My Flight Surgeon
Sr. Aviation Medical Examiner
This is the seventh of a series of threads regarding the history portion of the FAA Form 8500-8 that you complete every time you get a flight physical. For the vast majority of you, this will be just informational and you will not be affected. Heart disease is one of the commonest reasons we encounter requiring Special Issuance action for the pilot. As with many of the conditions discussed here and elsewhere in these threads, there is a requirement for the pilot to provide medical records and physician documentation regarding the medical condition being reported. I would suggest that if you are unsure of how to answer these questions in Item 18, you discuss them with your AME before you complete the form. Some things may not be significant while others will require explanation.
18g. Heart or vascular trouble
The applicant should describe the condition to include, dates, symptoms, and treatment, and provide medical reports to assist in the certification decision-making process. These reports should include: operative reports of coronary intervention to include the original cardiac catheterization report, stress tests, worksheets, and original tracings (or a legible copy). When stress tests are provided, forward the reports, worksheets and original tracings (or a legible copy) to the FAA. Part 67 provides that, for all classes of medical certificates, an established medical history or clinical diagnosis of myocardial infarction, angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, heart replacement, or coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant, is cause for denial. The following lists the most common conditions of aeromedical significance:
Arrhythmias (abnormal heart rhythm). There are more than a dozen types of arrhythmias. The FAA wants the pilot to have a full cardiac evaluation appropriate for the arrhythmia. The minimal evaluation includes:
·[FONT="] [/FONT]An assessment of personal and family medical history
·[FONT="] [/FONT]Clinical cardiac and general physical examination
·[FONT="] [/FONT]An assessment and statement regarding the applicant’s medications, functional capacity, modifiable cardiovascular risk factors
·[FONT="] [/FONT]Motivation for any necessary change
·[FONT="] [/FONT]Prognosis for incapacitation
·[FONT="] [/FONT]Blood chemistries (fasting blood sugar, current blood lipid profile to include total cholesterol, HDL, LDL, and triglycerides) performed within the last 90 days
In addition it may include echocardiograms to look at the structural anatomy of the heart, electrical monitoring studies, nuclear imaging studies or angiographic studies. Usually these studies provide sufficient information to allow the pilot to fly either with or without a Special Issuance medical certificate.
Atrial fibrillation. Unless the atrial fibrillation was more than 5 years ago, has not returned and there was a full evaluation for the cause, it will require a decision from the FAA. The evaluation includes:
1.[FONT="] [/FONT]Hospital admission summary (history and physical), coronary catheterization report, and operative report regarding all cardiac events and procedures.
2.[FONT="] [/FONT]A current cardiovascular evaluation must include an assessment of personal and family medical history; a clinical cardiac and general physical examination; an assessment and statement regarding the applicant's medications, functional capacity, modifiable cardiovascular risk factors, motivation for any necessary change, prognosis for incapacitation; and blood chemistries (fasting blood sugar and current blood lipid profile to include total cholesterol, HDL, LDL, and triglycerides).
3.[FONT="] [/FONT]A current maximal GXT
4.[FONT="] [/FONT]Echocardiogram
5.[FONT="] [/FONT]Holter monitor (24-hour recording heart monitor)
If a Special Issuance certificate was granted, the AME may issue subsequent certificates if the applicant provides the following:
[FONT="] [/FONT]An Authorization granted by the FAA;
[FONT="] [/FONT]A summary of the applicant’s medical condition since the last FAA medical examination, including a statement regarding any further episodes of atrial fibrillation;
[FONT="] [/FONT]The name and dosage of medication(s) used for treatment and/or prevention with comment regarding side effects;
[FONT="] [/FONT]A report of a current 24-hour Holter Monitor performed within last 90 days; and
[FONT="] [/FONT]A minimum of monthly International Normalized Ratio (INR) results for the immediate prior 6 months.
Coronary Heart Disease: For pilots with Angina Pectoris; Atherectomy; Brachytherapy; Coronary Bypass Grafting; Myocardial Infarction; Percutaneous Transluminal Angioplasty (PTCA); Rotoblation; and Stent Insertion, the evaluation requires the items listed in atrial fibrillation above plus a maximal thallium (nuclear) stress test and a “post-event “ heart catheterization. Without the catheterization, the likelihood of receiving a Class 1 or unlimited 2 medical certificate is slim to none. Limited second-class medical certificate refers to a second-class certificate with a functional limitation such as, Not Valid for Carrying Passengers for Compensation or Hire, Not Valid for Pilot in Command, Valid Only When Serving as a Pilot Member of a Fully Qualified Two-Pilot Crew, Limited to Flight Engineer Duties Only, etc.
Hypertension requiring medication: This requires an initial hypertension evaluation before the AME can issue a certificate. If the data from the evaluation is acceptable, the AME may issue the medical certificate. The evaluation includes: pertinent personal and family medical history, including an assessment of the risk factors for coronary heart disease, a clinical examination including at least three blood pressure readings separated by at least 24-hours each, a resting ECG, and a report of fasting plasma glucose, cholesterol (LDL/HDL), triglycerides, potassium, and creatinine levels. A maximal electrocardiographic exercise stress test will be accomplished if it is indicated by history or clinical findings. Specific mention must be made of the medications used, their dosage, and the presence, absence, or history of adverse effects. The initiation of medication or change in dosage is not disqualifying. However, the applicant must not exercise the privileges of the medical certificate for at least 2 weeks. Upon reevaluation, if the blood pressure is controlled without side effects the applicant may resume flying duties. In rare cases where the initial hypertension was severe, additional time may be necessary for normalization of renal and cerebral vascular circulation.
At subsequent flight physicals the AME may conduct a followup evaluation to include a current status report describing at least the medications used and their dosages, the adequacy of blood pressure control, the presence or absence of side effects, the presence or absence of end-organ complications and the results of any appropriate tests or studies. A potassium level is required if the airman is taking a diuretic.
1.[FONT="] [/FONT]Medication used to treat hypertension include all Food and Drug Administration (FDA) approved diuretics, alpha-adrenergic blocking agents, beta-adrenergic blocking agents, calcium channel blocking agents, angiotension converting enzyme (ACE inhibitors) agents, and direct vasodilators. The following Centrally acting agents (such as, reserpine, guanethidine, guanadrel, guanabenz, and methyldopa) are not usually acceptable to the FAA. These drugs are rarely used in the United States any more. Dosage levels of the medication used should be the minimum necessary to obtain optimal clinical control and should not be modified to influence the certification decision.
Valvular heart disease: All valvular heart disease requires an initial decision by the FAA before a medical certificate can be issued. Follow-up issuance for mitral or aortic insufficiency requires the AME to review:
[FONT="] [/FONT]An Authorization granted by the FAA;
[FONT="] [/FONT]A summary of the applicant’s medical condition since the last FAA medical examination, including a statement regarding any further episodes of atrial fibrillation; and
[FONT="] [/FONT]A current 2-D echocardiogram with Doppler performed within last 90 days.
Which are submitted by the pilot to the AME. If the results of this evaluation is acceptable, the AME may issue the medical certificate.
There are other serious heart conditions where the AME is required to defer the decision to OKC.
The following conditions must be deferred:
·[FONT="] [/FONT]Heart Transplant – at the present time, due to the unpredictability of segmental coronary artery disease, certification is not being granted
·[FONT="] [/FONT]Cardiac decompensation
·[FONT="] [/FONT]Congenital heart disease accompanied by cardiac enlargement, ECG abnormality, or evidence of inadequate oxygenation
·[FONT="] [/FONT]Hypertrophy or dilatation of the heart as evidenced by clinical examination and supported by diagnostic studies
·[FONT="] [/FONT]Pericarditis, endocarditis, or myocarditis
·[FONT="] [/FONT]When cardiac enlargement or other evidence of cardiovascular abnormality is found, the decision is deferred to the FAA. If the applicant wishes further consideration, a consultation will be required "preferably" from the applicant’s treating physician. It must include a narrative report of evaluation and be accompanied by an ECG with report and appropriate laboratory test results which may include, as appropriate, 24-hour Holter monitoring, thyroid function studies, ECHO, and an assessment of coronary artery status.
·[FONT="] [/FONT]Anti-tachycardia devices or implantable defibrillators
·[FONT="] [/FONT]With the possible exceptions of aspirin and dipyridamole taken for their effect on blood platelets, the use of anticoagulants or other drugs for treatment or prophylaxis of fibrillation may preclude medical certification
·[FONT="] [/FONT]A history of cardioversion or drug treatment, per se, does not rule out certification. A current, complete cardiovascular evaluation will be required. A 3-month observation period must elapse after the procedure before consideration for certification
·[FONT="] [/FONT]A history of low blood pressure requires elaboration.
For all classes, certification decisions will be based on the applicant's medical history and current clinical findings. Certification is unlikely unless the information is highly favorable to the applicant. Evidence of extensive multi-vessel disease, impaired cardiac functioning, precarious coronary circulation, etc., will preclude certification. Before an applicant undergoes coronary angiography, it is recommended that all records and the report of a current cardiovascular evaluation, including a maximal electrocardiographic exercise stress test, be submitted to the FAA for preliminary review. Based upon this information, it may be possible to advise an applicant of the likelihood of favorable consideration.
*Italicized text from FAA documents
I hope this stuff doesn't bum you out. It is important you know what to do if faced with any of the problems we are discussing in this series of posts. Remember, Knowledge is your best weapon.
18g. Heart or vascular trouble
The applicant should describe the condition to include, dates, symptoms, and treatment, and provide medical reports to assist in the certification decision-making process. These reports should include: operative reports of coronary intervention to include the original cardiac catheterization report, stress tests, worksheets, and original tracings (or a legible copy). When stress tests are provided, forward the reports, worksheets and original tracings (or a legible copy) to the FAA. Part 67 provides that, for all classes of medical certificates, an established medical history or clinical diagnosis of myocardial infarction, angina pectoris, cardiac valve replacement, permanent cardiac pacemaker implantation, heart replacement, or coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant, is cause for denial. The following lists the most common conditions of aeromedical significance:
Arrhythmias (abnormal heart rhythm). There are more than a dozen types of arrhythmias. The FAA wants the pilot to have a full cardiac evaluation appropriate for the arrhythmia. The minimal evaluation includes:
·[FONT="] [/FONT]An assessment of personal and family medical history
·[FONT="] [/FONT]Clinical cardiac and general physical examination
·[FONT="] [/FONT]An assessment and statement regarding the applicant’s medications, functional capacity, modifiable cardiovascular risk factors
·[FONT="] [/FONT]Motivation for any necessary change
·[FONT="] [/FONT]Prognosis for incapacitation
·[FONT="] [/FONT]Blood chemistries (fasting blood sugar, current blood lipid profile to include total cholesterol, HDL, LDL, and triglycerides) performed within the last 90 days
In addition it may include echocardiograms to look at the structural anatomy of the heart, electrical monitoring studies, nuclear imaging studies or angiographic studies. Usually these studies provide sufficient information to allow the pilot to fly either with or without a Special Issuance medical certificate.
Atrial fibrillation. Unless the atrial fibrillation was more than 5 years ago, has not returned and there was a full evaluation for the cause, it will require a decision from the FAA. The evaluation includes:
1.[FONT="] [/FONT]Hospital admission summary (history and physical), coronary catheterization report, and operative report regarding all cardiac events and procedures.
2.[FONT="] [/FONT]A current cardiovascular evaluation must include an assessment of personal and family medical history; a clinical cardiac and general physical examination; an assessment and statement regarding the applicant's medications, functional capacity, modifiable cardiovascular risk factors, motivation for any necessary change, prognosis for incapacitation; and blood chemistries (fasting blood sugar and current blood lipid profile to include total cholesterol, HDL, LDL, and triglycerides).
3.[FONT="] [/FONT]A current maximal GXT
4.[FONT="] [/FONT]Echocardiogram
5.[FONT="] [/FONT]Holter monitor (24-hour recording heart monitor)
If a Special Issuance certificate was granted, the AME may issue subsequent certificates if the applicant provides the following:
Coronary Heart Disease: For pilots with Angina Pectoris; Atherectomy; Brachytherapy; Coronary Bypass Grafting; Myocardial Infarction; Percutaneous Transluminal Angioplasty (PTCA); Rotoblation; and Stent Insertion, the evaluation requires the items listed in atrial fibrillation above plus a maximal thallium (nuclear) stress test and a “post-event “ heart catheterization. Without the catheterization, the likelihood of receiving a Class 1 or unlimited 2 medical certificate is slim to none. Limited second-class medical certificate refers to a second-class certificate with a functional limitation such as, Not Valid for Carrying Passengers for Compensation or Hire, Not Valid for Pilot in Command, Valid Only When Serving as a Pilot Member of a Fully Qualified Two-Pilot Crew, Limited to Flight Engineer Duties Only, etc.
Hypertension requiring medication: This requires an initial hypertension evaluation before the AME can issue a certificate. If the data from the evaluation is acceptable, the AME may issue the medical certificate. The evaluation includes: pertinent personal and family medical history, including an assessment of the risk factors for coronary heart disease, a clinical examination including at least three blood pressure readings separated by at least 24-hours each, a resting ECG, and a report of fasting plasma glucose, cholesterol (LDL/HDL), triglycerides, potassium, and creatinine levels. A maximal electrocardiographic exercise stress test will be accomplished if it is indicated by history or clinical findings. Specific mention must be made of the medications used, their dosage, and the presence, absence, or history of adverse effects. The initiation of medication or change in dosage is not disqualifying. However, the applicant must not exercise the privileges of the medical certificate for at least 2 weeks. Upon reevaluation, if the blood pressure is controlled without side effects the applicant may resume flying duties. In rare cases where the initial hypertension was severe, additional time may be necessary for normalization of renal and cerebral vascular circulation.
At subsequent flight physicals the AME may conduct a followup evaluation to include a current status report describing at least the medications used and their dosages, the adequacy of blood pressure control, the presence or absence of side effects, the presence or absence of end-organ complications and the results of any appropriate tests or studies. A potassium level is required if the airman is taking a diuretic.
1.[FONT="] [/FONT]Medication used to treat hypertension include all Food and Drug Administration (FDA) approved diuretics, alpha-adrenergic blocking agents, beta-adrenergic blocking agents, calcium channel blocking agents, angiotension converting enzyme (ACE inhibitors) agents, and direct vasodilators. The following Centrally acting agents (such as, reserpine, guanethidine, guanadrel, guanabenz, and methyldopa) are not usually acceptable to the FAA. These drugs are rarely used in the United States any more. Dosage levels of the medication used should be the minimum necessary to obtain optimal clinical control and should not be modified to influence the certification decision.
Valvular heart disease: All valvular heart disease requires an initial decision by the FAA before a medical certificate can be issued. Follow-up issuance for mitral or aortic insufficiency requires the AME to review:
Which are submitted by the pilot to the AME. If the results of this evaluation is acceptable, the AME may issue the medical certificate.
There are other serious heart conditions where the AME is required to defer the decision to OKC.
The following conditions must be deferred:
·[FONT="] [/FONT]Heart Transplant – at the present time, due to the unpredictability of segmental coronary artery disease, certification is not being granted
·[FONT="] [/FONT]Cardiac decompensation
·[FONT="] [/FONT]Congenital heart disease accompanied by cardiac enlargement, ECG abnormality, or evidence of inadequate oxygenation
·[FONT="] [/FONT]Hypertrophy or dilatation of the heart as evidenced by clinical examination and supported by diagnostic studies
·[FONT="] [/FONT]Pericarditis, endocarditis, or myocarditis
·[FONT="] [/FONT]When cardiac enlargement or other evidence of cardiovascular abnormality is found, the decision is deferred to the FAA. If the applicant wishes further consideration, a consultation will be required "preferably" from the applicant’s treating physician. It must include a narrative report of evaluation and be accompanied by an ECG with report and appropriate laboratory test results which may include, as appropriate, 24-hour Holter monitoring, thyroid function studies, ECHO, and an assessment of coronary artery status.
·[FONT="] [/FONT]Anti-tachycardia devices or implantable defibrillators
·[FONT="] [/FONT]With the possible exceptions of aspirin and dipyridamole taken for their effect on blood platelets, the use of anticoagulants or other drugs for treatment or prophylaxis of fibrillation may preclude medical certification
·[FONT="] [/FONT]A history of cardioversion or drug treatment, per se, does not rule out certification. A current, complete cardiovascular evaluation will be required. A 3-month observation period must elapse after the procedure before consideration for certification
·[FONT="] [/FONT]A history of low blood pressure requires elaboration.
For all classes, certification decisions will be based on the applicant's medical history and current clinical findings. Certification is unlikely unless the information is highly favorable to the applicant. Evidence of extensive multi-vessel disease, impaired cardiac functioning, precarious coronary circulation, etc., will preclude certification. Before an applicant undergoes coronary angiography, it is recommended that all records and the report of a current cardiovascular evaluation, including a maximal electrocardiographic exercise stress test, be submitted to the FAA for preliminary review. Based upon this information, it may be possible to advise an applicant of the likelihood of favorable consideration.
*Italicized text from FAA documents
I hope this stuff doesn't bum you out. It is important you know what to do if faced with any of the problems we are discussing in this series of posts. Remember, Knowledge is your best weapon.
