At the Heart of It All
ALPA’s medical team brings an update on FAA’s policies on pilots with cardiac problems
Air Line Pilot, March/April 2002, p. 32
By Dr. Quay Snyder and Dr. Tom Yasuhara, ALPA Associate Aeromedical Advisors
Medical issues affecting the cardiovascular (heart and circulation) system represent approximately 25 percent of all pilot inquiries to the ALPA Aeromedical Office each year. Cardiovascular disease also is the largest cause of death and disability in the U.S. population. The physicians of the ALPA Aeromedical Office encourage all pilots to take active steps to decrease their risk of heart disease. We strongly encourage pilots who suspect or discover that they have heart disease or one of its underlying risk factors to discuss the need for further evaluation and treatment with their physicians.
Pilots should not hesitate to follow through with medically appropriate evaluations and treatment because of concerns about a possible adverse effect on their aeromedical certification. Optimum health should be a pilot’s first priority in dealing with treatable medical conditions. Fortunately, the FAA’s Aeromedical Certification Division, in Oklahoma City, Okla., grants airman medical certificates or Special Issuance Authorizations that allow pilots to maintain a medical certificate even after they have been diagnosed and treated for a wide variety of heart conditions.
The FAA policies for certification of cardiac conditions are updated periodically, with the Fall 2001 edition of the Federal Air Surgeon’s Medical Bulletin containing the most recent updates. We intend to describe these new policy revisions and briefly review the existing FAA policy regarding other cardiovascular conditions.
Hypertension, or high blood pressure, is the most common cardiovascular disease. The maximum blood pressure permitted for issuance of an FAA airman medical certificate without further evaluation is 155/95, which is by no means a healthy level.
Pilots whose hypertension is controlled with diet and exercise do not need to undergo any special evaluation or certification process.
Pilots whose hypertension is adequately controlled with FAA-approved oral medication may be cleared by their FAA-designated aviation medical examiner (AME) or the FAA Aeromedical Certification Division after a relatively brief evaluation by their treating physician. This evaluation includes documentation of cardiac risk factors, a brief physical examination to document the absence of complications from hypertension, a resting ECG, and laboratory studies—measuring the total cholesterol, HDL (good) cholesterol, triglycerides, and fasting blood sugar.
Electrolytes, including potassium, must also be measured if the pilot is using diuretics.
If a pilot’s attending physician deems a stress test to be appropriate, the FAA does require the physician to submit those results to the FAA Aeromedical Certification Division for review.
Once a pilot has started using medication, a brief observation period of approximately 1–2 weeks is required to document that the medication is successful in controlling the high blood pressure and that the pilot is tolerating the medication without significant side effects. Pilots may take the above documentation from their treating physician to their AME for clearance to resume flying while using the blood pressure medications.
Alternatively, the ALPA Aeromedical Office, which has much experience with helping pilots seek a prompt clearance to resume flying while taking blood pressure medication, can help with preparing and submitting the applicable records to the FAA Aeromedical Certification Division.
Coronary artery disease
Coronary artery disease—narrowing of the blood vessels supplying oxygen to the heart muscle because of cholesterol and calcium buildup—may give an early warning sign of chest discomfort (angina), or even first manifest itself as a heart attack. Pilots with significant risk factors or symptoms possibly related to heart disease should be evaluated promptly.
After a pilot has a heart attack or surgery to reopen coronary arteries, the FAA requires a 6-month observation period before the pilot may petition for recertification under special issuance provisions of FAR Part 67. The FAA accepts all forms of coronary artery revascularization, including bypass grafting, angioplasty, stent placement, atherectomy, and other procedures.
The petition for special issuance requires a pilot to submit all records from the initial evaluation and treatment, interim progress notes, and the records of a maximal radionuclide stress test after the 6-month observation period. Also, for first- or unrestricted second-class certification, pilots are required to have a 6-month post-event heart catheterization (angiogram). This procedure is not required for third-class certification. If this documentation is favorable, the pilot will be granted a Special Issuance Authorization, with periodic follow-up testing specified.
The FAA recently liberalized its policy to allow follow-up after medical reinstatement to consist of cardiovascular exams with repeat plain-exercise stress testing every 12 months, alternating with radionuclide stress testing every 24 months. Previously, the follow-up stress test evaluations were required every 6 and 12 months, respectively. In a limited number of cases, because of increased concern about a pilot’s ongoing risk factors, FAA cardiology consultants may continue to require evaluations every 6 months.
|Pilots can be granted all classes of certification for a pacemaker that is functioning well, provided evidence exists that the pilot is not dependent on the pacemaker.|
Valve replacement or repair
The FAA will allow pilots to fly after replacement or repair of a single heart valve. Both mechanical valves or tissue valves are acceptable if replacement is required. Before a pilot who has had such surgery may petition the FAA for a Special Issuance Authorization, the agency will require a 6-month observation period and an evaluation that includes a clinical status report, cardiovascular evaluation with standard ECG, doppler echocardiography, and a Holter monitor.
The FAA, once it approves the Special Issuance Authorization, requires follow-up reports every 6 months that include a current status report with a cardiovascular evaluation, ECG, and echocardiogram for first- and second-class certification. Follow-up requirements for third-class medical certificate holders need be submitted only every 12 months.
Mechanical heart valves and anticoagulation
Pilots with mechanical heart valves are at risk for forming blood clots. The standard treatment includes anticoagulation (blood thinning), most commonly with Coumadin. Pilots taking Coumadin need to have at least monthly reports of their INR—an indicator of the blood’s ability to clot as compared to a normal individual—with at least 80 percent of those INRs falling between 2.5 and 3.5.
Multiple heart-valve replacements
The FAA does not certify pilots with multiple heart-valve replacements. An exception to this general rule is the Ross procedure, in which the patient’s pulmonic valve is transplanted to take the place of a defective aortic valve, and the pulmonic valve is, in turn, replaced with an artificial valve. The FAA has in the past granted Special Issuance Authorizations to pilots who have undergone the Ross procedure.
Atrial fibrillation is the uncoordinated beating of the upper chambers of the heart. A full description of this and other rhythm irregularities is available on the ALPA physicians’ "Virtual Flight Surgeons" website at www. aviationmedicine.com/rhythm.htm.
For pilots who have chronic atrial fibrillation, the usual recommended therapy includes Coumadin. Unlike heart valve replacements, the INR levels for pilots with atrial fibrillation need to be maintained between 2.0 and 3.0, with 80 percent of the values measured monthly falling within this range.
Pilots with chronic atrial fibrillation will first require a cardiovascular evaluation that includes a 24-hour Holter monitor, an exercise stress test, and an echocardiogram.
The FAA will disqualify any pilot whose heartbeat pauses for more than 2.5 seconds and will revoke the certificate of a pilot whose resting pulse rate is higher than 100 beats per minute or who has bursts of heart rate to more than 140 beats per minute when not exercising.
Medications to control the heart rate are allowed.
Anticoagulation therapy in arrhythmias
Pilots who have atrial fibrillation and certain high risk factors—including a history of stroke or transient ischemic attack, age greater than 75, a left ventricular ejection fraction of less than 40 percent, and coexisting mitral valve disease, coronary disease, or artificial heart-valve placement—are less likely to be certified to fly.
Coexisting factors considered to be of low risk, and therefore compatible with certification for atrial fibrillation, include diabetes, thyroid disease, and age less than 75. Anticoagulation with Coumadin is acceptable to reduce risks of blood clot formation in pilots with chronic atrial fibrillation. Use of aspirin is also authorized for low-risk, younger pilots.
Some pilots with heart arrhythmias will benefit from having a pacemaker implanted in their chests to control their heart rate. Pilots can be granted all classes of aeromedical certificate for a pacemaker that is functioning well, provided that the pilot shows no evidence of being dependent on the pacemaker.
Pilots whose heart rates drop to less than 40 beats per minute, or those with symptoms of lightheadedness or chest discomfort when the pacemaker is turned off, are considered dependent on the pacemaker.
The FAA will not approve such airmen for first- or second-class certificate, but they may hold a third-class Special Issuance Certificate.
A minimum 2-month observation period follows pacemaker placement; this is a liberalization of the FAA’s previous requirement for a 6-month observation period.
Initial waivers require a cardiovascular evaluation with stress testing, echocardiogram, and Holter monitoring. Additionally, regular pacemaker checks are required.
Depending on the type of pacemaker, the required checks must be made every 3 months in the first several years of placement, followed by checks every 2 months in the next several years, and thereafter, monthly checks are required.
As noted above, a pilot who has a pacemaker and who has also had a valve replaced or coronary artery disease that required treatment will still have to undergo the 6-month observation period for those conditions.
Automatic internal cardiac defibrillators (AICDs)
These devices are implanted in patients who are prone to life-threatening cardiac rhythm disturbances that require immediate electrical defibrillation to prevent sudden death. The FAA does not currently approve AICDs for any class of airman medical certificate, although this policy is under review.
Deep venous thrombosis
Pilots with blood clots in their legs may hold a Special Issuance Certificate after the symptoms have resolved and stable treatment with anticoagulation medications is documented. For pilots taking Coumadin, a minimum of three INRs in the therapeutic range (2.0–3.0) measured 1 month apart are required. Pilots using the new medication Lovenox may obtain a Special Issuance Authorization when the condition has stabilized.
Pilots who undergo a radiofrequency ablation to control heart arrhythmias must undergo a 6-month observation period after the ablation before applying for a Special Issuance Authorization. The initial certification petition must include reports of exercise stress testing, an echocardiogram, and a Holter monitor.
|Pilots are encouraged to get regular evaluations and appropriate treatment for any cardiac condition. This being said, pilots may want to discuss the implications of ultrafast CT scans and tilt-table testing with the ALPA Aeromedical Office before undergoing these procedures.|
Ultrafast CT scans of the heart (Cardioscan, Heart Scan, etc.) are widely touted and heavily advertised as a fast, non-invasive method for assessing risk of heart disease. The FAA has recently changed its previous policy of not considering the results of this testing in either a favorable or unfavorable light.
The new policy requires pilots with any calcium detected on the ultrafast CT scanning to obtain a maximal radionuclide stress test for continued first- or second-class certification. Plain-exercise stress testing is required for continued third-class certification.
Such scanning very commonly detects minimal calcium. From a clinical perspective, the presence of this calcium may not be considered medically significant. However, from an aeromedical perspective, the presence of any calcium does require the above-mentioned evaluation before the pilot returns to flight duties.
Neurocardiogenic syncope is a term used to describe a loss of consciousness with an unknown triggering event, presumably due to the nervous system sending signals to the heart that excessively slows its rate. In general, the pilot is grounded for a 4-year period after such an event, assuming no other underlying disease is found. Tilt-table testing is a commonly requested diagnostic procedure associated with evaluating loss of consciousness, but the medical community is still debating the significance of tilt-table test results.
The FAA’s current policy is that an abnormal tilt-table test, done for any reason, will result in a minimum 4-year grounding. For that reason, the ALPA Aeromedical Office discourages pilots from undergoing tilt-table testing unless a definite clinical indication requires that test.
Many causes of loss of consciousness can be defined with a careful evaluation of the history surrounding the events and eyewitness accounts of the episode.
The diagnosis of hypertrophic cardiomyopathy, also described as idiopathic hypertrophic subaortic stenosis (IHSS), or asymmetric septal hypertrophy (ASH), may result in increased risk for sudden death, particularly with exercise. The FAA has adopted a stringent policy disqualifying pilots with a diagnosis of hypertrophic cardiomyopathy for all classes of certification. Special Issuance Authorizations are not granted for this condition.
Cardiovascular conditions are the most common diagnoses that generate pilot inquiries to the ALPA Aeromedical Office. A broad variety of these conditions can be treated, with the expectation that the pilot will return to, or maintain, good health. FAA policy allows certification and Special Issuance Authorization for a broad variety of cardiovascular conditions and treatments.
Recent policy changes have liberalized the follow-up requirements for many of these conditions. Certification following diagnosis and treatment depends on submission of complete records, as well as periodic cardiovascular reevaluation. Only a relatively small number of cardiac conditions afflicting a minority of pilots are permanently disqualifying for medical certification.
Pilots are encouraged to get regular evaluations and appropriate treatment for any cardiac condition. This being said, pilots may want to discuss the implications of ultrafast CT scans and tilt-table testing with the ALPA Aeromedical Office before undergoing these tests.
The ALPA Aeromedical Office has encouraged pilots to take an active interest in maintaining their health, decreasing their risk factors for cardiac disease, and fully discussing any concerns with both their physician and the ALPA Aeromedical Office staff.
Several articles on cardiac conditions and the implications of these conditions for FAA aeromedical certification may be found on the Virtual Flight Surgeons website located under the Table of Contents at www.aviationmedicine.com/contents.htm.
The staff members of the ALPA Aeromedical Office, which is located in Aurora, Colo., are also available for telephone consultation at 303-341-4435, on weekdays between 8:30 a.m. and 4 p.m. Mountain Standard Time.
(Copyright 2002 Virtual Flight Surgeons, Inc. Reprinted with permission.)