You Gotta Have Heart


Posted on Apr 12, 2021 by Dr. Jerrold Seckler

The heart is a muscular organ located in the chest whose purpose is to pump blood throughout the body. It consists of four chambers – two atria and two ventricles. The right atrium receives blood from the body and pushes it into the right ventricle, which then pumps the blood to the lungs where it is oxygenated. The blood returns to the heart via the left atrium, and then goes into the left ventricle, which is the chamber that pumps blood throughout the rest of the body.

Like all organs, the heart requires oxygen to function and it has its own circulation provided by the coronary arteries. The coronary arteries arise from the aorta (the main artery leading from the heart) just after its junction with the heart. There are two primary coronary arteries, the left and the right. The right coronary artery supplies blood to the right atrium and ventricle as well as a small portion of the left ventricle. The left coronary artery branches into two smaller arteries, the left anterior descending coronary artery (LAD) and the circumflex artery. These arteries supply the left atrium and the bulk of the left ventricle, the heart’s main pump.

As we age, fat deposits on the walls of these arteries (the process begins in the teens) and as the process continues, other substances in the blood, including calcium and proteins, stick to the fat and form what’s called a plaque. These plaques narrow the diameter of the artery, restricting blood flow. Eventually the plaque “cracks” and serves as a nidus for a blood clot to form. These clots can further impede the blood flow causing the heart muscle to become ischemic (deprived of oxygen).

Cardiac ischemia causes chest pain, especially with exertion (angina), shortness of breath, palpitations, nausea, sweating and a feeling of weakness. The chest pain is usually described as a heavy pressure and may radiate into the left shoulder and down the left arm. With rest, angina may subside, but if the degree of ischemia is sufficient, some heart muscle may infarct (die due to lack of oxygen). That’s the classic “heart attack” or myocardial infarction.

While there is certainly a genetic predisposition to developing coronary artery disease (CAD), the progression of the condition is lifestyle related. You can minimize the risk of developing CAD by exercising regularly and maintaining your weight at an optimum level. For many years, health authorities advised eating a diet low in fat, but this is now being questioned. In fact, some researchers believe that many people responded to the low fat guidelines by replacing some of the fat in their diets with carbohydrates. That may have led to the increase in obesity and diabetes we’ve seen over the last 30 years. Both diabetes and obesity are risk factors for CAD. Until the role of diet is clearly understood, it’s best for persons to maintain a normal weight and normal blood lipid levels (cholesterol, high and low density lipoproteins and triglycerides).

Clearly coronary artery disease is of concern to the FAA. Myocardial infarction (MI) can result in sudden incapacitation or even death. If a pilot has symptoms of, or has been diagnosed with coronary artery disease, he must ground himself immediately. FAR 61.53 states that no person who holds a medical certificate … may act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person: 1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate for the pilot operation. FAR 67 states that any history or clinical diagnosis of myocardial infarction, angina, or coronary artery disease that has required treatment, or, if untreated, that has been symptomatic or clinically significant are disqualifying conditions. Therefore, any pilot with a history or symptoms of coronary artery disease may not fly unless he is specifically allowed to by the FAA Special Issuance procedures.

If one is diagnosed with coronary artery disease or has an actual MI, there is a waiting period before the FAA will even consider a Special Issuance. That waiting period varies from three to six months, depending on whether the patient received any invasive treatment (coronary bypass surgery, percutaneous stenting), and whether the affected artery was the right or left coronary. Any surgical or stenting procedures involving the left coronary artery requires the six month wait.

Once the waiting period has elapsed, the applicant can go to his AME and have an exam. The AME will defer issuance to the FAA Aeromedical Certification Branch in Oklahoma City. The FAA will want considerable documentation including all reports from your treating physician, a GXT (graded exercise test), blood lipid levels, medications, and cardiac catheterization. There are additional requirements if one wants a Special Issuance for a First or Second Class medical. The requirements are strict and complex and I would strongly recommend discussing them with your AME before deciding whether you want to proceed with the Special Issuance process.

Once a Special Issuance is issued, renewals can be done by the AME directly, although the airman will need a full status report and maximal GXT at the time of each renewal.

As with all conditions requiring a Special Issuance, ask yourself whether you would be happy with flying light sport aircraft (LSA) using your driver’s license as your “medical.” If you apply for a medical and are told a Special Issuance is needed, you MUST follow through and obtain it or your medical will be denied. If that happens, you are no longer eligible to fly using the LSA/driver’s license option.

This article was initially published in the November/December 2014 issue of COPA Pilot.

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