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Coronary Artery Disease case-based scenario
Heart-felt relief for captain Anthony
A 64 year old airline captain who always wanted to fly, Anthony was shocked when a routine exercise test showed he was at risk of a heart attack. Fortunately, after his mandatory grounding a minor surgical procedure and new medication soon had him back in the air.
Anthony started training on gliders when he was only 16 years of age and obtained his pilot's licence before he could drive a car. For him, becoming a 747 captain at 40 years of age was the realisation of a lifelong ambition.
"Flying is my life," Anthony says. "I fly a lot internationally, especially to the United States, and I am keenly aware of the toll being a long-haul pilot can take on your health. Although it isn't always easy, I try to exercise and eat well when I'm away from home. Finding I was at risk of coronary heart disease was a real worry."
Anthony has been subject to regular medical assessments for his aviation licence his entire adult life. Although his weight, blood pressure and cholesterol all slowly rose after he turned 40, until recently he had very few medical issues. His GP would occasionally recommend dietary changes and more exercise, but never felt that Anthony needed medical treatment.
Routine medical screening
At 55 years of age, all that began to change. Having plugged the results of Anthony's medical renewal into the risk calculator CASA uses, Anthony's DAME immediately ordered an exercise stress test. You could estimate a person's risk of a heart attack or stroke in the next five years based on their cholesterol levels, blood pressure, age, gender and whether or not they smoked, the DAME explained. Anthony's indications were not positive. Since the studies underpinning those risk projections were based on decades of study of tens of thousands of people, Anthony could be pretty confident the assessment was right.
Because Anthony was well, his DAME was happy to validate Anthony's medical certificate to cover him for the next couple of months so he could organise the test.
"I did the exercise stress test back home in Bowral," Anthony says. "That was not a good day, I can tell you. Being plugged into all those wires was really uncomfortable. I did okay when the treadmill was flat, but I couldn't believe how much I struggled when the treadmill got steeper. In the end, I was so short of breath and my chest felt so heavy that the technician had to stop the test."
Within 20 minutes, a cardiologist was advising Anthony that the test suggested the blood vessels supplying his heart were narrowing, consistent with a diagnosis of stable angina.
"I was due to fly to Los Angeles in three days, so I asked the cardiologist if I was okay to fly. She told me while she didn't expect me to have any problems in the near future, she would have to discuss my condition with my DAME, who would better understand the aeromedical implications," Anthony says.
Sadly the DAME explained that AvMed always required grounding in cases of a ‘positive' stress test and that a diagnosis of stable angina also demanded grounding. The DAME contacted AvMed to notify a change in Anthony's medical condition in accordance with his obligations under the Civil Aviation Safety Regulations.
The cardiologist recommended Anthony undergo an angiogram, a special procedure which x-rays the blood vessels around the heart. Anthony was dismayed to learn that during the procedure a wire would be inserted into an incision over a blood vessel in his groin and carefully threaded up to his heart. He was even less happy when he was told that he would be awake for the entire process.
He felt a little better when the cardiologist explained that the procedure would confirm whether or not there was significant narrowing of the blood vessels, and that it might even be possible to fix the narrowing problem at the same time.
Ultimately the angiogram showed narrowing of two of Anthony's blood vessels. During the procedure the cardiologist stretched both arteries open using a small balloon on the end of the wire and placed metal sleeves (stents) into the arteries to hold them open.
The cardiologist explained that the underlying problem causing Anthony narrowing is called atherosclerosis - a disease that can only be managed with permanent changes to lifestyle and diet and with special medications.
Anthony stayed in the hospital overnight and then went home the next day.
A week later, when he visited his cardiologist for review, he was told the stents were working well. The cardiologist advised Anthony his condition would need to be reviewed every year and that the effect of his new set of medications on his blood pressure and cholesterol would need to be closely monitored.
Visit to DAME
Next Anthony contacted his DAME and booked an appointment for review of the cardiologist's reports. The DAME reviewed the Clinical Practice Guidelines published by AvMed before the appointment. Anthony's DAME also notified AvMed of the change in Anthony's medical condition, in accordance with the requirements of the regulations.
After his earlier experience, Anthony was troubled to learn AvMed would need him to take another exercise stress test before he could be cleared back to flying. He wasn't looking forward to the test and was a little annoyed that his cardiologist hadn't told him he needed it.
Fortunately, second time around he found the stress test much less challenging; and because the result of the test was completely normal, AvMed was able to issue a clearance.
Even so, his DAME explained to Anthony that while his narrowed arteries had been successfully treated, the disease that caused the narrowing was still in those arteries and others.
This made it important for his risk factors to be closely monitored and reduced wherever possible, to slow or halt the progression of the disease.
Even though the disease of the arteries was still present, AvMed were able to assess the risk of Anthony having cardiac event in the next 12 months as acceptably low based on medical research that has looked at people with coronary artery disease after negative stress tests.