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.

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.

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.

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.

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.

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.

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.