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ACS Most Common Diagnosis in CV Patients on Cruise Ships
While the holidays are a time for relaxation and travel, health emergencies can and do happen. A study of cruise ship emergencies published online December 7, 2009, ahead of print in the American Journal of Cardiology suggests patients with known cardiovascular disease could benefit from pre-travel precautions such as a new medical evaluation before leaving and bringing all medications, updated medication lists, physician contact information and a hard copy of their baseline 12-lead electrocardiogram (ECG) with them.
Gian M. Novaro, MD, of Cleveland Clinic Florida (Weston, FL), and colleagues examined data they collected between January 1, 2004 and December 31, 2005 from 100 consecutive adult cardiology consultations for passengers aboard 5 large cruise lines.
The most common symptom was chest pain (50%) followed by dyspnea (19%), palpitations (13%), syncope/near syncope (10%) and "other," which included vague symptoms such as nausea, rashes and weakness (10%).
Mean age was 66 years and the most common principal diagnosis was acute coronary syndrome (58%; ST-elevation MI in 21% and non-ST elevation MI in 37%). Other diagnoses included atrial arrhythmias (15%), syncope (5%), noncardiac chest pain syndromes (5%), decompensated heart failure (4%), acute pericarditis (3%) and dyspnea (3%). Over the 2-year period, the on-board mortality was 3%. These deaths occurred in patients who presented with non-STEMI, pulmonary edema and profound hypotension.
Nearly 75% of patients requiring a cardiology consultation were triaged off the ships to a shore-side hospital. Of these, 10% reported active cardiac symptoms in the days to weeks before cruise ship travel. Triaged passengers were similar in age to those not requiring triage and had a similar prevalence of pre-existing coronary artery disease. During hospitalization, at least 20 patients required cardiac catheterization followed by PCI or CABG. Mortality among these patients was 4%.
Better Safe Than Sorry
Dr. Novaro and colleagues say while the risk of cardiovascular events aboard cruise ships is low, their report highlights the not insignificant risk of morbidity and mortality for passengers who do develop symptoms.
While the medical staff aboard the cruise lines had access to ECG, continuous telemetry monitoring, chest radiography, oxygen saturation, arterial blood gas, and laboratory studies, there was variation in the types of available medical therapy.
Therefore, the researchers say it is important for passengers to inform themselves about cruise ship medical capabilities. While most large cruise lines adhere to guidelines set by the American College of Emergency Physicians, many smaller or independent cruise lines do not, and only minimal information about their medical evacuation or telemedicine capability may be available.
They recommend the following medical checklist for passengers prior to cruise ship travel:
- Pack an adequate supply of all medications and bring an updated medication list
- For passengers with known coronary artery disease, travel with sublingual nitroglycerin
- Bring a hard copy of a 12-lead ECG if baseline is abnormal
- For passengers with pacemakers, defibrillators, coronary stents, or heart valves, carry a manufacturer's card
- For passengers with known cardiovascular disease, travel with physician's contact information and a recent summary of medical history
- For the elderly, sedentary, or those with known cardiovascular disease, consider pretravel evaluation with physician
- Evaluate new cardiovascular symptoms or change in clinical status with physician before travel
- Check with physician regarding safety of initiating an exercise program
- Consider purchasing medical evacuation insurance if not covered under existing health insurance
In addition, Dr. Novaro and colleagues say prospective passengers should keep in mind that some behavioral changes related to travel such as dietary indiscretions, altered sleep cycles, increased alcohol intake, and increased physical exertion may worsen or precipitate cardiovascular events.
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