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

Abstract

This manuscript focuses on the broad aviation medicine considerations that are required to optimally manage aircrew with established coronary artery disease (CAD) without myocardial infarction (MI) or revascularisation (both pilots and non-pilot aviation professionals). It presents expert consensus opinion and associated recommendations and is part of a series of expert consensus documents covering all aspects of aviation cardiology.Aircrew may present with MI (both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI)) as the initial presenting symptom of obstructive CAD requiring revascularisation. Management of these individuals should be conducted according to published guidelines, ideally with consultation between the cardiologist, surgeon and aviation medical examiner. Return to restricted flight duties is possible in the majority of aircrew; however, they must have normal cardiac function, acceptable residual disease burden and no residual ischaemia. They must also be treated with aggressive cardiac risk factor modification. Aircrew should be restricted to dual pilot operations in non-high-performance aircraft, with return to flying no sooner than 6 months after the event. At minimum, annual follow-up with routine non-invasive cardiac evaluation is recommended.

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

“…Consequently, following the 1% rule, the pilot in Case 2 will be denied for recertification as the annual event rates of restenosis is 2%-4% per year. 7 Risk assessment is begun by performing an initial riskstratification using a population-appropriate risk calculator. The risk assessment classifies risk as low (<10%/decade or <1%/year), intermediate (10%-20%/decade or 1%-2%/ year), and high (>20%/decade or >2%/year).…”

“…Pilots with FFR values less than 0.8 may be allowed restricted flight duties (nonperformance aircraft and multicrew-operation). 7,10 Although revascularization looks promising for recertification of flying fitness, a pilot who undergoes a revascularization procedure are critically assessed for the following three elements: (1) type of revascularization (PCI vs CABG);…”

“…In contrast, for revascularization using PCI, most of the baremetal stents and drug-eluting stents (DES) are acceptable for pilots, with the exception of nonstent (plain old balloon) angioplasty (POBA), which has early restenosis rates as high as 35% which most often occurs within the first two to three months. 7 For case 2, a SYNERGY stent was used for the PCI. It is a metal stent with a special drug coating added to help reduce the chance of the artery becoming blocked again.…”

“…However, it is generally recommended to wait for six months due to the risk of restenosis, late in-stent thrombosis, or the possibility of MACE. 7 In evaluating return-to-work of pilots with CAD the cardiopulmonary exercise (CPX) test was not performed as all the pilots have good effect tolerance (except cases 3 and 4). All of them were asymptomatic and had EF of more than 50%.…”

An introduction to aviation cardiology

“…It is possible to return to flying after a diagnosis of CVD, although this may be in a limited occupational role, and special attention to the pharmacological management, intervention or perioperative planning is essential. The choice of procedure (eg, percutaneous coronary intervention (PCI) with stenting vs full revascularisation with coronary artery bypass grafting (CABG)) 13 or consideration of the prosthetic material (eg, stentless bioprosthesis) used for a valve replacement 18 are often critical in the determination of licence renewal, but intervention should always be driven by the clinical need, not the occupational one.…”