Coronary Artery Disease Screening

Guidance for medical examiners when assessing a patient for either a general topic or condition – Coronary Artery Disease Screening.

Definition

This guidance applies to pilots undergoing coronary artery disease screening as required in the Special Reports and Tests schedule found in chapter 4.4 Special Reports and Tests Required for Medical Certification of the DAME Handbook.

Aeromedical implications

Effect of aviation on condition

  • Lifestyle constraints
  • Sedentary work

Effect of condition on aviation

  • Incapacitation risk due to undetected coronary artery disease

Effect of treatment on aviation

  • Medication side-effects
    • postural hypotension
    • haemorrhage.

Approach to medical certification

  • Multifactorial risk assessment to stratify risk (Framingham) using the Coronary Heart Disease Risk Factor Prediction Chart (CRI) found in chapter 4.4 Special Reports and Tests Required for Medical Certification of the DAME Handbook.
    • CRI > 14 indicates increased risk of coronary artery disease
    • Further evaluation by cardiologist required
  • Certification of applicants with elevated risk (CRI >14) will depend upon satisfactory functional testing
  • Referral for Exercise ECG
  • If exercise ECG suggestive of reversible myocardial ischaemia:
    • Ground applicant
    • Exercise echocardiogram or
    • Myocardial perfusion scan
  • Functional testing acceptance criteria:
    • no reversible myocardial ischaemia
    • ejection fraction (LVEF) of 50% or more
    • absence of significant arrhythmias
  • Cardiological interventions as clinically indicated and report on risk factor management.

Risk assessment protocol - information required

An assessment a Cardiologist with respect to:

  • confirmed diagnosis
  • clinical status including any symptoms
  • investigations conducted including the results of a recent stress test (echo or myocardial perfusion scan)
  • angiogram reports if applicable
  • management:
    • control of risk factors
    • treatment and any side-effects
    • risk of any acutely disabling cardiovascular event
    • planned monitoring.

If intervention is required see the information below.

Indicative outcomes

  • Initial notification to CASA and grounding required on positive (or equivocal) stress test. Clearance by CASA required before exercising privileges

Favourable

  • No reversible myocardial ischaemia
  • Ejection fraction (LVEF) of 50% or more
  • Absence of significant arrhythmias
  • Management of risk factors for coronary artery disease (e.g. smoking, lipids, glucose)
  • Acceptable risk of future cardiovascular event

Unfavourable

  • Symptoms of chest pain (angina) or inappropriate shortness of breath with stress test
  • Stress ECG changes consistent with ischaemia
  • Stress ECG changes consistent with stress induced arrhythmia
  • Evidence of reversible ischaemia on stress echocardiogram (note: findings on coronary angiogram do not negate the prognostic significance of reversible ischaemia)
  • Evidence of reversible ischaemia on stress myocardial perfusion scanning (note: findings on coronary angiogram do not negate the prognostic significance of reversible ischaemia)
  • LV ejection fraction less than 50%

Pilot and controller information

  • Cardiovascular risk management reduces the risk of sudden incapacitation from heart attack and stroke
  • Early detection of coronary artery disease improves health outcomes
  • Coronary artery disease risk is not static and increases steadily with age. Variable risk factors include age, smoking, diabetes, high blood pressure and high cholesterol. Fixed risk factors include male gender, ethnicity and family history
  • Pilots and controllers who have a positive (or equivocal) stress test are required to ground themselves and notify this result to their DAME and CASA AVMED
  • Processing of the application is halted pending the outcome of further investigations

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

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