An introduction to aviation cardiology

Abstract

The management of cardiovascular disease (CVD) has evolved significantly in the last 20 years; however, the last major publication to address a consensus on the management of CVD in aircrew was published in 1999, following the second European Society of Cardiology conference of aviation cardiology experts. This article outlines an introduction to aviation cardiology and focuses on the broad aviation medicine considerations that are required to manage aircrew appropriately and optimally (both pilots and non-pilot aviation professionals). This and the other articles in this series are born out of a 3 year collaborative working group between international military aviation cardiologists and aviation medicine specialists, many of whom also work with and advise civil aviation authorities, as part of a North Atlantic Treaty Organization (NATO) led initiative to address the occupational ramifications of CVD in aircrew (HFM-251). This article describes the types of aircrew employed in the civil and military aviation profession in the 21st century; 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.

The role of cardiovascular CT in occupational health assessment for coronary heart disease: An expert consensus document from the Society of Cardiovascular Computed Tomography (SCCT)

“…Despite efforts to unify standards, diverse approaches exist to evaluate a pilot's risk for CVD events with variable requirements to report medical conditions to authorities, although efforts have recently been undertaken to improve consensus in cardiovascular risk assessment by a group of aviation cardiologists working as part of a NATO initiative to develop international consensus in this field. 94 When considering occupational limitations in aircrew, the usual acceptable risk of incapacitation for multi-pilot commercial flying is based on the so-called "1% rule." This rule states the maximum acceptable risk of pilot incapacitation should be less than 1% per year from any medical condition.…”

Congenital heart disease in aircrew

“…For those with an aortopathy, surgical intervention may be required if the ascending aorta is dilated, 6 and treatments such as β-blockers, with their potential impact on G z tolerance, may result in restriction or grounding of certain aircrew. 5 …”

“… 3 4 Additionally, most individuals require long-term follow-up due to the risk of long-term sequelae and the need for intervention and surgery, while the aviation environment may expose aircrew to additional physiological stressors (such as hypoxia, hypobaria and potentially sustained acceleration (+G z )) that may increase these risks further. 5–7 Therefore, appropriate risk assessment is paramount to ensure flight safety.…”

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

“… 3 This is particularly important in the risk assessment of aircrew, many of whom are young and undertaking routine high hazard activities in which incapacitation or distraction may prove catastrophic. 4 In military aircrew, this may be further compounded by operating in a hostile environment with limited access to health facilities and sometimes in high performance aircraft with additional haemodynamic consequences. For example, a 50% stenosis may demonstrate no ischaemia on a full Bruce exercise protocol, but theoretically may still cause ischaemia under 9 G z in a fighter aircraft.…”