related ( 40 , 8.0% ) .
descriptive statistics for reasons for using private transportation ( n=501 ) over half ( 323 , 55.0% ) of the participants stated that they did not know the telephone number for ems in abu dhabi .
there were no differences between males and females in terms of their reasons for using private transportation rather than ems ( p = 0.26 ) .
there was also no statistically significant differences in age between individuals citing different reasons for using private transportation ( p = 0.68 ) participants from pakistan were less likely to feel that it was quicker to go through private transportation ( 37.2% ) compared to between 42.3% and 56.6% for individuals from other countries , and individuals from the united arab emirates and syria were less likely to feel that it was easier to go through private transportation ( 3.8% and 5.6% , respectively , compared to between 12.2% and 16.8% for individuals from other countries ) .
participants with knowledge of the ems number and those without that knowledge were compared in terms of their reason for using private transportation , and the results indicated a significant difference between the groups ( p = 0.03 ) [ table 3 ] .
participants who knew the number for ems 15.4% ( but nevertheless took private transportation ) were more likely to think that their event was not a cardiac event or did not warrant an ems call than those who did not know the number 7.1% [ table 4 ] .
cross - tabulation of gender , nationality , language , and english as the first language versus reasons for using private transportation ( n=501 ) cross - tabulation of city of event , transfers , and knowledge of the emergency medical services number versus reasons for using private transportation * there was a significant difference in reasons for using private transportation between the two cities ( p < 0.001 ) [ table 4 ] .
residents of abu dhabi city were more likely to feel it was quicker to use private transportation ( 50.9% ) .
however , the residents of al ain city were more likely to feel it was easier to use private transportation ( 27.8% ) .
there was no significance difference in reasons for using private transportation and those who were transferred ( p = 0.75 ) .
most participants ( n = 557 , 94.9% ) were male , and the average age was 51 ( 11 ) years . however , this finding is not surprising considering that the united arab emirates has a large expatriate workforce which is predominately male .
the most common countries of origin were the india subcontinent ( n = 421 , 71.7% ) .
arabic was the most common language ( n = 183 , 31.2% ) , with substantial percentages of these participants being able to comprehend basic english ( n = 96 , 16.4% ) , hindi ( n = 104 , 17.7% ) , and urdu ( n = 100 , 17.0% ) .
english was the first language of only 23.7% ( n = 139 ) of the participants [ table 1 ] .
most participants ( n = 501 , 85.3% ) used private transportation to get to the hospital , and only a small percentage ( n = 86 , 14.7% ) used ems .
the most common responses were that it was quicker ( 232 , 46.3% ) and easier ( 67 , 13.4% ) to go through private means .
a smaller percentage of participants stated that they had not called ems because they did not think their symptoms were cardiac - related ( 40 , 8.0% ) .
descriptive statistics for reasons for using private transportation ( n=501 ) over half ( 323 , 55.0% ) of the participants stated that they did not know the telephone number for ems in abu dhabi .
there were no differences between males and females in terms of their reasons for using private transportation rather than ems ( p = 0.26 ) .
there was also no statistically significant differences in age between individuals citing different reasons for using private transportation ( p = 0.68 ) participants from pakistan were less likely to feel that it was quicker to go through private transportation ( 37.2% ) compared to between 42.3% and 56.6% for individuals from other countries , and individuals from the united arab emirates and syria were less likely to feel that it was easier to go through private transportation ( 3.8% and 5.6% , respectively , compared to between 12.2% and 16.8% for individuals from other countries ) .
participants with knowledge of the ems number and those without that knowledge were compared in terms of their reason for using private transportation , and the results indicated a significant difference between the groups ( p = 0.03 ) [ table 3 ] .
participants who knew the number for ems 15.4% ( but nevertheless took private transportation ) were more likely to think that their event was not a cardiac event or did not warrant an ems call than those who did not know the number 7.1% [ table 4 ] .
cross - tabulation of gender , nationality , language , and english as the first language versus reasons for using private transportation ( n=501 ) cross - tabulation of city of event , transfers , and knowledge of the emergency medical services number versus reasons for using private transportation * there was a significant difference in reasons for using private transportation between the two cities ( p < 0.001 ) [ table 4 ] .
residents of abu dhabi city were more likely to feel it was quicker to use private transportation ( 50.9% ) .
however , the residents of al ain city were more likely to feel it was easier to use private transportation ( 27.8% ) .
there was no significance difference in reasons for using private transportation and those who were transferred ( p = 0.75 ) .
our findings showed persistent underuse of ems , with rates comparable to those of previous regional studies .
it has been shown that ems use rates vary between countries but were predominantly low , including 2% in yemen , 7% in kuwait , 17% in the united arab emirates , 23% in bahrain , and 30% in qatar .
interestingly , a study conducted in turkey found that despite a high knowledge of the emergency services number , only 29% of stemi patients used ems .
in other countries such as the united states and china , ems utilization rates varied between 20% and 50% . however , higher rates of ems have been reported in other studies .
for example of 619 patients with an stemi presenting to a singapore hospital , 58.6% arrived by ems .
mathews et al . reported that in data from the national cardiovascular registry ( action registry 
gwtg ) , detailing almost 40,000 stemi patients , ems transport was used by 60% .
our study also indicated that public awareness of how to access ems was a barrier to utilization .
a high percentage of patients were not aware of the emergency contact number for the ems in abu dhabi .
our research found that majority of the patients who used private transport did so as they thought that it would be a quicker means to access emergency health care . in our study , we found that many participants were from foreign countries and with arabic or english not as their first language , raising the question could complicate any public education campaigns to benefit future cardiac patients ?
our findings emphasize the need for greater public education and awareness , with regards to not only the benefits of using ems during chest pain events but also the signs and symptoms of cardiac emergencies .
the public should be educated to the fact that ems is not only a transport modality , but that early treatment can be initiated en route , and cardiac interventions services can be activated before patient arrival .
education should also be directed at lower - income patients such as those involved with manual labor and encompass languages including urdu , hindi , malayalam , and bengali , as these patients comprised a large percentage of our study population .
strategies should focus on enhancing awareness of this particular population demographic , in their native languages dialects , with greater emphasis perhaps placed on newspapers and television as well as education in the workplace and the accommodations facilities under the auspices of government health - care programs .
the internet and electronic social media platforms may not be the best way to educate these potential patients .
we acknowledge the potential for referral bias , as a disproportionate number of patients may also have presented to private facilities that have interventional cardiology services in these two cities .
we also acknowledge that despite previous research in the middle east describing low ems use rates , our results may not be generalizable due to postresearch recommendation changes in these countries having been initiated .
we acknowledge the potential for referral bias , as a disproportionate number of patients may also have presented to private facilities that have interventional cardiology services in these two cities .
we also acknowledge that despite previous research in the middle east describing low ems use rates , our results may not be generalizable due to postresearch recommendation changes in these countries having been initiated .
patient knowledge and perceptions may contribute to this underutilization , and public education efforts are needed to raise awareness of both the signs and symptoms of acs and the importance of ems utilization .
current public education appears to be ineffective and needs to target more specific demographic groups .
it is hoped that the results of this study can be used as a foundation for future research and assist with public education strategies .
 background : data on the use of emergency medical services ( ems ) by patients with cardiac conditions in the gulf region are scarce , and prior studies have suggested underutilization . 
 patient perception and knowledge of ems care is critical to proper utilization of such services.objectives:to estimate utilization , knowledge , and perceptions of ems among patients with st - elevation myocardial infarction ( stemi ) in the emirate of abu dhabi.methods:we conducted a multicenter prospective study of consecutive patients admitted with stemi in four government - operated hospitals in abu dhabi . 
 semi - structured interviews were conducted with patients to assess the rationale for choosing their prehospital mode of transport and their knowledge of ems services.results:of 587 patients with stemi ( age 51  11 years , male 95% ) , only 15% presented through ems , and the remainder came via private transport . over half of the participants ( 55% ) stated that they did not know the telephone number for ems . 
 the most common reasons stated for not using ems were that private transport was quicker ( 40% ) or easier ( 11% ) . 
 a small percentage of participants ( 7% ) did not use ems because they did not think their symptoms were cardiac - related or warranted an ems call . 
 stated reasons for not using ems did not significantly differ by age , gender , or primary language of the patients.conclusions:ems care for stemi is grossly underutilized in abu dhabi . 
 patient knowledge and perceptions may contribute to underutilization , and public education efforts are needed to raise their perception and knowledge of ems . 
INTRODUCTION
METHODS
Study setting
Design
Statistical analysis
Ethics
RESULTS
Baseline demographics
Transport demographics
DISCUSSION
Limitations
CONCLUSIONS
Financial support and sponsorship
Conflicts of interest