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.