FAA Medical After a Heart Attack

FAA Medical After a Heart Attack

Can I get my FAA medical after a heart attack? If you are asking this question, there is hope for you, as there are many pilots who are able to reestablish eligibility for a FAA medical after a heart attack. The protocols for consideration of your medical eligibility following a heart attack are a bit nuanced, however, and they don’t always correlate to clinical practices. In other words, after a heart attack, the FAA’s risk mitigation protocol can often be different from what your treating physician may consider clinically necessary or relevant. On the other hand, the FAA’s standards and practices are designed for assessing and mitigating the risk for sudden incapacitation within the National Airspace System. As a result, there is often a disconnect between what your doctor would require from you in the normal course of treatment and what the FAA may require for mitigation of risk to aviation safety. This article will discuss some of these nuances and also, how you can get your FAA medical after a heart attack.

Having a medical history or clinical diagnosis of myocardial infarction or “heart attack” is a specifically disqualifying condition for airman medical certification pursuant to the Federal Aviation Regulations. See 14 C.F.R. §§ 67.111(a)(1), 67.211(a)(1), and 67.311(a)(1). What’s more (and significant to the process for showing the FAA that you are eligible for a medical after a heart attack) is that the regulations also identify the following, disqualifying condition: “coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant.” See 14 C.F.R. §§ 67.111(a)(3), 67.211(a)(3), and 67.311(a)(3). It is important to look at these two “conditions” together for FAA medical certification purposes. Why? Well, because these conditions are identified in the regulations as being specifically disqualifying for FAA medical certification, you will require a special issuance authorization (waiver) in order to be issued a FAA medical certificate. During the process of evaluating your medical history for purposes of special issuance authorization, the FAA will consider whether you have coronary artery disease which remains untreated following your heart attack. Typically, this is where we see a disconnect between clinical medicine and regulatory medicine. For example, we typically see cases where an airman’s treating physician may not believe that an artery occlusion may be significant enough for treatment (such as implantation of a stent); however, the FAA might believe that for purposes of risk mitigation, the very same artery occlusion should be treated with a stent or some other form of treatment. More often than not, it has been the experience of our practice that it is usually a heart attack which will cause an airman to be denied a FAA medical certificate, but rather, it is the coronary artery disease which is left untreated and exposed to the FAA as a result of the heart attack.

So, what will the FAA look for after a heart attack? At the “heart” of the issue, is whether your heart attack or remaining coronary artery disease, if any, puts you at risk for prolonged physical deficiencies or risk for repeat heart attack/sudden incapacitation. The FAA’s assessment of your application will depend on the type of treatment you received for your heart attack, as well as what class FAA medical certificate you apply for.

There are four broad categories in which the FAA triages coronary artery disease, whether you have had a heart attack, or not. These categories include the following:

Category One: open revascularization of any coronary artery(s) and left main artery stenting

  • According to the FAA, this is considered “open revascularization includes coronary artery bypass grafting (CABG; on- or off-pump), minimally invasive procedures by incision, and robot operations. Left main coronary artery stenting carries the same risk of future cardiac events as CABG, thus it is treated the same for certification or qualification purposes.”

Category Two: percutaneous intervention

  • According to the FAA, this is considered “angioplasty (PTCA) and bare metal or drug-eluting stents.”

Category Three: myocardial infarction without any open or percutaneous intervention

  • This is a situation in which there has been no treatment for your heart attack.

Category Four: myocardial infarction from non-coronary artery disease causes

  • According to the FAA, these are situations in which a heart attack may be caused by something other than coronary artery disease such as “epinephrine injection, cardiac trauma, complications of catheterization, blood clotting disorders (e.g. PT/PTT, Protein S and C, Factor V Leiden), etc.”

Once your situation has been appropriately categorized, the FAA will determine what observation period, post-heart attack/treatment, will be required and what level of testing/documentation will be required for FAA review. Both the observation/recovery period and testing will be different based on you the category of your situation (from above) and the class medical you have applied for. These requirements are as follows:

FIRST CLASS MEDICAL
6-Month Observation Period

Category One Situations

3-Month Observation Period

Categories Two, Three, and Four Situations

SECOND CLASS MEDICAL
6-Month Observation Period

Category One Situations

3-Month Observation Period

Categories Two, Three, and Four Situations

THIRD CLASS MEDICAL
Observation Not Required

Once you’ve achieved the required observation period, the FAA will require that you provide records regarding your heart attack, as well as your current function. Again, this is where there may be a disconnect between what your treating physician and the FAA may believe to be reasonable. In many cases, but not all cases, we experience treating cardiologists disagreeing with the necessity of repeat or redundant testing, as required by the FAA. Nevertheless, the FAA’s requirements, generally, are as follow:

CATEGORY ONE
First and Unlimited Second Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies;
  3.  6-month, post event, maximal, radionuclide, graded stress test; and,
  4.  6-month, post-event, cardiac catheterization.

Third Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies; and,
  3.  Maximal, plain graded stress test.

 

CATEGORY TWO
First and Unlimited Second Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies;
  3.  Copy of operative or post procedure report. If a stent was placed, the report must include make of stent, implant location(s), and the length and diameter of each stent(s).
  4.  3-month, post event, maximal, radionuclide, graded stress test; and,
  5.  3-month, post-event, cardiac catheterization.

Third Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies; and
  3.  Copy of operative or post procedure report. If a stent was placed, the report must include make of stent, implant location(s), and the length and diameter of each stent(s).
  4. Maximal, plain graded stress test.
CATEGORY THREE
First and Unlimited Second Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies;
  3.  3-month, post event, maximal, radionuclide, graded stress test; and,
  4.  3-month, post-event, cardiac catheterization.

Third Class:

  1.  Current, detailed, clinical progress report from treating cardiologist;
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies; and,
  3.  Maximal, plain graded stress test.

 

CATEGORY FOUR
All Classes

  1.  Current, detailed, clinical progress report from treating physician; and,
  2.  Copies of all medical records (inpatient and outpatient) relevant to the event, including all labs, tests, or studies.

We recommend that you consider the following when applying for a FAA medical certificate after a heart attack, especially when applying for the first time following an event:

  • You should always report your history of a heart attack or coronary artery disease to the FAA on your application for FAA medical certificate, Form 8500-8 (MedXPress). The responsive question to such an event is question 18g., which asks if you in your life whether you have been diagnosed with, had, or presently have “heart of vascular trouble.” A heart attack and/or treatment would qualify as a “yes” to this question. Remember, that if the FAA discovers a diagnosis or treatment which has not been appropriately reported on your application for airman medical certification, you could be at risk for enforcement action and revocation of your airman certificates.
  • There is often a struggle, especially in cases of post-event, cardiac catheterization, in convincing treating cardiologists that testing required by the FAA is necessary. Usually, explaining to your physician that the FAA’s standards are regulatory in nature and not to clinical standards can help provide context for the FAA’s requests.
  • When performing a standard, Bruce protocol stress test, the FAA will require that your heart rate achieve no less than 85% of the calculated maximum predicted heart rate and that you walk for a minimum of 9 minutes if you are under the age of 70 and a minimum of 6 minutes if you are over the age of 70.
  • Your treating cardiologist should identify in a statement to the FAA, if applicable, that you are demonstrating attempts to meet goals regarding the modifiable risk factors as recommended by the ACC or AHA guidelines, especially as it relates to lipid panels.
  • If post-event, testing reveals any level of remaining coronary artery disease or ischemia, be sure to have your treating cardiologist identify for the FAA why such disease is not clinically significant, if applicable. See 14 C.F.R. §§ 67.111(a)(3), 67.211(a)(3), and 67.311 (a)(3).
  • If you are applying for a first-class medical certificate following a heart attack and the FAA denies you, consider applying for a lower-class medical certificate (in the event your desired operations are suitable to a lower class medical certificate). The FAA may consider your situation favorably.
  • Your current status report from the treating cardiologist (cardiovascular evaluation (CVE) should include:
    • Personal and family medical history assessment; clinical cardiac and general physical examination; assessment and statement regarding the applicant’s functional capacity and prognosis for incapacitation
    • Documentation of counseling on modifiable cardiovascular risk factors
    • All medications and side-effects, if any
    • Labs (lipids, blood glucose)
  • Remember that if you also have hypertension, the FAA will likely consider you for the CACI program, but hypertension following a heart attack may be considered an aggravating factor in considering future risk mitigation. Listen to more on The Pilot Lawyer Podcast.
  • For more information, check out The Pilot Lawyer Podcast, Episode 27.

If you are facing a FAA medical after a heart attack, consider a consultation with a FAA medical defense attorney at The Ison Law Firm before applying for a FAA medical certificate. We are happy to evaluate your case and discuss with you a plan for presenting your case to your AME or the FAA. Aviation law is all we do. Nothing else.