From the Head to the Heart

There has been a great deal of attention the last couple of years to the growing epidemic of mental health issues that affect not just the pilot population but our entire population, from adolescents to senior citizens.

Life often gets in the way of living, and in our first-world pressure cooker society, those life events that may begin as a minor annoyance can slowly and insidiously escalate into a bona fide medical crisis, leaving the patient despondent, fearful, and feeling lost without a rudder.

In early December, the National Transportation Safety Board (NTSB) convened a day-long summit for a deeper dive into the dilemma facing the FAA, the medical community, and the thousands of pilots who suffer the double whammy of experiencing life events that affect their mental well-being, compounded by the stress of fearing that coming forward with the problem will result in the loss of a career for working pilots, or the avocation for an active recreational pilot. Our PPS contributors have tackled this issue previously, and most recently, PPS lead in-house attorney, Ian Arendt, wrote on ways the FAA could mitigate their approach to medically certificating pilots.

Aside from obvious mental health compromises that result from untreated or undertreated depression, anxiety, PTSD, and the myriad other DSM-5 diagnoses that fall into the behavioral health category, mental instability can affect the function of other organ systems in us humans.

Our cardiac health and mental health often correlate with morbidity and mortality, and in both directions. In a quite interesting paper published in Dialogues in Clinical Neuroscience, March 2018, the authors note that coronary heart disease and mental illness are among the leading causes of severe illness and death worldwide, and, although the links are not clearly understood, it is also thought that both the conditions may be interactively causal.

The paper notes that epidemiological prospective data shows that people with severe mental health diagnoses, as a group, have an increased risk of developing heart disease. Symptoms of anxiety or anxiety disorders, along with experiences of persistent or intense or posttraumatic stress disorder, may, to a lesser degree, “be independently associated with an increased risk of developing coronary heart disease” (CHD).

The paper goes on to say that “an intriguing relationship between mental illness and CHD appears to exist,” and that “a higher prevalence of mental diseases in CHD patients has been demonstrated.”

That’s a lot to unpack, but when we think it through, physically, the human body is a “closed system” with incredibly complex cooperative interactions between all our organ systems that make us operate “normally.” Spiritually, though, our minds are not closed at all, but that’s a topic for someone much smarter than me to jump into.

That said, we can shift from the mental to the cardiac and take note again of the comment earlier in the paper, that CHD is one of the most lethal diseases that strikes humanity without impunity. Not too surprising, then, is it that heart disease in all its iterations and treatment modalities is one of the most common medical conditions that the FAA sees among pilots who submit medical applications.

The FAA 2022 Aerospace Medical Certification Statistical Handbook cites over 10,000 cardiac-related issuances, including myocardial infarction (MI), coronary angioplasty with and without stent, coronary artery bypass surgery, pacemaker, and aortic and mitral valve pathologies.

The FAA requirements for a cardiac special issuance start with a standard recipe of basic testing. The secret sauce may include additional testing based on what the FAA sees in the initial batch of records, but every case is slightly different.

For MI, chest pain (angina pectoris), angioplasty with or without stent, or coronary artery bypass (CABG), the FAA will want basic hospital records, including admission history and physical, pre-op cardiac cath, if performed, operative report, and discharge summary. That is no more than 10-20 pages of printed records.

You will also need a current (within the preceding 90 days) cardiovascular evaluation including a maximum exercise Bruce protocol stress test, lab report for cholesterol and triglycerides, and fasting blood sugar (because there is a correlation between diabetes and coronary heart disease).

You will also need a current detailed narrative evaluation from your treating physician.

The last important point to keep in mind is the FAA is overwhelmed with medical applications and the wait time for a special issuance is 4-7 months after all required information is in their system. Since the pandemic and the ongoing pilot shortage, the Aerospace Medical Certification Division processed more than 430,000 applications for medical certificates in 2023, far more than in the past. They simply do not have the resources to handle that much work, so be patient, don’t let stress and frustration get to you, and just accept the fact that it will take a while to get a response! If it helps, recite the abbreviated Serenity Prayer as part of your daily meditation!

God, give me Grace to accept with serenity
the things that cannot be changed,
Courage to change the things
which should be changed,
and the Wisdom to distinguish
the one from the other.


Best wishes for a blessed 2024!

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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