heart and artery disease
Coronary artery disease (CAD) is the leading cause of death and disability
in the United States. Nearly 14 million Americans have had angina or a
heart attack. Over 450,000 will die from this condition each year.
Cardiovascular disease is the leading cause of death in the United States
contributing to over 40% of all deaths. Each year, over one million
Americans will develop angina or have a heart attack for the first time
and over one third of these will die from it this year. A quarter of a
million people will die within one hour of their first symptom. The
American Heart Association (AHA) estimates the annual costs to Americans
for heart disease exceeds $250 billion. It is the leading cause of death
in men after age 40 and women after age 50. Men have double the death rate
from CAD as women do.
Despite these sobering statistics, the death rate from heart disease in
the US has dropped dramatically over the last 10 years. The death rate
from heart attacks has dropped 28.7% during this time according to the
AHA. This drop is attributable to increased awareness and understanding of
the disease, aggressive intervention to control risk factors and a shift
in public and medical thinking toward prevention.
Airmen and Controller Statistics
The Air Line Pilots Association Aeromedical Office 's experience is that
23% of the over 9000 pilots contacting the office each year do so for
cardiovascular disease and 35% of all cases of disability. In 1997, the
FAA granted nearly 6,500 Special Issuance Authorizations/SIA (waivers) for
pilots with coronary artery disease. Of these, most were for coronary
artery disease or heart attacks (myocardial infarctions) treated with
bypass grafting, angioplasty and/or intracoronary artery stents. With
respect to class of medical certificate, 509 were for First Class, 512
were for Second Class and 5,555 were for Third Class. Pilots with heart
valve replacements, rhythm disturbances, pacemakers and heart failure also
were granted SIAs. Only 0.1% of medical applications to the FAA receive a
The bottom line from this information is that cardiac disease is very
common. Pilots and controllers should seek early treatment to avoid
medical complications and disability. The FAA will routinely waiver
adequately treated heart disease, so there should be no reluctance to seek
treatment for fear of permanent grounding. Pilots and controllers who
optimize their health also optimize their chances for FAA medical
Risk Factors For Heart Disease
There are several well-defined risk factors for coronary artery disease.
The risk factors are divided into modifiable and non-modifiable groups.
The decreased rates of heart disease over the last 3 decades are
attributable to addressing the modifiable risk factors.
The non-modifiable risk factors include male gender, family history of
premature heart disease and increasing age. Post-menopausal women not on
hormone replacement therapy are also at increased risk, but this is
Men have twice the risk of heart disease than women. This difference
narrows with increasing age. People with a family history of heart disease
(heart attacks, angina) in a male relative before age 55 and in a female
relative before age 60 are at higher risk for CAD. Finally, the risk of
CAD increases with each decade of life.
Modifiable Risk Factors
The major modifiable risk factors for heart disease are smoking, diabetes,
high blood pressure, physical inactivity, obesity and abnormal blood
cholesterol levels. A full discussion of each of these topics if available
in other articles in the VFS Information Resource Centre.
To briefly summarize the major modifiable risk factors, male smokers
increase the risk of CAD by 60-70% over non-smokers. Sudden death due to
heart disease is two to four times more likely in smokers. Women who smoke
and take birth control pills have up ten times greater increased risk of
dying from heart disease and stroke than non-smokers. After 15 years of
not smoking, former smokers' risk of CAD returns to non-smoking levels.
See the VFS article on Smoking Cessation and Tobacco Abuse for an
Diabetics have a greatly increased risk of heart disease. Over 80% of
diabetics have some form of heart disease. The risk seems to be related to
the degree of blood sugar control. The better the control, the lower the
risk of heart disease is. Insulin requiring diabetics have an even higher
incidence of heart disease. See the VFS article on Diabetes for an
Like diabetes, people with high blood pressure increase their risk of
heart disease directly with poorer control of their condition. Studies
show that the higher the blood pressure (both systolic and diastolic), the
higher the risk of heart disease. See the VFS article on Blood Pressure
and Hypertension for an extensive discussion.
Cholesterol has several components or subtypes. Total cholesterol levels
above 200 mg% and LDL cholesterol levels above 130 mg% are at increased
risk for heart disease. Lowering these values through diet, exercise, or
medication will reduce the risk of heart disease and death. About 51% of
Americans have cholesterol levels above 200 mg%. HDL cholesterol below 35
mg% also raise the rate of cardiovascular disease. See the VFS article on
Cholesterol Reduction for an extensive discussion.
Overweight (weight more than 20% of ideal body weight or body mass index
of 25.0-29.9) and obesity (an elevated body mass index greater than 30) is
a common condition. In American adults aged 20-74, approximately 60% of
males are overweight and 45-65% of females are overweight varying by
ethnic background. Obesity not-only contributes to CAD, but also plays a
major role in diabetes, hypertension, back pain, arthritis and stroke. Publicity for the high protein, low carbohydrate diets (Atkins) in
November 2002 at the American Heart Association Annual scientific Meeting
generated much confusion about a proper diet. For information on the AHA's
current position, see the AHA Statement on High-Protein, Low-Carbohydrate
Diet Study Presented at Scientific Sessions.
Lack of regular exercise increases the risk of death due to heart disease
by 1.5-2.4 times according to the AHA. Two thirds of Americans do not
participate in enough regular physical activity to help prevent heart
disease. Individuals should exercise at least 30 minutes per day, four
days per week. This will help control weight, reduce blood pressure,
improve cholesterol levels and enhance control of diabetes.
Minor Risk Factors
The minor risk factors for CAD also contribute to higher rates, but do not
have as significant an impact. Many are interrelated with major risk
factors and each other. High dietary fibre intake, avoidance of depression
and stress, and adequate nutritional intake (particularly of folate and
niacin) have also been associated with reduced rates of CAD. See the VFS
Nutrition in Heart Disease Prevention article as well as the article on
Vitamins and Minerals for an extensive discussion on dietary and nutrient
factors in heart disease prevention. A June 2002 article in The Lancet, a
renowned British medical journal, published original research on the
positive effects of a diet rich in fruit and vegetables on reducing heart
C Reactive Protein (CRP) is another laboratory study possibly useful in
predicting the risk of coronary artery disease. This protein is elevated
in a number of conditions that cause inflammation in the body. The
inflammatory response is a possible provocateur for atherosclerosis,
although the value of testing for this protein is not certain. A recent
paper in the New England Journal of Medicine showed the value of
determining CRP in women. For more information see the American Heart
Association article on C Reactive Protein and associated links.
Current recommendations by several organizations include the daily use of
low dose aspirin to reduce inflammation and clotting that may lead to
heart disease and myocardial infarction. For additional information, see
American Family Physician articles for the article "U.S. Preventive
Services Task Force: Recommendations and Rationale Aspirin for the Primary
Prevention of Cardiovascular Events" and an accompanying editorial "An
Aspirin a Day Keeps the MI Away (For Some)".
Types of Heart Disease
Disease of the heart may involve the coronary arteries, the electrical
conduction system, the heart valves or the heart muscle. The most common
type of heart disease is coronary artery disease (CAD), which is discussed
in this article. CAD involves the narrowing of the four major vessels
supplying blood to the heart. This narrowing is similar to the clogging of
a pipe. The process of narrowing is termed atherosclerosis or "hardening
of the arteries." It occurs in all parts of the body, but when it occurs
in the heart, the term coronary artery disease is used.
The narrowing process starts with deposits of cholesterol on the inner
walls of the blood vessels to form soft "plaques." These plaques are
similar to the greasy soft buildup in a kitchen pipe. Gradually, more
plaque is deposited and the diameter of the coronary arteries narrow. This
narrowing is termed "stenosis". Less blood flow is able to reach the heart
muscle, just as a drain slows as it clogs. Some research indicates that
aggressive lowering of cholesterol complemented with exercise may reverse
this clogging plaque.
Later, the plaque damages the lining of the blood vessel, called the
intima, triggering a reaction that converts some of the soft cholesterol
plaques into hardened "calcified" narrowings. This calcification generally
is not reversible without some type of surgery. Despite all the blood in
the body running through the heart, only that blood that is pumped out of
the heart and back through the coronary arteries to the heart muscle
actually supplies oxygen to the heart.
Symptoms of CAD
As long as the oxygen and blood supply demands to the heart muscle are not
too great, a person with CAD has no symptoms. When greater demands of
exercise or progressive narrowing of the coronary arteries limits blood
flow to the heart muscle, symptoms of CAD begin to occur. These symptoms
include a tightening or pressure in the chest (angina), pain in the neck,
jaw or arm with exercise, shortness of breath or a sense of anxiety. These
symptoms deserve immediate attention. The New England Journal of Medicine
published an interesting article in June 2002 on the mechanisms of angina
and how the symptoms are produced.
Unfortunately, approximately one third of people with CAD may have a
disturbance in the rhythm of the heart or sudden cardiac death as the
first symptom. Angina, which represents reversible interruption of
adequate blood flow to the heart, may progress to a heart attack, also
known as a myocardial infarction. A heart attack usually causes permanent
damage to the heart muscle, leaving a scar in a portion of the heart
rather than contracting muscle.
Evaluation of CAD
The evaluation of CAD is usually a stepwise process of less invasive, less
expensive testing moving toward more definitive testing which cost more
and may involve more risk.
History Physical and Labs
The most basic evaluation involved the physician discussing the "history"
and performing a physical exam and laboratory studies. The history
includes a personal account of any symptoms, any relatives with early
heart disease, lifestyle, habits and risk factor analysis. The physical
examination evaluates blood pressure and heart/lung sounds, but is a
relatively weak tool to detect CAD. Laboratory studies check cholesterol
levels, blood sugar (diabetes), and electrolyte levels (high blood
pressure and kidney failure).
Electrocardiogram (ECG / EKG)
The next stage of evaluation is a resting electrocardiogram (ECG or EKG).
The ECG is a snapshot look at the rhythm and character of the electrical
activity of the heart. Each individual has a relatively unique pattern on
the ECG which does not change significantly during a lifetime unless there
is some damage to the heart. The FAA First Class medical certification
requires a baseline ECG on the initial First Class physical after age 35
and annually after age 40. This is to look for changes and evidence of
damage. See the VFS Medical Information section feature on "ECG Variants"
for a more complete discussion. A person with rather advanced CAD may have
a completely normal ECG. The weakness of the ECG is that it only can give
indications of the past and present, but cannot predict the future.
Exercise stress testing is a provocative test in a controlled monitored
setting designed to detect CAD before severe symptoms exist. By forcing
the heart to work near its maximum capacity, the physician can look for
changes on the ECG characteristic of "reversible ischemia." These changes
indicate the heart gets enough blood flow and oxygen at rest, but not
enough with stress. This is similar to comparing the power output of a
piston engine at sea level versus at a high density altitude.
A person being tested has ECGs taken at rest and with hyperventilation as
baseline readings, and then starts to walk on the treadmill. The ECG is
monitored continuously and recorded every one to three minutes. The Bruce
Protocol is the standard testing method. A Bruce stress test increases the
speed and incline of the treadmill until any one of several endpoints is
reached. These endpoints include complete fatigue, reaching a target heart
rate (usually 85-100% of predicted maximum for age), cardiac rhythm
problems or symptoms of angina.
The baseline, maximum exercise and recovery ECGs are compared, looking to
diagnose or exclude CAD. Occasionally, the baseline ECG has abnormalities
that make interpretation of a stress test difficult or impossible. For the
individual who cannot walk on a treadmill, the heart rate can be increased
with the administration of several intravenous drugs, adenosine,
dipyridamole or dobutamine.
A more sophisticated type of stress testing involves taking an
echocardiogram of the heart at rest and with exercise, in addition to
recording the ECG tracings. The echocardiogram involves using a ultrasound
transducer on the chest to take a two dimensional and Doppler image of the
heart walls. The echocardiogram can assess the pumping efficiency of the
heart. In people with CAD, the echocardiogram may show poor contraction of
the heart muscle with high stress. This occurs because the heart does not
get enough blood through the coronary arteries to function properly,
similar to a failed fuel boost pump.
Radionuclide Stress Testing
None of the above procedures can quantify the amount of blood from the
coronary arteries reaching the heart. Myocardial perfusion imaging or
radionuclide stress testing gives an estimate and picture of blood flow to
regions of the heart muscle at rest and with stress. In addition to a
stress ECG, people undergoing this testing receive an injection of a brief
acting radioisotope. The radioisotope flows through the blood and collects
in the heart muscle where a specialized scanning camera evaluates the
quantity of blood reaching each part of the heart. The camera rotates
around a patient to create images representing "slices" of heart muscle
viewed from several angles. The scanning technique is called Single Photon
Emission Computed Tomography (SPECT).
The blood flow at rest is compared with the blood reaching the heart
muscle (myocardium) during stress. Four possible outcomes are reported. If
the rest and stress images are uniform, indicating the myocardium has
adequate blood flow, with stress and rest, the results are reported as no
evidence of fixed or reversible ischemia. This is a normal study or "no
evidence of fixed or reversible ischemia".
The second possible outcome is a "fixed perfusion defect." This indicates
that a portion of the myocardium is not getting blood flow with stress or
at rest. A previous heart attack (myocardial infarction) is the usual
cause. A fixed perfusion defect is not necessarily disqualifying for
flying after an appropriate observation period and treatment of underlying
The third possible outcome is a "reversible perfusion defect." This
reversible defect is caused by a portion of heart muscle that receives
marginal blood flow. The myocardium receives enough blood at rest, but
when stressed with exercise, inadequate amounts of blood reach a portion
of the heart. The scanning camera demonstrates reversible perfusion
defects as a doughnut hole appearance in the heart image with stress that
fills in at rest. Reversible perfusion defects are generally disqualifying
for medical certification because a portion of the heart muscle is in
jeopardy for further damage or electrical irregularities in the heartbeat.
Reversible perfusion defects indicate ongoing and possibly progressive
heart disease that should be treated if significant.
The fourth possible outcome is an equivocal test, frequently caused by
"possible diaphragmatic attenuation." The position of the heart in the
chest, particularly in heavier people, may be partially shielded from the
scanning camera by the diaphragm. The diaphragm is the slightly curved
muscle that separates the heart and lungs in the chest from the organs in
the abdomen. This "diaphragmatic attenuation" may look similar to fixed or
reversible perfusion defects, particularly in the bottom (inferior)
portion of the heart. This result may be acceptable for medical
certification or may require further evaluation.
Types of Radionuclide Testing
Three types of radionuclide testing are common. All use radioisotopes that
have a short half-life and are quickly eliminated from the body after
injection into the blood stream. The isotopes collect in the heart muscle
(myocardium) and are quantified by a scanning camera that detects
radioactive signals. The camera generates a picture of the thick
myocardium of the left ventricle. Black and white pictures similar to
x-rays are called scintigrams. Heart muscle with adequate blood flow
appears black. Areas of poor blood flow are lighter, similar to a hole in
a doughnut and are termed "perfusion defects." Colour photographs can also
be computer generated where colours represent amount of blood flow. See an
article in American Family Physician on "Radionuclide Imaging in the
Evaluation of Heart Disease" for a complete explanation.
The most common types of radionuclide testing involve the use of
thallium-201, technetium-99 sestamibi (Cardiolyte testing) or both (dual
isotope scanning). Thallium testing requires injection of the isotope at
maximum exercise with immediate scanning followed scanning several hours
later to get the rest images. Cardiolyte testing uses an injection and
scanning at rest followed by exercise and repeat injection and scanning.
The dual isotope scan combines both techniques. Many cardiologists prefer
to do Cardiolyte testing because it is faster, more flexible in technique
and the isotope is easier to handle. The FAA cardiology consultants prefer
Thallium or dual isotope scans, feeling that these studies have a lower
false negative rate than Cardiolyte studies. However, If initial
diagnostic studies were done with Cardiolyte, the consistency in study
techniques makes follow-up Cardiolyte imaging acceptable.
PET Scanning of the Heart / Ultrafast CT (Cardioscan) / EBCT
New technologies attempting to define areas of stenosis and decreased
blood flow include the Position Emission Tomography (PET) and Ultrafast CT
scans. Both of these techniques are relatively new non-invasive ways of
detecting CAD. Neither has been studied enough to state that it is
superior to the commonly used radionuclide scans. The FAA updated its
policy on positive finding on Ultrafast CT scans of the heart. Previously,
the results were of no significance to the FAA, regardless of the results.
The policy as of October 2001 considers the presence of any calcification
in the coronary arteries as potentially disqualifying for certification.
If calcifications are noted, pilots and controllers must obtain nuclear
stress testing to further define the risk of heart disease. The FAA does
not accept the results of PET/CT scans as substitutes for required testing
following treatment for cardiac disease.
PET scans are very similar to thallium studies, but use a different
tracers to image the heart. Currently, rubidium-82 is the only FDA
approved tracer. The advantages of this technique are speed, improved
sensitivity and non-invasive nature. The disadvantages are the cost and
the relatively minimal experience with the technique in co-relating PET
findings with angiograms. The American Heart Association recently stated
the PET scan does not yield superior diagnostic accuracy compared to SPECT
Ultrafast CT scans, now called electron beam computed tomography (EBCT),
can detect calcium deposits of atherosclerosis in coronary arteries. The
test can be done on almost anyone in 10-15 minutes. People with high
degrees of calcium in the artery have increased risk for heart disease.
The weaknesses of the test include the lack of correlation between the
location of the calcium and the degree of narrowing of the coronary
arteries. Some degree of stenosis comes from soft plaque that has not
formed calcium. Therefore, an individual may have significantly more
narrowing than indicated by the EBCT. The EBCT does not give any
information about actual blood flow to the myocardium.
Although heavily advertised in some areas, no heart organization has
recommended the ultrafast CT for routine screening. A positive test result
(those showing ANY calcium in the coronary arteries, even if low-risk)
should be evaluated using other techniques. A positive EBCT/UFCT currently
is disqualifying for FAA certification, pending evidence from exercise
stress testing that here is no evidence of ischemia. For this reason,
Virtual Flight Surgeons recommend pilots carefully consider the effects of
this testing on both health and FAA certification prior to undergoing
testing by this technique. The evaluation does generate a reporting
obligation on the next FAA physical exam, even if no disease was found.
See articles in the New England Journal of Medicine (May 1999) and
Circulation (May 1999) on the subject. The Health Technology Advisory
Committee also has a report on Detection of Coronary Artery Disease (CAD)
with Electron Beam Computed Tomography (EBCT), October 1997 and patient
information guidance Electron Beam Computed Tomography for Coronary Artery
Disease, March 1997 (Questions & Answers). A study reported in American
Family Physician indicates that knowledge of EBT scores does not
positively effect cardiac risk factor modification in middle aged adults.
Another analysis in published in American Family Physician, Coronary
Artery Calcium Score Predicts Risk of CHD, indicates that a high calcium
score in high-risk persons predicts risk of cardiac events. However, there
was no analysis of whether it changed management or outcomes.
Coronary Artery Angiography
The most definitive test of blood flow through the arteries that supply
blood to the myocardium is coronary artery angiography or arteriography.
The procedure involves using a catheter (thin hollow tube) inserted into
the blood vessels of the groin or arm. The catheter is routed back to the
heart by visualizing the catheter under a fluoroscope (real-time x-ray).
The tip of the catheter is inserted into the opening (ostium) of each of
the coronary arteries and a dye visible by the fluoroscope is injected.
The dye fills each artery. Areas of narrowing (stenosis) of the coronary
artery do not fill with dye. The degree of narrowing is expressed as a
percent of the full diameter of the coronary artery. Several views
(projections) of each narrowing are viewed to construct a three
dimensional picture of the stenosis from two dimensional views. The images
are recorded on 35 mm film or on a CD-ROM. Defects noted on radionuclide
imaging are compared to areas of stenosis on angiography. Areas of
significant (>50%) stenosis are often accompanied by reversible
radionuclide perfusion defects "downstream" from the stenosis.
Significant Coronary Artery Disease Defined
Unlike many other medical conditions which are either present or not
present, CAD exists to varying degrees in almost all adults. Whether one
degree or another of CAD is significant depends on the perspective of the
evaluator. Medical significant CAD might be defined as that causing
symptoms such as angina, decreased exercise tolerance or shortness of
breath. This degree of symptoms usually correlates with stenosis of
greater than 90%. Others may consider any stenosis of 75% or greater
significant with a positive radionuclide scan. The FAA uses a conservative
figure of approximation 50% stenosis with a positive radionuclide scan in
an area of the heart corresponding to the stenosis. The FAA uses this
conservative position of aeromedical significance because of the margin of
safety required for aviation and because airmen are medically certified
for 6 months to three years. The dilemma facing pilots with aeromedically
significant lesions (50-75%) that their treating physicians do not
consider medically significant is how to do what is medically appropriate
and retain medical certification. FAA certification may depend on the
presence or absence of reversible ischemic defects on radionuclide imaging
in the area of myocardium supplied by the stenotic vessel.
Treatment of Coronary Artery
Disease - Coronary Artery Bypass Grafting (CABG)
The original surgical treatment for CAD and stenosis is CABG. In this
technique, an incision in the chest and rib cage exposes the heart and
coronary arteries. Arteries from the chest can be repositioned to attach
to a narrowed coronary artery "downstream" from the stenosis. Similarly,
veins from the leg are used to "bypass" the stenosis by attaching them to
the major artery from the heart (aorta) to the blocked coronary artery.
Blood flow is re-established beyond the blockage.
Some blocked vessels are too small to bypass, although CABG can often be
done in areas where angioplasty cannot. Newer "keyhole", or minimally
invasive, procedures allow CABG without splitting the rib case. The CABG
is completed through a small incision between the ribs. The American Heart
Association and American College of Cardiology published Practice
Guidelines for Coronary Bypass Surgery in 1999.
Approximately 10-15% of by-pass grafts will restenose (close off) over
time. The FAA requires a six month observation period following CABG
before applying for reinstatement of a medical certificate to minimize
pilots with early restenosis returning to flying with significant and
persistent heart disease. Arteries used for by-pass grafts tend to have
better outcomes and lower early restenosis rates than do veins.
Treatment of Coronary Artery Disease - Percutaneous Transluminal
Coronary Angioplasty (PTCA)
A newer technique to open narrowed coronary arteries is termed the
percutaneous transluminal coronary angioplasty or balloon angioplasty. The
PTCA is done using a catheter similar to the angiography catheter, only
equipped with a narrow balloon near the end of the catheter. The tip of
the catheter is passed through the narrowed area until the deflated
balloon portion is inside the stenosis. The balloon is inflated to several
atmospheres of pressure, pushing the cholesterol-narrowed walls of the
coronary artery open. Frequently, the stenosis is reduced to less than 10%
of the vessel diameter.
The advantages of the procedure are the speed and avoiding major surgery
requiring opening the chest. Most people return home the same day as the
PTCA. The disadvantages of PTCA include the inability to "balloon" total
obstructions or stenosis located at the far end of a coronary artery. The
possibility of treating or rupturing a coronary artery with the balloon
requires emergency CABG team back-up. Though the experience with PTCA is
not as long as with CABG, some concerns exist that a PTCA will not last as
long as a CABG.
Treatment of Coronary Artery Disease - Stent Placement
A refinement of the PTCA designed to decrease the likelihood of restenosis
after PTCA includes placing a stent inside the coronary artery after
balloon angioplasty. Stents are similar to the wire springs/coils inside a
ball-point pen. They overlie the balloon portion of the PTCA catheter and
expand when the balloon is inflated. After deflation, the stent remains
expanded in the previously narrowed vessel providing a structure similar
to fuselage tubing. The stents are about 1/2-1 cm in length and several
millimeters in diameter. Once in place, they cannot be removed. See the
American Heart Journal article on stent implantation during heart attacks.
Some individuals have restenoses of stents several weeks to months after
placement. A developing technology uses stents coated with radioisotopes
to decrease tissue growth around the stent. These seem to have improved
rates of remaining patent than do standard stents. See an article in the
April 18, 2002 issue of the New England Journal of Medicine for more
A new technology stent that secretes an anti-inflammatory type substance
to lower the risk of early restenosis was approved by the FDA in April
2003. According to preliminary research published in the New England
Journal of Medicine, the restenosis rate for these stents has been lowered
to 4% compared to a rate of 27% in non-treated stents. The newer stents
are very expensive, but given the lower rate of requirements for repeat
procedures for restenosis, may be just as economical if widely used in a
Treatment of Coronary Artery Disease - Arthrectomy
Atherectomy involves using a catheter in the coronary artery with a high
speed burr at the tip to bore through a narrowing of the vessel. A common
lay person term is "rotoblator" or "roto-rooter." Different types of
arthrectomy include directional, rotational and extraction. Laser
arthrectomy is an alternative to the mechanical types described above.
Following arthrectomy, angioplasty can be performed on the same vessel.
The procedure is not very common.
Treatment of Coronary Artery Disease - Thrombolytic Therapy
In some cases, heart attacks (myocardial infarctions) are caused by a
blood clot obstructing and already narrowed coronary artery. This clot is
called a thrombus. If detected and treated within a few hours of onset,
the damage from a heart attack can be minimized if the thrombus is
dissolved. The procedure to dissolve the clot involves the use of coronary
artery catheterization and the infusion of "clot busting" (thrombolytic)
blood thinners into the artery. The presence of a clot as a possible cause
of a heart attack is the reason many physicians recommend anyone with
chest pain resembling angina take an aspirin as soon as possible and seek
care. Aspirin can inhibit the formation of clots and may also reduce the
damage from a heart attack. Thrombolysis is not a treatment for heart
disease without acute infarction and must be performed within hours of the
onset of symptoms to be beneficial. Please see the Health Technology
Advisory Committee report on Thrombolytic Therapy for Acute Myocardial
Infarction, May 1994 (Executive Summary).
Non-Invasive Treatment of CAD
Some people wish to avoid any surgery to treat CAD. None of these
techniques work as quickly the more invasive procedures. Moreover, there
is minimal scientific evidence documenting actual reversal of CAD. Early
research supports the role of aggressive lowering of the LDL cholesterol
and homocysteine levels with medications, vitamins and nutritional
supplements to possibly reverse CAD. The 71st Annual Scientific meeting of
the American Heart Association published a study that the lowering of LDL
cholesterol to levels below 100 mg/dL resulted in a lower than expected
number of heart procedures compared to those who had angioplasty. For the
pilot, the long duration of non-interventional therapy before any change
in the extent of CAD is seen usually makes a return to the cockpit after
disqualification a lengthy process, if successful.
An accepted method of treating CAD in those who find the risk of surgery
unacceptable is medical management. With this therapy, medications are
used to minimize symptoms of CAD and maximize heart function.
Nitroglycerin and other medications are used. Some research indicates
aggressive lowering of cholesterol levels with medication, diet and
exercise may possibly reduce the degree of CAD stenosis, although
minimally. Although the FAA allows pilots to take most heart medications
if there is no evidence of ischemia, the use of nitroglycerin usually
indicates a tangible risk of ischemia and is disqualifying.
One treatment that is sometimes attempted is chelation therapy. This
"treatment" uses repeated doses of a chemical designed to bind metals in
the blood stream. This binding is supposed to reverse atherosclerosis. The
Mayo Clinic, American College of Cardiology, National Institutes of Health
and FDA conclude this technique is not effective. Many physicians consider
chelation quackery when used for CAD. The January 23/30, 2002 issue of the
Journal of the American Medical Association included an article showing no
objective benefit from chelation therapy in terms of exercise capacity and
quality of life measurements.
FAA Testing for CAD
The diagnosis of coronary artery disease requiring treatment, manifesting
by a heart attack or evidence of ischemia (symptoms or diagnostic testing)
is disqualifying for all classes of FAA medical certification. A positive
stress test requires further testing with more definitive testing before
returning to fly or control. This testing includes radionuclide stress
testing or stress echocardiography. If these results show evidence of
reversible ischemia, a pilot or controller is disqualified pending the
results of coronary angiography. In general, lesions with stenoses of 50%
or greater are disqualifying for flying/controlling until reversed.
For pilots, a heart attack or intervention procedure for treatment of CAD
triggers a minimum of a 6 month observation period before repeat
evaluation for FAA recertification through the Special Issuance
Authorization (SIA) procedures of FAR Part 67.401. For First Class and
unrestricted Second Class SIA, the follow-up testing must include
radionuclide stress testing (preferably Thallium or dual isotope) and
repeat coronary artery angiography. No indication of reversible ischemia
on radionuclide testing and all lesions less than 50% stenoses are
required for favourable SIA consideration. Generally, follow up studies
are required every 12 months with stress testing and every 24 months with
radionuclide stress testing. Some cases may require follow-up reports
every six months.
Restricted Second Class and Third Class certification does not require
repeat angiography. If a case is uncomplicated, a Maximal Exercise Stress
Test may be sufficient follow up. If there is a question of cardiac muscle
damage, a radionuclide stress test may be necessary (VFS physicians can
help you with this decision). Stress echocardiography is an acceptable
substitute for radionuclide stress testing for Third Class SIA only.
For controllers with coronary artery disease and intervention, the FAA
requires only a three month wait before maximal exercise stress test
follow up to petition for Special Consideration to return to controlling
duty. For contract controllers that operate under a 2nd class airman
certificate, the FAA will still consider returning to controlling after
only 3 months.
The requirements for the basic FAA heart evaluation for all cardiac
conditions including hypertension, arrhythmias, coronary artery disease
and heart surgery are delineated in FAA Form 8500-19, Specifications for
FAA Testing for CAD - FAA Forms
and Protocols for Cardiovascular Conditions
The results of all diagnostic testing and treatment records must be
forwarded to the FAA Aeromedical Certification Division for SIA
consideration. The biggest delays in certification result from pilots not
submitting complete records, include complete ECG tracings and scintigrams/photographs/VHS
cassettes from stress testing and 35 mm films from angiography. The
results of a recent cardiovascular evaluation must also be included in the
These summaries and other test results may be mailed to the FAA at :
Federal Aviation Administration
Aeromedical Certification Division
CAMI Bldg./ AAM-300
P.O. Box 26080
Oklahoma City, OK 73126-9922
However, airmen and controllers should be aware that often well-meaning
specialists may not necessarily be cognizant of all the aeromedically
significant aspects of a case. Incomplete, erroneous, or unclear
information can result in significant delays or potential denials.
What heart conditions are not waverable by the FAA?
Very rarely, a pilot will be diagnosed with a condition that is not
wavered by the FAA. One condition is a heart transplant, or as stated in
Part 67 of the FARs, "cardiac replacement." In the past, a few pilots were
wavered for this condition, but complications led to a more conservative
A diagnosis of IHSS (Idiopathic Hypertrophic Subaortic Stenosis) is also
currently disqualifying for all classes of medical certificate, although
some cases meeting very specific criteria may be considered for 3rd class
certification. See an article on IHSS from the Federal Air Surgeon's
Spring 1999 Medical Bulletin. Another article from the New England Journal
of Medicine January 23, 2003, addresses clinical outcomes in this
The Aeromedical Certification Division has stated that related syndromes
might be considered for Special Issuance if there is no evidence of
cardiomyopathy. Each case is evaluated individually and subject to
periodic review. One case of IHSS was granted a Special Issuance in early
2002 following an appeal to the NTSB. Whether further cases will be
certified without legal appeal remains to be seen.
Some pilots with cardiac pacemakers may get wavered to fly. Until
recently, those who are characterized as "pacemaker dependent" for a heart
rhythm were not wavered. The FAA does have a written protocol for pilots
with pacemakers to petition for certification. See an article on pacemaker
failure in a pilot with congenital heart conditions from the Federal Air
Surgeon's Winter 1998 Medical Bulletin. Note that the pilot was initially
waivered despite a variety of heart conditions. Also see the Aeromedical
Certification Update on pacemaker policy and Consideration of Pacemakers
Case Study, by Susan Ferguson, MD in the Fall 2001 Bulletin. The VFS
article on Arrhythmias - Abnormal Heart Beats has extensive information on
conditions that may lead to pacemakers.
Currently, the FAA does not waiver any pilots with Automatic Internal
Cardiac Defibrillators (AICDs). This policy is being reviewed, but no
change in the policy is anticipated. Individuals diagnosed with
Arrhythmogenic Right Ventricular Dysplasia (ARVD) frequently will have an
AICD placed prior to having any significant cardiac event. Some
individuals who have been successfully resuscitated from Sudden Cardiac
Death (Ventricular Fibrillation with loss of consciousness) will also have