Management of established coronary artery disease in aircrew without myocardial infarction or revascularisation

Abstract

This paper is part of a series of expert consensus documents covering all aspects of aviation cardiology. In this manuscript, we focus on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease in those without myocardial infarction or revascularisation (both pilots and non-pilot aviation professionals). We present expert consensus opinion and associated recommendations. It is recommended that in aircrew with non-obstructive coronary artery disease or obstructive coronary artery disease not deemed haemodynamically significant, nor meeting the criteria for excessive burden (based on plaque morphology and aggregate stenosis), a return to flying duties may be possible, although with restrictions. It is recommended that aircrew with haemodynamically significant coronary artery disease (defined by a decrease in fractional flow reserve) or a total burden of disease that exceeds an aggregated stenosis of 120% are grounded. With aggressive cardiac risk factor modification and, at a minimum, annual follow-up with routine non-invasive cardiac evaluation, the majority of aircrew with coronary artery disease can safely return to flight duties.

Return to flying after coronary artery disease: A case series among Malaysian pilots

“…Thus, according to the latest study, a pilot with an increased risk of a cardiovascular event should undergo enhanced screening with a coronary artery calcium score (CACS) or in combination with a CT coronary angiogram. 9 If the lesion at LAD is increased to 30%-49% or 30%-40% at LMS or proximal LAD, the pilot should be given a flight restriction (nonhigh-performance aircraft) as recommended by Davenport E. D. et al 10 A pilot with any stenosis between 50% and 70% should undergo fractional flow reserve (FFR) assessment to verify hemodynamic significance. Pilots with F I G U R E 1 The 4 × 4 aeromedical risk matrix for a pilot (Adopted from ).…”

An introduction to aviation cardiology

“… 14 Stenotic valve disease, if more than mild, is of significant concern in aircrew, whereas mild regurgitant lesions may be slightly better tolerated, 15 while for coronary artery disease, stenosis that would be considered of little concern in a terrestrial environment may be deemed significant in an aeromedical context. 12 …”

“…This manuscript describes the current medical regulatory framework for aircrew; aircrew roles in the civil and military aviation profession; the types of aircraft and aviation environment that must be understood when managing aircrew with CVD; the regulatory bodies involved in aircrew licensing and the risk assessment processes that are used in aviation medicine to determine the suitability of aircrew to fly with medical (and specifically cardiovascular) disease; and the ethical, occupational and clinical tensions that exist when managing patients with CVD who are also professional aircrew. It serves as an introduction to the subsequent papers on risk assessment of aircrew, 10 screening of aircrew 11 and specific articles that address coronary artery disease (both pre- and post-intervention), 12 13 electrical abnormalities of the heart, 14 valvular disease, 15 heart muscle disease, 16 congenital heart disease 17 and cardiac intervention 18 in aircrew. This article does not address cabin crew or passengers.…”

Management of established coronary artery disease in aircrew with previous myocardial infarction or revascularisation

“…Whether done at time of event, or staged (PCI of culprit vessel, followed by repeat PCI or CABG non- culprit lesions later), it is imperative that all aircrew have no residual haemodynamically significant disease. Non-revascularized CAD burden, including aggregate stenosis, 44 can then be calculated on non-obstructive disease to determine risk. All aircrew with a prior MI and/or revascularisation should be risk assessed, and if within acceptable risk limits, can be considered for limited aircrew roles (ie, non-high-performance airframes), and for pilots, limited to dual pilot operations, with another suitably qualified pilot on that aircraft type, even when residual disease is minimal.…”