Cardiovascular emergencies in cruise ship passengers.

More than 10 million people, many elderly and likely to harbor cardiovascular (CV) disease, embark on cruise ship travel worldwide every year. The clinical presentation and outcome of CV emergencies presenting during cruise ship travel remain largely unknown. Our department provides contracted cardiology consultations to several large cruise lines. We prospectively maintained a registry of all such consultations during a 2-year period. One hundred consecutive patients were identified (age 66 +/- 14 years, range 18 to 90, 76% men). The most common symptom was chest pain (50%). The most common diagnosis was acute coronary syndrome (58%; ST elevation in 21% and non-ST elevation in 37%). On-board mortality was 3%. Overall, 73% of patients required hospital triage. Of the 25 patients triaged to our institution, 17 underwent a revascularization procedure. One patient died. Ten percent of patients had cardiac symptoms in the days or weeks before boarding; all required hospital triage. Access to a baseline electrocardiogram would have been clinically useful in 23% of cases. In conclusion, CV emergencies, such as acute coronary syndrome and heart failure, are not uncommon on cruise ships. They are often serious, requiring hospital triage and coronary revascularization. A pretravel medical evaluation is recommended for passengers with a cardiac history or a high-risk profile. Passengers should be encouraged to bring a copy of their electrocardiogram on board if abnormal. Cruise lines should establish mechanisms for prompt consultation and triage.

Release pattern of N-terminal probrain natriuretic peptide after intra-aortic balloon pump counterpulsation: Insights into the effects of mechanical unloading in patients with acute decompensated heart failure.

A 60-year-old man with dilated cardiomyopathy and severe decompensated heart failure was acutely managed with intra-aortic balloon pump (IABP) counterpulsation. The present report shows the release pattern of plasma natriuretic peptides after IABP therapy. Preliminary findings suggest that natriuretic peptide levels can be used to measure adequate ventricular unloading by IABP counterpulsation, and that a significant early decrease in natriuretic peptide levels after IABP therapy may potentially help identify future candidates for cardiac recovery after prolonged circulatory support.

Use of the prehospital ECG improves door-to-balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week.

BACKGROUND: The use of the prehospital electrocardiogram (ECG) to identify patients with ST-segment elevation myocardial infarction (STEMI), coupled with a centralised system to alert the cardiac catheterisation team in preparation for prompt intervention, has been shown to reduce door-to-balloon times (DBT) effectively. A confounding variable in prolonging the recommended 90 min DBT is the time of day or day of the week of patient presentation. We postulated that use of the prehospital ECG, coupled with an emergency department initiated "Cath Alert" system, could neutralise DBT delays related to time of day or day of week. METHODS: A prospective study was conducted on 167 consecutive patients presenting to our emergency department with acute STEMI. All patients were treated with primary percutaneous coronary intervention. Patients were grouped according to time of presentation: during regular hours (Monday to Friday 08:00 to 17:00) vs off hours (after 17:00 on weekdays and all hours on weekends). Baseline recorded variables included mode of presentation, transmission of prehospital ECG, and activation of Cath Alert system. RESULTS: Overall, the mean (SD) DBT was 69 (35) mins, with the majority of patients (n = 131, 78%) achieving the recommended DBT of 90 mins. The shortest DBT occurred in patients who arrived by emergency medical services with use of the prehospital ECG and Cath Alert system (53 (21) min), while those who arrived as a walk-in without use of emergency medical services had the longest DBT (105 (38) min; p<0.001). Compared to regular hours, presentation during off hours prolonged DBT in patients presenting via emergency medical services (75 (16) vs 53 (18) min, p = 0.03). With transmission of the prehospital ECG, the delay in DBT was improved among those presenting off hours, nullifying the adverse effect of off hour presentation (54 (21) vs 49 (22) min; p = 0.26). CONCLUSION: Variables such as time of day and mode of presentation have an impact on achieving currently recommended DBT in patients with STEMI. With the addition of each prehospital variable in succession-that is, arrival by emergency medical services, Cath Alert system, and the prehospital ECG-the DBT can be progressively shortened and the adverse "off hour effect" nullified.

Drug-eluting stent implantation in ST-elevation acute myocardial infarction: 'real world' 30-day and mid-term results.

Primary percutaneous coronary intervention (PCI) with stent implantation is the preferred method of reperfusion for ST-elevation acute myocardial infarction. Concern remains over the use of drug-eluting stents in the acute ST-elevation myocardial infarction setting, with limited published reports on their use for this application. We studied 64 consecutive patients presenting with an acute ST-elevation myocardial infarction who underwent mechanical reperfusion with implantation of a drug-eluting stent. Both sirolimus- and paclitaxel-eluting stents were used. Primary outcome was the occurrence of major adverse cardiac events, defined as death, nonfatal reinfarction or clinically driven target vessel revascularization. Post-procedural success was achieved in 63 patients (98%). In-hospital mortality was 1.6%. During a median follow-up of 234 days, there were no cases of stent thrombosis, reinfarction or reintervention. These findings conducted in a 'real world' practice setting in the United States demonstrate that drug-eluting stent implantation for acute ST-elevation myocardial infarction is safe and effective, with a low rate of major adverse cardiac events during mid-term follow-up.