Methods

Our cardiology department provides contracted cardiology consultations to 5 large cruise lines to aid in the appropriate management of CV emergencies. Initial consultation is established by teleconference with the requesting on-board physician at his/her discretion from the ship’s infirmary. Over a 2-year period, we prospectively maintained a registry of all such consultations in consecutive fashion. Data from adult passengers (≥18 years of age) were prospectively collected. Patient demographics (age, gender), presenting symptoms, selected medical history (history of coronary artery disease, previous myocardial infarction, previous coronary bypass grafting, history of atrial fibrillation, and previous permanent pacemaker), 12-lead electrocardiograms, initial diagnosis, recommended medical therapy, and triage were recorded. Initial diagnoses were defined as acute coronary syndromes (presence of cardiac symptoms of ischemic origin in combination with abnormal cardiac biomarkers and/or electrocardiographic changes) and atrial arrhythmias (atrial fibrillation or atrial flutter). Data were made available to the consulting cardiologist by teleconference and from data transmitted by facsimile and/or scanned into electronic mail. The study was approved by the Cleveland Clinic Florida (Weston, Florida) institutional review board.

Patients triaged to our institution from the cruise ship were followed until date of hospital discharge. For patients triaged to our hospital, medical charts were reviewed for the principal diagnosis, symptom history, medical and surgical histories, diagnostic and interventional procedures performed, and in-hospital mortality.

Patient data were collected in a Microsoft Excel database (Microsoft, Redmond, Washington), and Microsoft Excel was used for statistical analysis. Results are presented as mean ± SD and median and range. Statistical comparisons were made using Student’s t test for continuous variables and chi-square analysis for categorical variables. Statistical significance was defined as a p value <0.05.

Results

From January 1, 2004, to December 31, 2005, there were 100 consecutive adult cardiology consultations obtained from participating cruise lines. Baseline passenger characteristics are listed in Table 1 . There were 76 men and 24 women, with a mean age of 66 ± 14 years (median 68, range 18 to 90). Most passengers were in their seventh decade of life (n = 30), followed by those in their sixth decade of life (n = 26). Nearly 1/5 of passengers (19%) had previous coronary artery disease.

Chest pain was the most common presenting symptom (n = 50), followed by dyspnea, palpitations, and near syncope/syncope ( Figure 1 ). Acute coronary syndromes accounted for the most common principal diagnosis (n = 58), followed by atrial arrhythmias (n = 15). Syncope, noncardiac chest pain syndromes, decompensated heart failure, and acute pericarditis were less frequent ( Figure 2 ).

Most common presenting CV symptoms to cruise ship infirmary. *Others include nausea (n = 2), rash and/or angioedema (n = 2), cardiac arrest (n = 1), cough (n = 1), transient neurologic deficits (n = 1), and weakness (n = 1).

Most common principal CV diagnosis presenting to cruise ship infirmary. *Others include transient ischemic attack (n = 1), sudden cardiac death (n = 1), uncontrolled blood pressure (n = 1), dyspepsia with electrocardiographic changes (n = 1), and palpitation (n = 1). AF = atrial fibrillation; ICD = implantable cardioverter–defibrillator; NSTE ACS = non–ST-elevation acute coronary syndrome; STE ACS = ST-elevation acute coronary syndrome; SVT = supraventricular tachycardia.

Complete history and physical examination with vital signs were always performed by the ship’s physician. Common diagnostic studies performed in the cruise ship’s medical center included 12-lead electrocardiography, continuous telemetry monitoring, chest radiography, oxygen saturation, arterial blood gas, and laboratory studies (complete blood count, basic metabolic panel, creatine kinase, cardiac troponin, myoglobin, prothrombin time).

Available medical therapy differed among the various cruise ships. Medical therapy available and often provided included but was not limited to oxygen, defibrillation kits, aspirin, diuretics, β blockers, calcium channel blockers, nitroglycerin, angiotensin-converting enzyme inhibitors, fibrinolytic agents, unfractionated and low-molecular-weight heparins, antibiotics, atropine, dopamine, dobutamine, epinephrine, morphine, β-agonist inhalers, intravenous amiodarone, adenosine, and clopidogrel.

On presentation, an abnormal 12-lead electrocardiogram was present in 92% of passengers. Of the 21 passengers with acute ST-elevation myocardial infarction, fibrinolytic therapy was withheld in 5 (24% of the time). Reasons for which fibrinolytic therapy was held included spontaneous resolution of ST elevations (n = 1), concerns over aortic dissection (n = 1) and head trauma after a syncopal event (n = 1), short triage time to a local catheterization laboratory (n = 1), and delayed time to presentation of >6 hours (n = 1). Of the 16 passengers with acute ST-elevation myocardial infarction who received fibrinolytic therapy, 13 (81%) achieved successful reperfusion by clinical predictors and electrocardiographic criteria. The 3 passengers with unsuccessful reperfusion were triaged to the nearest shore-side hospital for cardiac catheterization no sooner than 24 to 48 hours after administration of fibrinolytic therapy. In 23% of cases, a copy of a passenger’s baseline 12-lead electrocardiogram would have been useful in clinical decision-making.

Of the 100 passengers requiring cardiology consultations, 3 passengers died while on board (71, 58, and 80 years old). One passenger presented with a non–ST-elevation myocardial infarction, 1 with pulmonary edema, and 1 with profound hypotension. The exact underlying causes of death are not known. Seventy-three passengers required triage off the cruise ship to a shore-side facility. Of these, 47 passengers were triaged to the nearest shore-side hospital, 25 were triaged to our institution, and 1 refused triage and remained on board the ship. Of the triaged passengers, 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 (65 ± 14 vs 67 ± 13 years, p = 0.42) and had a similar prevalence of pre-existing coronary artery disease (21% vs 15%, p = 0.58).

Twenty-five passengers were triaged to our institution for further cardiac care and management ( Table 2 ). Many of these passengers required invasive procedures during hospitalization. In regard to invasive treatments, cardiac catheterization was performed in 20, followed by percutaneous coronary intervention in 11, and coronary artery bypass grafting in 6. Of the 25 passengers, 1 (4%) died during the hospital stay (acute ST-elevation myocardial infarction, died from a ventricular free wall rupture).

Table 2

Clinical characteristics and outcomes of passengers triaged to our institution (n = 25)

Patient No.	Age/Sex	Presenting Diagnosis	Previous CVD	Cruise Ship Therapy	Hospital Outcome
1	62/M	CA, NSTEMI ACS	+	CPR, ASA, dopamine	CC, PCI
2	62/M	CA, STEMI	+	CPR, UFH, lytics, ASA	CC, CABG, ICD
3	66/F	CHF	+	LMWH, ASA, NTG	CC, CABG
4	67/M	NSTEMI ACS	+	UFH, BB, NTG, ASA	CC, PCI
5	73/M	CHF, USA	+	UFH, BB, NTG, ASA	CC, PCI
6	75/M	CA, NSTEMI ACS	+	CPR, LMWH, ASA, BB	CC, CABG
7	82/M	NSTEMI ACS, CHF	+	UFH, BB, NTG, ASA	CC, medical therapy
8	87/M	NSTEMI ACS, GIB	+	NTG, BB, ASA	CC, PCI
9	45/M	STEMI	0	UFH, lytics, ASA	CC, PCI
10	48/M	USA	0	NTG	CC, CABG
11	48/F	STEMI	0	UFH, lytics, ASA, BB	CC, PCI
12	50/M	STEMI	0	UFH, lytics, ASA, BB	CC, CABG
13	50/M	STEMI	0	UFH, lytics, ASA, BB	CC, PCI
14	55/M	NSTEMI ACS	0	UFH, NTG, BB, ASA	CC, medical therapy
15	63/M	Anaphylactic reaction	0	Epinephrine, ASA, steroids	Medical therapy
16	63/F	STEMI	0	UFH, lytics, ASA, BB	CC, IABP, PCI
17	67/M	CHF, URI	0	Lasix, beta agonist inhaler	Medical therapy
18	68/F	STEMI	0	NTG, BB, ASA	CC, PCI
19	71/M	AF	0	BB	Medical therapy
20	72/M	NSTEMI ACS, AF	0	UFH, BB, NTG, ASA	CC, CABG
21	74/M	NSTEMI ACS, CHF	0	UFH, NTG, BB, ASA	CC, PCI
22	74/F	STEMI	0	LMWH, ASA, BB	CC, IABP, PCI
23	74/M	AF, COPD	0	Lasix, BB, antibiotics	Medical therapy
24	75/M	CHF, NSTEMI ACS	0	LMWH, ASA, NTG, Lasix	MPI, medical therapy
25	84/M	STEMI	0	UFH, lytics, ASA, BB	CC, CA, wall rupture, died

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