Back to Basics

For the past few months everyone has been immersed in the COVID-19 “altered reality,” so now that summer is upon us and our new normal is beginning to appear, I thought it time to get back to some of the more conventional medical certification issues that pilots face. 

This time we’ll review the special issuance process for coronary artery disease, angina, myocardial infarction (heart attack), coronary bypass surgery, stent placement, and a few other cardiac conditions.

Heart disease is one of the most prevalent clinical pathology presentations that the FAA docs review. It makes sense, though, when considering how common heart disease is in the US and other countries. The FAA has a valuable tool called Special Issuance Authorization that allows the discretionary issuance of medical certification for the above mentioned cardiovascular conditions.

Special Issuance (SI) is a two-edged sword for operations that require medical certificates, and with the good comes the not so good. It’s actually great that our CFR (Code of Federal Regulations) contains Part 67.401, because it provides the FAA Administrator, through the Federal Air Surgeon, the ability to medically qualify pilots with certain disqualifying medical conditions through an “off ramp,” so to speak, from the medical standards in Part 67. But the special issuance process can be daunting if you go into the process unprepared!

The cardiovascular standards disqualify for regular issuance a “history” of:

  1. Myocardial infarction;
  2. Angina pectoris (chest pain associated with underlying coronary heart disease);
  3. Coronary heart disease that has required treatment or, if untreated, that has been symptomatic or “clinically significant”;
  4. Cardiac valve replacement;
  5. Permanent cardiac pacemaker implantation; or
  6. Heart replacement (“transplant”).

With any of these conditions, special issuance is the only avenue for the FAA to qualify pilots with time-limited medical certificates; that is, they are bound by their own regulations to use the discretionary authority to grant medical certificates.

For all the cardiac conditions, the FAA will almost always require a basic set of treatment records and current testing that includes a Cardiovascular Evaluation (CVE). In addition, for specific cardiac conditions and based upon the class of medical applied for, a Bruce protocol exercise stress test, nuclear perfusion scanning, cardiac catheterization (angiogram), 24-hour ambulatory heart monitor (Holter), and echo or stress echocardiogram are the main “go to” tests the FAA will require. The details of the conditions and requirements are available on our website.

The key takeaways with any medical condition that the FAA is reviewing is that the condition cannot be considered serious enough to result in impairment or incapacitation during the time the medical certificate will be in force (usually about 12 months.) The rub is that the determination of a safe condition is in the hands of the FAA, and as a bureaucracy, that decision-making process is sometimes conservatively applied.

The Bruce protocol stress test is a “a maximum” stress test. That is, the FAA wants to see the full nine minutes of exercise and achievement of your maximum predicted heart rate (220 minus your age = MPHR). The wiggle room is that 85% of maximum predicted is acceptable, but 84% won’t be. The “cut points” for some conditions are established by “policy” and are applied across the board for a given condition. For the FAA, the stress test requirements aren’t negotiable.

The other important thing on the stress test is that there can be no identifiable “myocardial ischemia” on the treadmill ECG or on the nuclear perfusion imaging (if required). Ischemia is the clinical term for inadequate blood supply to the heart muscle during exercise stress. The coronary arteries, the Right, Left Anterior Descending, and Circumflex, branch off the left main coronary artery and further divide into tributaries throughout the heart to supply blood to the heart muscle. When there is enough obstruction in one or more of the arteries to limit adequate blood flow, especially during exercise stress on a treadmill, chest pain or discomfort may become present, and the electrocardiogram will begin to present abnormalities, often in the ST segment of the tracing found in the different leads that are attached to your chest.

Referring back to the regulations citing coronary artery disease that is “symptomatic or clinically significant,” an abnormal stress ECG, with or without chest pain, is considered clinically significant and will result in either a denial of medical certification, or a request for a nuclear exercise perfusion scan, a more sensitive and accurate stress test that images the area of the heart muscle that isn’t getting adequate blood supply. When the nuclear study is abnormal, a visit to the cath lab for an angiogram, the “gold standard” for diagnosis of heart disease, usually results in a dye study that more definitively identifies the anatomy of the coronary artery or arteries that are obstructed. If disease is found, an intervention with either a stent or coronary bypass surgery is the remedy in most cases.

Similarly, when evaluating a heart arrhythmia such as atrial fibrillation or frequent PVC (premature ventricular contractions), the stress test and the 24-hour Holter monitor are used to evaluate the situation. For valvular disease, the same tests, plus an echocardiogram, are done to determine the severity of the defect.

The final takeaway to keep in mind is that your treating doctor is doing “clinical medicine” while the FAA is doing “regulatory medicine,” and the two are not the same animal. The FAA, remember, is evaluating your risk for experiencing impairment or incapacitation, while your cardiologist is treating you to keep you pain free, with a good quality of life, as well as mitigating your risk. There is some overlap in the two roles, but the FAA always wins the contest when it comes down to the issuance of your medical certificate!

If you have questions, call the Pilot Information Center and speak with our medical certification specialists and we can get into your specific situation.

Fly safe and fly often!

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.
Topics: Pilot Health and Medical Certification

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