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Coronary Artery Disease - Suspected or Confirmed

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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 eg 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 eg 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 (within the last 3 months) stress test
• 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

• 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

An exception may be made for stenting, where recertification may be considered from six weeks after the procedure, provided that all the following requirements are met:

• stent placement is a planned/elective non-urgent procedure and there is no evidence of recent myocardial damage (ie. asymptomatic and normal troponins pre-procedure)
• stent is to a vessel other than the left main stem (left coronary artery)
• stent is NOT to a previous vein graft
• satisfactory Troponin-T level within 24 hours of the procedure (current guidance is no more than 5 times the upper reference limit)
• satisfactory exercise echocardiogram or myocardial perfusion scan no less than one month after the procedure.

In such a case, a new Application for a Medical Certificate is not required. However, full operative and follow-up details are required as listed above. It is recommended that you consult your DAME to see if your situation meets these requirements. IF so, the relevant information can be gathered.

PLEASE NOTE: If the post-treatment Troponin-T test is not done, you cannot qualify for this early reassessment. A new application will be required after the 6 months’ grounding period has passed. Make sure to discuss this with your cardiologist before the procedure.

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

Disclaimer

The Clinical Practice Guideline is provided by way of guidance only and subject to the Clinical practice guidelines disclaimer