Aeromedical Report:  Airline Pilots and High Blood Pressure

Air Line Pilot, November/December 2001, p. 5
By Dr. Robert J. Stepp, ALPA Associate Aeromedical Advisor

Typically, the first thing that happens to you during any visit to a doctor or dentist is that you are asked for your insurance card. The second thing that usually happens is that someone takes your blood pressure. Have you ever wondered why this is so?

The first happens because your doctor or dentist, as well as the office staff, actually expects to get paid for his/her services. Shocking, I know, but true nonetheless. The second happens because untreated high blood pressure, or hypertension, is a killer. If it remains high enough for long enough, it can and will lead directly to stroke, heart failure, loss of vision, kidney failure, and other nastiness guaranteed to interfere significantly with your pursuit of happiness and is also guaranteed to make the FAA a bit squeamish about signing off your airmanís medical certificate.

Hypertension is defined as sustained elevation of systolic blood pressure (the upper number) above 140 mm Hg and/or elevation of diastolic blood pressure (the lower number) above 90 mm Hg. Systolic blood pressure represents the maximum pressure that contraction of the heart generates in the arterial tree. Diastolic blood pressure represents the residual pressure remaining in the arterial tree between heart contractions. Which is more important? No one knows for certain, but elevation of either above the specified limits definitely increases the risk of the undesirable health effects noted above, so the current practice is to begin treatment whenever either one remains consistently elevated.

Many pilots reading this column will be aware that the FAA "standards" are somewhat different. The FAA does not require the medical examiner to take action until a pilotís blood pressure exceeds 155/95, but this higher standard is merely intended to give the aviation medical examiner (AME) some wiggle room in dealing administratively with "cuff reactor" pilots, and is definitely not intended to imply that sustained elevations of this magnitude are medically acceptable. Left untreated, it could lead to your being grounded or worse.

What causes hypertension? Approximately 85 to 90 percent of hypertension cases are classified as primary, i.e., hypertension of no identifiable cause. The other 10 to 15 percent of cases are caused by a motley collection of rare, mostly hereditary abnormalities such as deformations in the aorta or renal arteries, hormonal imbalances, tumors, kidney disease, etc. This type of hypertension is referred to as "secondary" hypertension. Most individuals with secondary hypertension develop hypertension early in life, so the likelihood of secondary hypertension in an airline pilot is very low. Nonetheless, whenever any individual is found to have sustained hypertension, a few screening tests are appropriate to rule out identifiable causes, and most physicians administer these routinely.

Probably the most difficult aspect of treating hypertension in pilots is determining whether a given pilot really has hypertension at all. We all know that most pilots regard the physicianís office as hostile territory, especially if the physician in question is the pilotís AME. Therefore, we can expect a pilotís blood pressure to increase when said pilot is in a physicianís office. This raises the obvious question: Is the pilotís blood pressure elevated all the time, or only when in the physicianís office? In my opinion, the very best way to answer this question is for the pilot to obtain his or her own blood pressure cuff (about $75 to $100), calibrate it with the physicianís cuff to ensure that the readings are similar, then take a series of blood pressure measurements at home. In most cases, 10 or 12 home readings will yield a reliable indication of what a pilotís baseline blood pressure really is, and whether treatment is appropriate.

The treatment of primary hypertension is one of the great but little known success stories of modern medicine. The first generation antihypertensive medications were nasty indeed, with very narrow safety margins and absolutely horrible side effects. Frequently, blood pressure control would be marginal at best, and the patient would be faced with major lifestyle disruption due to side effects. The third and fourth generation medications used today have changed that picture completely. Only rarely now can an individualís blood pressure not be well controlled without medication side effects.

Secondary hypertension is usually treated by correcting the underlying cause. Constricted arteries can be surgically repaired, hormonal imbalances can be adjusted, etc., and this usually eliminates the hypertension.

The FAAís position on pilots who require treatment for primary hypertension is straightforward and reasonable. With very few exceptions, any of the modern antihypertensive medications or combination of medications is acceptable. Once the pilot can present documentation demonstrating that his/her blood pressure is under good control without medication side effects, and associated diseases and complications have been ruled out, the pilot can resume flying on his/her current medical certificate. In most cases, from the day a pilot begins treatment to the day of a return to flying will be about 2 weeks. For further information on the administrative details, pilots should consult with their AME or call ALPAís Aeromedical Office.

Bottom line: Hypertension is a serious medical problem that has the potential to adversely affect your quality of life in a major way, terminate your career, and shorten your life. Nonetheless, the problem can be easily dealt with from both clinical and aeromedical perspectives. Failure to deal with it early constitutes trading a small problem now for a giant problem later. Definitely not the smart way to go.

Dr. Robert J. Stepp, M.P.H., is an associate aeromedical advisor with ALPAís Aeromedical Office, which is located in Aurora, Colo.