Cardiac Quandary

Following the theme of last month’s back to basics topic of hypertension and medical certification, we shall continue this month with a discussion about “heart disease,” a term that can be a broad header for a number of heart-related conditions. 

For our purposes we will stay in the lane and deal with the aeromedical concepts of “coronary heart disease,” myocardial infarction, and the interventions used in mainstream clinical medicine to treat heart disease – percutaneous transluminal coronary intervention (PTCA), or “stenting,” and coronary artery bypass surgery, CABG.

Among the specifically disqualifying medical conditions found in FAR part 67, an “established medical history or clinical diagnosis” of any of the six cardiac pathologies requires an Authorization for Special Issuance, a discretionary, time-limited medical certification. They include:

  • myocardial infarction;
  • angina pectoris (chest pain associated with underlying coronary heart disease);
  • coronary heart disease that has required treatment, or, if untreated, that has been symptomatic or clinically significant;
  • cardiac valve replacement;
  • permanent cardiac pacemaker implantation;
  • ·or heart “replacement.”

The initial medical records and testing review for almost all these “cardiac histories” require the same basic package of reports:

Specific hospitalization records including admission history and physical exam, preoperative diagnostic testing results, imaging studies such as coronary angiography, any reports of surgical procedures, and the discharge summary. Often, that bundle of records amounts to maybe 15 to 20 pages, tops! (The FAA literature is specific about what they want to see, so don’t be overzealous and give them a data dump of your entire hospitalization record!)

That is the historical information that doesn’t change. It is your medical “history,” and it is an important piece of the equation when the FAA is reviewing medical records, but the other important part is the current diagnostic testing done post-operatively to assess how you’re doing as a result of the corrective fixes.

These include a current maximum exercise Bruce protocol stress test OR a nuclear exercise perfusion scan to assess the state of the coronary arteries’ ability to deliver oxygenated blood to the heart muscle during exercise stress. The FAA wants to see a “maximal” exercise stress test defined by reaching the maximum predicted heart rate (220 minus your age) OR at least 85% of the predicted maximum calculation. You also need to stay on the treadmill for as close to nine minutes as possible. Nine minutes is the standard Bruce protocol – a stress test of three stages of three minutes each, with an increasing treadmill speed and incline for each stage. (If over age 70, the minimum duration is six minutes.)

The Bruce stress test is a standard requirement in most cardiac cases reviewed by the FAA. In addition, a 24-hour ambulatory Holter heart monitor and a 2D/M Mode echocardiogram make up the trifecta of baseline cardiac testing involving coronary artery disease, valvular disease including mild murmurs all the way up to valve replacement or repair, and pacemaker implantation. The FAA will customize the requirements for additional testing based upon the presenting history, so everyone’s situation may be fine-tuned after the initial battery of testing is reviewed.

So, what determines the pass/fail for these kinds of cases? As the FAA always says, “it depends.” For heart disease, the FAA will pay attention to your stress test results as depicted on the stress ECG. If the stress ECG is “positive” (and in medicine, positive is not necessarily a good thing!) for a condition called ischemia, meaning the heart muscle isn’t getting an adequate blood flow during exercise stress, certification will likely be denied. When the heart isn’t happy, the FAA isn’t either, so a “negative” stress ECG is what you want to see.

For a Holter monitor, the presence of arrhythmias, and there are all kinds of cardiac arrhythmias, may be problematic. High numbers of PVCs (premature ventricular contractions) or ventricular tachycardia, or a prolonged or sustained high heart rate are just a couple of findings that may raise concerns on the electrical side of the heart pump.

An echocardiogram captures dimensional performance data on the heart, as well as structural viability of the heart valves that control the one-way flow of blood through the atria and ventricles and into the aorta that is the main conduit for blood distribution from the heart to the body. Another key performance value is the ejection fraction, the volume of blood that is pumped out of the left ventricle with each contraction. This number, expressed as a percentage, indicates the efficiency of the pump in getting the blood into the circulatory system. A “normal” EF is about 50% or more, and the FAA looks at a minimum of 40% as a floor for medical certification purposes.

In addition, the FAA will ask for current labs, including cholesterol, triglycerides, and fasting glucose, and a current clinical progress note from the treating physician that summarizes the patient’s history, diagnosis, treatment, prognosis, and medications usage.

The FAA is suffering some serious processing delays now here at the end of summer 2022, so when you’re asked to provide something, be sure to send them everything that’s asked for in the letter. If they don’t get everything, the penalty is a longer wait time before you get a decision.

As always, if you have any questions, just give us a call.

As fall gets closer and the really sizzling summer of ’22 becomes a memory, enjoy the cooler flying weather.

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, Pilot Health and Medical Certification

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