Coronary Artery Disease - suspected or confirmed

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

Definition

This protocol applies to the following:

  • Suggestive symptoms
  • Positive stress ECG
  • Myocardial infarction
  • Coronary artery surgery
  • Angioplasty
  • Stenting.

Aeromedical implications 

Effect of aviation on condition

  • Increased cardiac workload during stressful phases of flight
  • Potential sedentary nature of occupation

Effect of condition on aviation

  • Overt incapacitation
    • Distracting pain
    • Acute shortness of breath
    • Arrhythmia
    • Sudden death.

Effect of treatment on aviation

  • Impaired ‘g’ tolerance secondary to drug therapy
  • Haemorrhagic complications of anti-platelet treatment

Approach to medical certification

Based on the condition

  • Confirmed diagnosis of coronary artery disease
  • Exclusion of other diagnoses e.g. ischaemic cardiomyopathy significant arrhythmias
  • Absence of reversible myocardial ischaemia

Based on treatment

  • Acceptable, stable treatment without significant side effects
  • LVEF of 50% or more

Demonstrated stability

  • Adequate period of grounding before new assessment (minimum 6 months)
  • Absence of symptoms e.g. chest pain and shortness of breath
  • Absence of evidence of reversible ischaemia on exercise or chemical stress testing

Risk assessment protocol

New cases

CASA requires a report from a cardiologist. The report(s) should detail:

  • Confirmed diagnosis
  • Clinical status
    • symptoms such as pain, palpitations, dizziness, breathlessness
    • progress
  • Investigations conducted by your treating doctors (which may include)
    • echocardiogram with ejection fraction
    • results of a recent (within the last 3 months) stress test
    • results of a (post intervention) stress nucleotide scan or stress echocardiogram including left ventricular ejection fraction
    • 24 hour ECG (if performed / may be requested by CASA if risk of rhythm disturbance)
    • angiographic findings (if performed)
    • surgical report (if performed)
  • Investigations required by CASA
    • in case of positive exercise ECG, results of a stress nucleotide scan or stress echocardiogram including left ventricular ejection fraction scan OR
    • results of a (post intervention) stress nucleotide scan or stress echocardiogram including left ventricular ejection fraction scan that is conducted no less than 6 months post event.
  • Management (if applicable)
    • control of cardiac risk factors
    • treatment or interventions (note any residual stenoses)
    • side-effects
  • Proposed monitoring and follow-up plan
  • Prognosis including annualised percentage risk of recurrence and incapacitation.

Renewal for confirmed disease

CASA requires a report from the doctor monitoring the applicant’s coronary artery disease. The specialists report should detail:

  • Clinical status
    • symptoms such as pain, palpitations, dizziness, breathlessness
    • progress
  • Investigations conducted
    • results of a recent stress test (Cannot be attended to prior to 6-month grounding period lapsing)
  • Management
    • control of cardiac risk factors
    • side-effects
  • Proposed monitoring and follow-up plan
  • Prognosis including annualised percentage risk of recurrence and incapacitation.

Note: if additional investigations or interventions were required during the review period the relevant reports will also be required.

Indicative outcomes

Suspected disease

  • Initial notification to CASA and grounding required pending diagnosis
  • There are no certification implications for positive stress ECG’s with subsequent negative myocardial perfusion scans or stress echocardiograms

Confirmed disease

  • For elective stenting, please contact CASA prior to procedure for further guidance
  • After myocardial infarction (a heart attack): A minimum of six months grounding will be required before risk assessment by CASA
  • After most coronary artery procedures (stents, balloon angioplasty, coronary artery bypass etc): A minimum of six months grounding will be required before risk assessment by CASA

CASA risk assessment requirements are:

  • a new medical application and assessment by CASA
  • specialist / cardiologist documentation as listed above
  • applicants with unacceptable recurrence risk of myocardial infarction may not meet the required standard for medical certification
  • applicants with persisting angina, dyspnoea, rhythm disturbance, reduced ejection fraction or reversible ischaemia may not meet the required standard for medical certification
  • applicants on medication for the above
  • certification with permanent Multi-crew (Class 1) or Safety Pilot (Class 2) restriction may be required
  • ongoing surveillance including a permanent annual requirement for cardio-vascular risk assessment may be required.

Favourable

  • Absence of significant symptoms
  • Effective management of risk factors for coronary artery disease (e.g. smoking, lipids, glucose, appropriate medication) IAW American Heart Association Guidelines for risk factor management
  • Ongoing anticoagulation / antiplatelet therapy as advised by specialist
  • Successful surgical management e.g. Percutaneous angioplasty and stent or Coronary Artery Bypass Grafting

Unfavourable

  • Persisting angina or ongoing requirement for angina medications
  • Exertional dyspnoea
  • Evidence of reversible ischaemia (note: findings on coronary angiogram do not negate the prognostic significance of reversible ischaemia)
  • Evidence of rhythm disturbance
  • LV ejection fraction <50% or significant abnormality of wall motion on echocardiogram

Pilot and controller information

  • Coronary artery disease (CAD) is an aero-medically significant medical condition
  • Pilots and controllers who have been diagnosed with CAD are required to ground themselves and notify this condition to their DAME and CASA AVMED
  • A minimum of six months grounding is required following a heart attack or coronary artery intervention (stent or bypass except as above)
  • There is an increased risk of another event during this time, even in those cases that have been successfully treated
  • Annual review will be required as a minimum
  • Multi-crew restriction may be required for pilots
  • The risk of future events is greatly reduced by  lifestyle modification and the use of preventative medications

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Disclaimer

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

Last updated:
Online version available at: https://www.casa.gov.au//licences-and-certificates/medical-professionals/dames-clinical-practice-guidelines/coronary-artery-disease-suspected-or-confirmed
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