Aim The aims of this study were to describe the characteristics of and outcome of patients with chest pain in relation to transport by the emergency medical services (EMS) and to describe possible changes in this relationship in a 20-year perspective. Methods In the 2 periods, 1986 to 1987 and 2008, all patients with chest pain admitted to hospitals in Gothenburg, Sweden, were retrospectively evaluated in terms of previous history, final diagnosis, and mortality. P values were age adjusted. Results In 1986 to 1987 and 2008, 34% of 4270 patients with chest pain and 39% of 2286 patients, respectively, were transported to the hospital by the EMS (P = .0001). In both periods, patients who used EMS were older and had a higher prevalence of previous cardiovascular diseases and more often had a final diagnosis of acute myocardial infarction (AMI) than those who did not use EMS. The EMS users were more frequently hospitalized in 1986 to 1987 than in 2008 (P < .0001). Emergency medical service use was related to a significantly higher age-adjusted 1-year mortality in both periods for all patients with chest pain as well as for those hospitalized. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality in 1986 to 1987. Regardless of the use of EMS, there was a decrease in the proportion of patients developing AMI as well as the rate of death at 30 days and 1 year in 2008 as compared with 1986 to 1987. Conclusions For 20 years, the proportion of patients with chest pain using the EMS increased. EMS users were more frequently hospitalized in 1986 to 1987 than in 2008. In overall terms, mortality was higher among EMS users than among nonusers in both periods. Among hospitalized patients with myocardial ischemia and among patients with a final diagnosis of AMI, EMS use was associated with a higher 30-day mortality only in 1986 to 1987.