My Flight Surgeon
Sr. Aviation Medical Examiner
This is one of a series of posts about medical issues potentially affecting a pilot’s ability to obtain a medical certificate. In this series, we will look at common problems seen by the AME, review the requirements the FAA has to consider allowing one to fly and discuss what you need to do to expedite consideration by the FAA to allow you to fly. We plan to go through all of the medical history items in Section 18 on the front of Form 8500-8 over the next several months.
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.
Item 18. h. High or low blood pressure
Hypertension (high blood pressure) requiring medication is a common problem seen by the AME. The short version is, if the pressure is controlled with medication and there are no side effects the AME may issue the certificate. There is some supporting information the AME must have though.
For those presenting with hypertension for the first time:
Disease Protocols
Hypertension - Initial
The Examiner (this is the AME) may issue first-, second-, or third-class medical certificates to otherwise qualified airmen whose hypertension is adequately controlled with acceptable medications without significant adverse effects. In such cases, the Examiner shall:
1. Conduct an evaluation or, at the applicant's option, review the report of a current (within preceding 6 months) cardiovascular evaluation by the applicant's attending physician. This evaluation must include 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.
2. Summarize the results of this evaluation in Item 60 of the transmitted application and forward the appropriate documents to the Aeromedical Certification Division.
3. Report the results of any additional tests or evaluations that have been accomplished.
4. If appropriate, state in Item 60 on the FAA Form 8500-8 that the applicant's blood pressure is adequately controlled with acceptable medication, there are no known significant adverse effects, and no other cardiovascular, cerebrovascular, or arteriosclerotic disease is evident.
5. Defer certification if the person declines any of the recommended evaluations.
For those who have previously reported their hypertension:
Disease Protocols
Hypertension – Follow-up
Follow-up evaluations must 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. This evaluation can be performed by the Examiner if the Examiner can attest to the accuracy of the above information. Hypertension follow-ups are required annually for first- and second-class medical certificate applicants and at the time of renewal for third-class certificate applicants.
There are now many medications approved by the FAA for the treatment of hypertension. The citation is reproduced below regarding these medications.
Disease Protocols
Hypertension - Medications
1. Medications acceptable to the FAA for treatment of hypertension in airmen 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. Centrally acting agents (such as, reserpine, guanethidine, guanadrel, guanabenz, and methyldopa) are not usually acceptable to the FAA. Dosage levels should be the minimum necessary to obtain optimal clinical control and should not be modified to influence the certification decision.
2. The Examiner may submit for the Federal Air Surgeon's review requests for Authorization under the special issuance section of part 67 (14 CFR § 67.401) in cases in which these or other usually unacceptable medications are used. Specialty evaluations are required in such cases and must provide information on why the specific drug is required. The Examiner's own recommendation should be included. The Examiner must defer issuance of a medical certificate to any applicant whose hypertension is being treated with unacceptable medications.
As with any medical problem, it is better to talk with your AME ahead of time rather than waiting until you get to the flight physical to only discover the certificate must be deferred because you need to supply more information.
Low Blood Pressure
A history of low blood pressure requires elaboration. If the Examiner is in doubt, it is usually better to defer issuance rather than to deny certification for such a history. We rarely see anyone with blood pressure low enough to interfere with flying unless they have some other significant medical problem.
*Italicized text is from FAA documents
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.
Item 18. h. High or low blood pressure
Hypertension (high blood pressure) requiring medication is a common problem seen by the AME. The short version is, if the pressure is controlled with medication and there are no side effects the AME may issue the certificate. There is some supporting information the AME must have though.
For those presenting with hypertension for the first time:
Disease Protocols
Hypertension - Initial
The Examiner (this is the AME) may issue first-, second-, or third-class medical certificates to otherwise qualified airmen whose hypertension is adequately controlled with acceptable medications without significant adverse effects. In such cases, the Examiner shall:
1. Conduct an evaluation or, at the applicant's option, review the report of a current (within preceding 6 months) cardiovascular evaluation by the applicant's attending physician. This evaluation must include 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.
2. Summarize the results of this evaluation in Item 60 of the transmitted application and forward the appropriate documents to the Aeromedical Certification Division.
3. Report the results of any additional tests or evaluations that have been accomplished.
4. If appropriate, state in Item 60 on the FAA Form 8500-8 that the applicant's blood pressure is adequately controlled with acceptable medication, there are no known significant adverse effects, and no other cardiovascular, cerebrovascular, or arteriosclerotic disease is evident.
5. Defer certification if the person declines any of the recommended evaluations.
For those who have previously reported their hypertension:
Disease Protocols
Hypertension – Follow-up
Follow-up evaluations must 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. This evaluation can be performed by the Examiner if the Examiner can attest to the accuracy of the above information. Hypertension follow-ups are required annually for first- and second-class medical certificate applicants and at the time of renewal for third-class certificate applicants.
There are now many medications approved by the FAA for the treatment of hypertension. The citation is reproduced below regarding these medications.
Disease Protocols
Hypertension - Medications
1. Medications acceptable to the FAA for treatment of hypertension in airmen 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. Centrally acting agents (such as, reserpine, guanethidine, guanadrel, guanabenz, and methyldopa) are not usually acceptable to the FAA. Dosage levels should be the minimum necessary to obtain optimal clinical control and should not be modified to influence the certification decision.
2. The Examiner may submit for the Federal Air Surgeon's review requests for Authorization under the special issuance section of part 67 (14 CFR § 67.401) in cases in which these or other usually unacceptable medications are used. Specialty evaluations are required in such cases and must provide information on why the specific drug is required. The Examiner's own recommendation should be included. The Examiner must defer issuance of a medical certificate to any applicant whose hypertension is being treated with unacceptable medications.
As with any medical problem, it is better to talk with your AME ahead of time rather than waiting until you get to the flight physical to only discover the certificate must be deferred because you need to supply more information.
Low Blood Pressure
A history of low blood pressure requires elaboration. If the Examiner is in doubt, it is usually better to defer issuance rather than to deny certification for such a history. We rarely see anyone with blood pressure low enough to interfere with flying unless they have some other significant medical problem.
*Italicized text is from FAA documents
