Pilot Protection Services March Medical Mailbag

Topic of the Month: Heart Health
QUESTION: Given the change to Third Class Medicals am I correct that I cannot have the exam until May 1st and cannot take the online course until after the exam?  
ANSWER: As far as we know now, the Comprehensive Medical Exam Checklist (CMEC) forms and online education course will be available May 1st.  We are hopeful that everything will be in place prior to May 1st, but as of mid-February, there is no indication that pilots can have their physical exams and complete the course prior to the effective date of the BasicMed regulations.  Stay tuned to for updates as we get closer to May. 

QUESTION: I have been under directions to have a cardiac stress test yearly, and nuclear test every other year and have always passed with almost perfect results and experienced no cardiac difficulties since I underwent coronary artery bypass surgery 13 years ago. Am I to understand that after April no FAA physicals are required for third class ops?            
ANSWER: Coronary artery disease is the nation’s number one killer and is a topic we have covered extensively. For the benefit of other readers it is worth noting that this can be largely avoided by keeping weight under control, eating a healthy diet, exercising regularly, not smoking and having regular checkups, especially if there is a family history.
Once treated either by bypassing the blocked arteries or inserting stents, it has been a mainstay of FAA regulatory medicine (different to what your normal clinician would do) to have tests each year to “stress” the heart, see how it behaves and use this to diagnose any recurrent problems earlier.
New regulations called BasicMed take effect May 1st that will alter the way in which FAA maintains aeromedical safety in the national airspace.  The regulations will allow pilots flying recreationally in aircraft that fall within certain operational parameters to “self-assess” their medical fitness to fly without the need for a medical certificate.  The Third Class medical is not going away, and will still be required for certain operations or in aircraft that exceed the operational limits under BasicMed
If your most recent medical special issuance was reissued, and if you fly an aircraft that weighs less than 6000 lbs. maximum certificated gross take-off weight, with no more than six occupants, at less than 18,000 feet MSL, and less than 250 kts indicated airspeed, you would be eligible to do so without having to renew your annual special issuance authorization.  You can read the details of the new regulations here.  If you fly a “covered aircraft” under the new regulations, you may want to consider the benefits of BasicMed going forward!

QUESTION: I am wondering if I can fly if I am taking these pills-  Isosorbide and Brilinta.  I have no physical problems, like pain or dizziness?
ANSWER: Brilinta is a platelet inhibitor, meaning it reduces the “stickiness” of blood platelets that contributes to them adhering to one another and increasing the risk of a clot forming somewhere in your circulatory system that could lead to heart attack or stroke.  The FAA allows the use of this medication provided the medical condition being treated is determined to be acceptable for flying.  
Isosorbide, on the other hand, is not allowed by the FAA.  Isosorbide is one of a group of drugs that dilate or expand blood vessels to improve blood flow, and is often prescribed for patients who have chest pain associated symptomatic heart disease. You need to discuss the purpose for this drug with your doctor.

QUESTION: I want to ascertain if I will qualify for BasicMed due to a heart issue. My last 3rd class medical was issued March 25, 2014.  It has not been suspended, revoked, etc., just expired.  
Sometime after the 3rd class was issued, I was diagnosed with atrial fibrillation (A-Fib), high blood pressure, and low-level sleep apnea. The A-Fib and high blood pressure are very well controlled with Metoprolol and Flecainide, and the sleep apnea is no longer presenting itself, likely due to the successful treatment of the other conditions that caused it to appear.  I have had several Bruce protocol EKG’s that are negative for A-Fib, and a heart catheterization that showed no blockages whatsoever.
My question is, can I qualify under BasicMed or will I have to try and get a special issuance 3rd class?  Any advice would be greatly appreciated.
ANSWER: You will qualify under BasicMed as the conditions that you were treated for do not require a one-time special issuance from the FAA.  Once you have completed the medical exam checklist and been signed off by a state licensed physician, and have taken the online medical education course, you will be eligible to fly under BasicMed effective May 1st.  Atrial fibrillation, a topic we have covered in some detail is where the upper heart chamber is pumping erratically due to misfiring electrical signals, it is the most common rhythm disorder and is often totally asymptomatic.

QUESTION: I am a healthcare practitioner and have a patient who takes flecainide, an anti-dysrhythmic agent and diltiazem, for rate control. He has been on these medications for 6 months and no longer has premature ventricular beats (PVB). He was not symptomatic with the PVBs, when he did have them, before the medication.  He wishes to be weaned from the flecainide.  He takes a mild diuretic as needed for swelling of the ankles (hydrochlorothiazide) and no other medications. He has a great echocardiogram, no coronary heart disease and is an active and healthy 63-year-old and a private pilot for over 30 years.
What can I tell him regarding his 3rd class medical which will expire the end of February?
ANSWER: It sounds like he will require a special issuance because of the arrhythmia.  The FAA would typically ask for a current cardiovascular evaluation with a maximum exercise treadmill stress test, M-Mode/2D echocardiogram, and a 24 hour Holter monitor. If his rhythm is well controlled and there is no evidence of heart disease, he would most likely be found eligible for a special issuance medical.  All the meds, including flecainide, are allowed by the FAA if his cardiac status is otherwise good.  

Since my open heart surgery, my resting pulse rate is much higher than it used to be. It now runs about 80-85/minute and used to be about 55. Is there any upper limit on resting pulse, and is this any concern?
ANSWER: Open heart surgery refers to any occasion where a surgeon opens up the chest and operates on the heart or large vessels emanating from it, often after bypassing the blood flow into an external pump and stopping the heart from beating. One can then address blocked arteries, defective valves or other abnormalities without having to deal with a “moving target!”
Changes in heart rate variability was studied in a paper published in 2015 in BioMed Research International.  The article looked at patients who had a myocardial infarction (heart attack) and/or coronary artery bypass grafting and the incidence of post event heart rate variability.  Normally, a resting heart rate of less than 100 would not necessarily be noteworthy, but with your history of “open heart surgery,” the FAA would be looking at the heart rate in the context of your overall medical history from an “aeromedical certification standpoint.” 
If the required cardiac evaluation, including a stress test, cardiovascular evaluation report from your cardiologist, and possibly a 24 hour Holter monitor, showed nothing out of the ordinary, and your average resting heart rate at rest didn’t exceed 100 beats per minute, you would probably be in good position to be granted a special issuance authorization.  
For Basic Med, what are the health requirements? Blood pressure limits? Hearing and eyesight requirements? Does one need an electrocardiogram?  Physical examination? Any guidance gratefully received.
The exam is very similar to the current FAA third class medical exam. The difference being that the exam is a checklist with a sign off by a qualified physician, and the results will not be transmitted to the FAA as a pass/fail as with a regular Third Class medical examination.  You can review the form in the Advisory Circular 68-1. 

Portrait of Gary Crump, AOPA's director of medical certification with a Cessna 182 Skylane at the National Aviation Community Center.
Frederick, MD USA

Gary Crump

Gary is the Director of AOPA’s Pilot Information Center Medical Certification Section and has spent the last 32 years assisting AOPA members. He is also a former Operating Room Technician, Professional Firefighter/Emergency Medical Technician, and has been a pilot since 1973.

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