Your Heart in the Sky 
A pilot’s patched-up heart can fly again

 
Stephen D. Leonard, MD Aeromedical Advisory Council

Sport Aviation - June 2000

Not too many years ago, an aviator who had a heart attack (myocardial infarction), or evidence of coronary artery disease, was an ex-aviator with little or no hope of getting back in the cockpit. But advances in the treatment of ischemic heart disease (inadequate blood supply to the heart muscle) have been matched by a change in the way FAA deals with the problem. 

It is now possible for many private pilots, and even determined commercial pilots, to get back in the air after a brush with this potentially catastrophic condition. Naturally, not everyone will be able to resume flying. Heart attacks still kill more Americans than any other illness, and some who survive are unstable enough that they can never be medically recertified to fly. But for many, with proper treatment and a bit of luck, the recovery from a heart attack or coronary revascularization procedure (bypass or angioplasty/stent) results in a strong, stable heart, and minimal chance of sudden incapacitation. 

FAA’s interest is in determining that you won’t pose a danger to yourself or the public if you resume flying. The first thing it requires before you try to spread your wings again is to wait six months. The first six months after a heart attack carry the highest risk for further heart damage, and the highest risk of clotted bypasses and failed angioplasties, so the pilot who goes six months with no problems has shown that he’s in a better risk category. At the end of the six-month period, if you feel good, and your cardiologist pronounces you fit, it’s time to start gathering the evidence to convince FAA that your body is airworthy. Again, the evaluation cannot begin until after six full months have passed. FAA will not accept tests done any sooner.

Gathering all the evidence is tedious, but we’re talking about your wings here, so it’s worth the effort. Some of the tests are ones your cardiologist is likely to have wanted anyway, but some are definitely extra. Here’s what you’ll need: 

1. A formal request from the pilot to the FAA for a Special Issuance under FAR 67.19. 
2. Copies of ALL medical and hospital records concerning the cardiac condition. Hospital records must include admission and discharge summaries, operative report, history and physical exam, progress notes, laboratory work, and all diagnostic test results, including originals or legible copies of complete ECG treadmill tracings (not just the interpretation). This will be an inch-thick pile of paper, but it’s what they require. 
3. A cardiovascular evaluation by your treating cardiologist or internist, including: (a) a reassessment of personal and family medical history; (b) clinical cardiac exam and general physical exam; (c) blood lipid profile (cholesterol, HDL, LDL, and triglycerides) and blood glucose determination; (d) assessment regarding the medications, functional capacity, modifiable cardiovascular risk factors, motivation for necessary change, and (critically important) the physician’s estimate of your risk of sudden incapacitation; (e) maximal treadmill stress ECG, which should achieve 100 percent of predicted heart rate, and must achieve at least 85 percent to be considered, even if this requires discontinuing medications—with your doctor’s permission; and (f) stress echocardiography or nuclear cardiology studies (MUGA, technecium, SPECT thallium, or cardiolite scans) may be required if indicated, or if the treadmill ECG is abnormal or equivocal. As with the treadmill test, original films, as well as interpretations and blood pressure/pulse recordings must be submitted for FAA’s cardiology consultants to review. 
4. If anticoagulants (“blood thinners”) are used, an evaluation by the attending physician must include evidence that the dosage is stable, with no complications. Dose schedules, prothrombin times, or INR values (including lab controls) must be reported at monthly or shorter intervals, for a six-month period. 
5. For commercial pilots requesting a first-class or unlimited second-class certificate, cardiac catheterization/coronary angiography must be done no sooner than six months after the event. All films, reports, and line drawings must be sent to FAA. 

The bottom line is that it’s not an easy road back to the cockpit, but it can be accomplished with luck and determination. The FAA Aeromedical Certification Division wants to certify everyone who can fly safely, and these requirements, stiff as they seem, are a hurdle that many pilots have successfully cleared. You’ll need an AME who is willing to take the extra time to work with you to be sure all the “i’s” are dotted and the “t’s” crossed. If you don’t know where to find a good one, EAA can direct you to the nearest AME Pilot Advocate. So don’t give up. Quit smoking, follow your doctor’s advice on diet and exercise, and start building a case to regain your Airman Medical Certificate, and slip again the surly bonds of Earth.