Acute chest pain on cruise ships.

* Every day, in various forms, emergency physicians and their patients face the question: how safe is safe enough? Is the risk of something bad low enough that it is reasonable to neglect it [1]? Acute chest pain is a daily challenge and even more so for doctors on cruise ships at sea who face additional questions: is the cause something that can be treated aboard, and if not, what can be done until safe evacuation to definitive care is possible? Although not internationally regulated, medical practice on cruise vessels has evolved over the years, mostly because of efforts by the American College of Emergency Physicians (ACEP). " Health Care Guidelines for Cruise Ship Medical Facilities " was created by consensus in the mid-1990s by ACEP's Section for Cruise Ship and Maritime Medicine [2]. Regularly updated and last revised in July 2014, these guidelines are now actively promoted by the Cruise Lines International Association, the world's largest cruise industry association with representation in North and South America, Europe, Asia and Australasia [3]. They can thus be considered globally accepted minimal medical requirements for international cruising. For diagnostic work-up of acute chest pain, the ACEP Guidelines include X-ray imaging, electrocardiography (ECG) and cardiac enzymes, and there are therapeutic remedies for advanced cardiac life support including fibrinolytic agents, as well as equipment for assisted respiration, cardiac pacing and defibrillation [2]. The ship's doctor may be able to exclude some non-cardiac causes for chest pain and to a certain degree follow established practice guidelines for diagnosis and management of acute coronary syndrome (ACS) and myocardial infarctions (MI) without ST segment elevation (NSTEMI) and with ST segment elevation (STEMI) [4]. Three case reports have recently been published in " International Maritime Health " about patients with ischaemic heart disease presenting with acute chest pain on cruise ships [5–7]. Their chest discomfort turned out to have other causes than initially suspected, and the cases demonstrate how difficult it can be to determine whether this often mild or unclear symptom can safely be observed aboard until the end of the voyage or suggests a serious enough condition to attempt immediate medical evacuation. The 2 described female patients both had atypical pains as well as abnormal electrocardiographic and/or cardiac enzyme findings [5, 6]. MI was suspected and anticoagulation therapy started, but the causes were found ashore to be spontaneous coronary artery dissection (SCAD) and takotsu-bo cardiomyopathy (" …