Cardiology Flashcards
That factors in the aviation environment may effect cardiovascular disorders
Hypoxia - all types Sustained G G countermeasures Stress Physical activity/workload
Effects of CVS disorders on aviation operations
Distracting symptoms: pain, palpitations Suddenly incapacitation, Haemodynamic compromise - Hypotension - syncope - silent disease - sudden death - thromboembolism
Medication side effects
Aortic stenosis, fit to fly?
No
Can’t increase CO in response to stresses
G strain eg would reduced CO
Possible exertional syncope
Relevant clinical information needed to access fit for fly
Aim to. Establish the Dx, ID aviation-relevant factors, determine risk of incapacitation, quantify risk of progression or recurrence, determine impact of tx on aviation safety.
Role, aircraft, type, crew configuration Hx of symptoms - symptoms awareness - episodes of incapacitation - relation to exertion Cardiovascular RF Lifestyle factors Family history
What to ask a cardiologist on a referral
Confirm diagnosis Management recommendation Prognosis Risk of incapacitification Follow up Or very specific Q
Never ask if pt fit to fly
Benefit and limitation of resting ECG
Cheap and easy, non invasive
Works better in serial
Useful for detection of rhythm and conduction disturbances
Very poor sensitive for underlying IHD in young asymptomatic individual
Benefit and limitation of exercise stress ECG
Easy, non-invasive, first line test for CAD
Bruce protocol required
- 100% predicted HR
- At least 9 mins
Monitor for 5 mins into recovery phase
No b blockers 48 hours
Contraindicated in unstable angina
Indication for holter monitor
Non-invasive test for 24 hours IX for - rhythms and conduction disturbances - syncope and pre-syncope - post ablation success
Use of MPS
Useful for detecting arterial spasm that doesn’t show up in coronary angiogram
The prognostic value related to ability of MPS to identify the presence and extent of jeopardised viable myocardium
Post MI - angiographic variables were not significant predictors of jeopardised viable myocardium regardless of underling coronary anatomy
Great negative predictive value
When to order a ECHO
IX murmurs Suspicion of structure all heart disease Pressure gradient/velocities Pericardial conditions Cardiomyopathy Ejection fraction estimation
Benefit of stress ECHO
Better sensitivity than exercise stress ECG
Assess functional ischaemia
Useful if ECG uniinterpretable
Negative results is very reassuring
Indications for coronary angiogram
Gold standard test for IHD
Clearly denies luminal coronary anatomy
Assesses left ventricular function
Clinical vs occupational indications
- pilot will need angiogram very 3-5 year after intervention
Indications for ambulatory BP monitoring
Diagnostic confirmation or investigate syncope
Eg rule out white coat hypertension
Calcium score benefit
Calcium score is an independent risk factor
Expensive
Stress echo is a better predictor
CAC means that atherosclerosis is present
Treatment considerations when assessing aircrew
Is the clinical conditions itself disqualifying
Is there definitive tx
What are the aviation relevant side effects
Is a ground trail required
Is tx providing effective control
Does control need to be monitored
Are there logistical treatment issues that interfere with aviation or deployment.
Consideration when starting antihypertensive therapy
Trial conservative therapy first
- no TMUFF in this time as long as <160/100mmHg and CVD risk score is acceptable and <6months
After trial then consider medication
- TMUFF 14 days initial and 7 day after a change
- UMECR required
Types
- ACEI/ARB first line agents
- Thiazides diuretics
- Ca Channel and B blocker - unfit for high-performance flying
- Alpha blockers not permitted for flying duties
Consideration for lipid lowering agents
Conservative therapy +fish oil
- no TMUFF and MECR if CVD score ok
Statins first line
- TMUFF 7 days initially and 7 days subsequent changes
- UMECR required
- Can add ezetimibe, bile acid sequestration, fibrates
- Nicotinic acid not permitted for flying duties
Considerations for anti arrhythmic
Underlying condition is likely disqualifying
In civilian aviation case by case assessment
- AF increasingly common
- rate control vs prophylaxis of AF
- Sotalol and other B - Blockers
Considerations for anti coagulation
Military aviation
- aspirin acceptable
- clopidogrel disqualifying
- Factor Xa inhibitors - NOACs
Civilian aviation
- warfarin requires evidence of stable dINR control
- Class 1 multi crew only
When to start anticoagulation
CHA2DS VASc
>/=2 high risk - oral anticoagulant maintain INR 2-3
1. Moderate risk - aspirin or oral anticoagulant INR 2-3
0 Low risk - no antithrombotic therapy or aspirin up to 325mg
Consideration if pt requires CABG
At least 6-12 months recovery Waiver consideration - cardiology review annually - EF >50% - Myocardial perfusion scan - demonstrates RF control
Consideration for pt after angioplasty. +/stenting
There is a risk of early re-stenosis which eases over time 6-12 months recovery Waiver considerations - cardiology review annually - normal ejection fraction - Myocardial perfusion scan normal - demonstrates risk factor control - no combination anti-platelet therapy
What factors define MI as significant disease
Any LM lesion or >30% stenosis LAD
>50% luminal obstruction in any major vessel
>1 lesion of 30% stenosis in major vessels
Extensive disease with maximal lesion not exceeding 30-50% occlusion also requires consideration
Considerations for pacing
Pacemaker use disqualifying for military flying due to potential for EMR interaction with device
CASA
- restricted verification
- Dual chambered, bipolar leads, annual check
