The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident

Abstract

Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.

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)

“…12 Cardiovascular screening in safety sensitive occupations may be divided into initial screening and enhanced screening. 56 Initial screening often includes the use of risk assessment calculators, a standard 12-lead, or exercise, electrocardiogram, and screening bloods. Enhanced screening may include coronary artery calcium scoring and, increasingly coronary CT angiography (CTA).…”

“…For this reason, the Exercise ECG should be discouraged as a stand-alone tool to determine significant CAD in those who undertake safety sensitive employment. 56…”

“…18,111 Furthermore, there is evidence of systemic underreporting of cardiac symptoms among the military pilot and aircrew population 112 likely stemming from aircrew being cognizant that CV disease is the most common reason for flight disqualification. 56,[112][113][114]…”

Exercise Testing in Firefighters : Work Capacity and Cardiovascular Risk Assessment in a Low-Risk Population

“…Subjects at increased risk should go through enhanced screening with cardiac CT. Lastly, if the enhanced screening indicates high risk, second line investigations including functional ischaemia testing and potentially invasive coronary angiography, follow. The aircrew recommendation also states that ExECG may be added after performing the cardiac CT, but that it is discouraged as a sole screening tool for CAD [100]. Implementing a similar model for firefighters is attractive.…”

An introduction to aviation cardiology

“…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.…”