Prevalence and Characteristics of Outpatient Palliative Care Services in California

two patients had 1 positive marker, 36 had 2, and 44 had 3.A total of 176 patients were immediately transported to hospital (4 refused).Of these, 90 (51%) were discharged with the hospital record-determined diagnosis of acute myocardial infarction (AMI).One-fifth of the remaining 641 patients (126 of 641) were reexamined within the 3-day follow-up because of continuing complaints, and another 15 AMIs were diagnosed.The sensitivity, specificity, and positive and negative predictive values were 86.6%, 83.3%, 53.8%, and 97.6%, respectively.The overall mortality rate for the study population was 3.3% (27 patients).Mortality among patients with a negative kit result was 3% (19 patients) during the 3 days of follow-up (4 from cardiogenic shock, 2 from sudden cardiac death with failed resuscitation, and 13 from unrelated causes).Of 180 patients, 8 (4.4%) with a positive kit result died from sequelae of an AMI (7 underwent cardiogenic shock and 1 had a post-AMI stroke). Comment. Elevation of cardiac markers in individualsin whom an AMI is not diagnosed in the end is well known, 5,6 and this finding characterized 50% of our patients in whom the uncertainty was clarified by appropriately extended evaluations in the emergency services.Ninety AMI cases (9.1%) were identified but would probably have been missed because of the patients' inconclusive clinical and ECG presentations.Positive test results alone determined their transport to hospital, sparing them possible serious untoward consequences.Than et al 7 recently reported satisfactory results in ruling out an AMI by following a protocol in which the same cardiac markers were measured twice in patients with early (Ͻ6 hours) symptom onset and who had already arrived to the emergency department.We needed to test those markers only once and could do so at the point of care, thus safely obviated unnecessary trips to the emergency department.Importantly, 6 hours or more from symptom onset, the 98% negative predictive value of assessment by cardiac markers provides further support to the physician at the point of care in the decisionmaking process, which is sometimes daunting when the source of the pain is inconclusive.