Cardiovascular : What to Expect at the Flight Physical

I. Code of Federal Regulations:

Legal Extract

First-Class Cardiac Standards: 14 CFR § 67.111(a)(b)(c)

Cardiovascular standards for first-class airman medical certificate are:

1. (a) No established medical history or clinical diagnosis of any of the following:

   1. Myocardial infarction See MI Waiver Options...
   2. Angina pectoris See Angina Waiver Options...
   3. Coronary heart disease that has required treatment or, if untreated, that has been symptomatic or clinically significant See CHD Waiver Options...
   4. Cardiac valve replacement See Prosthetic Valve Waiver Options...
   5. Permanent cardiac pacemaker implantation See Pacemaker Waiver Options..., or
   6. Heart replacement See Cardiac Transplant Waiver Options...

2. (b) A person applying for first-class airman medical certification must demonstrate an absence of myocardial infarction and other clinically significant abnormality on electrocardiographic examination:

   1. At the first application after reaching the 35th birthday; and
   2. On an annual basis after reaching the 40th birthday

3. (c) An electrocardiogram will satisfy a requirement of paragraph (b) of this section if it is dated no earlier than 60 days before the date of the application it is to accompany and was performed and transmitted according to acceptable standards and techniques.

Legal Extract: Second-Class Cardiac Standards § 67.211(a)(b)(c)(d)(e)(f) and Third-Class Cardiac Standards § 67.311(a)(b)(c)(d)(e)(f)

Cardiovascular standards for a second- and third-class airman medical certificate are:

II. Examination Techniques

A. General Physical Examination.

1. A brief description of any comment-worthy personal characteristics as well as height, weight, representative blood pressure readings in both arms, funduscopic examination, condition of peripheral arteries, carotid artery auscultation, heart size, heart rate, heart rhythm, description of murmurs (location, intensity, timing, and opinion as to significance), and other findings of consequence must be provided.
2. The AME should keep in mind some of the special cardiopulmonary demands of flight, such as changes in heart rates at takeoff and landing. High G-forces of aerobatics or agricultural flying may stress both systems considerably. Degenerative changes are often insidious and may produce subtle performance decrements that may require special investigative techniques.
   
   1. Inspection. Observe and report any thoracic deformity (e.g., pectus excavatum), signs of surgery or other trauma, and clues to ventricular hypertrophy. Check the hematopoietic and vascular system by observing for pallor, edema, varicosities, stasis ulcers, and venous distention. Check the nail beds for capillary pulsation and color.
   2. Palpation. Check for thrills and the vascular system for arteriosclerotic changes, shunts, or AV anastomoses. The pulses should be examined to determine their character, to note if they are diminished or absent, and to observe for synchronicity. The medical standards do not specify pulse rates that, per se, are disqualifying for medical certification. These tests are used, however, to determine the status and responsiveness of the cardiovascular system. Abnormal pulse rates may be reason to conduct additional cardiovascular system evaluations.
      
      1. Bradycardia of less than 50 beats per minute, any episode of tachycardia during the course of the examination, and any other irregularities of pulse other than an occasional ectopic beat or sinus arrhythmia must be noted and reported. If there is bradycardia, tachycardia, or arrhythmia further evaluation may be warranted and deferral may be indicated.
      2. A cardiac evaluation may be needed to determine the applicant's qualifications. Temporary stresses or fever may, at times, result in abnormal results from these tests. If the AME believes this to be the case, the applicant should be given a few days to recover and then be retested. If this is not possible, the AME should defer issuance, pending further evaluation.
   3. Percussion. Determine heart size, diaphragmatic elevation/excursion, abnormal densities in the pulmonary fields, and mediastinal shift.
   4. Auscultation. Check for resonance, asthmatic wheezing, ronchi, rales, cavernous breathing of emphysema, pulmonary or pericardial friction rubs, quality of the heart sounds, murmurs, heart rate, and rhythm. If a murmur is discovered during the course of conducting a routine FAA examination, report its character, loudness, timing, transmission, and change with respiration. It should be noted whether it is functional or organic and if a special examination is needed. If the latter is indicated, the AME should defer issuance of the medical certificate and transmit the completed FAA Form 8500-8 to the FAA for further consideration. AME must defer to the AMCD or Regional Flight Surgeon if the treating physician or AME reports the murmur is moderate to severe (Grade III or IV). Listen to the neck for bruits.
      
      It is recommended that the AME conduct the auscultation of the heart with the applicant both in a sitting and in a recumbent position.
      
      Aside from murmur, irregular rhythm, and enlargement, the AME should be careful to observe for specific signs that are pathognomonic for specific disease entities or for serious generalized heart disease. Examples of such evidence are: (1) the opening snap at the apex or fourth left intercostal space signifying mitral stenosis; (2) gallop rhythm indicating serious impairment of cardiac function; and (3) the middiastolic rumble of mitral stenosis.

B. When General Examinations Reveal Heart Problems.

These specifications have been developed by the FAA to determine an applicant's eligibility for airman medical certification. Standardization of examination methods and reporting is essential to provide sufficient basis for making determinations and the prompt processing of applications.

1. This cardiovascular evaluation, therefore, must be reported in sufficient detail to permit a clear and objective evaluation of the cardiovascular disorder(s) with emphasis on the degree of functional recovery and prognosis. It should be forwarded to the FAA immediately upon completion. Inadequate evaluation, reporting, or failure to promptly submit the report to the FAA may delay the certification decision.
   
   
   1. Medical History. Particular reference should be given to cardiovascular abnormalities-cerebral, visceral, and/or peripheral. A statement must be included as to whether medications are currently or have been recently used, and if so, the type, purpose, dosage, duration of use, and other pertinent details must be provided. A specific history of any anticoagulant drug therapy is required. In addition, any history of hypertension must be fully developed to also include all medications used, dosages, and comments on side effects.
   2. Family, Personal, and Social History. A statement of the ages and health status of parents and siblings is required; if deceased, cause and age at death should be included. Also, any indication of whether any near blood relative has had a "heart attack," hypertension, diabetes, or known disorder of lipid metabolism must be provided. Smoking, drinking, and recreational habits of the applicant are pertinent as well as whether a program of physical fitness is being maintained. Comments on the level of physical activities, functional limitations, occupational, and avocational pursuits are essential.
   3. Records of Previous Medical Care. If not previously furnished to the FAA, a copy of pertinent hospital records as well as out-patient treatment records with clinical data, x-ray, laboratory observations, and originals or copies of all electrocardiographic (ECG) tracings should be provided. Detailed reports of surgical procedures as well as cerebral and coronary arteriography and other major diagnostic studies are of prime importance.
   4. Surgery. The presence of an aneurysm or obstruction of a major vessel of the body is disqualifying for medical certification of any class. Following successful surgical intervention and correction, the applicant may ask for FAA consideration. The FAA recommends that the applicant recover for at least 3 months for ATCS's and 6 months for airmen.

   A history of coronary artery bypass surgery is disqualifying for certification. Such surgery does not negate a past history of coronary heart disease. The presence of permanent cardiac pacemakers and artificial heart valves is also disqualifying for certification.

   The FAA will consider an Authorization for a Special Issuance of a Medical Certificate (Authorization) for most cardiac conditions. Applicants seeking further FAA consideration should be prepared to submit all past records and a report of a complete current cardiovascular evaluation in accordance with FAA specifications.

C. Medication.

• Medications acceptable to the FAA for treatment of hypertension in airmen include all Food and Drug Administration (FDA) approved diuretics, alpha-adrenergic blocking agents, beta-adrenergic blocking agents, calcium channel blocking agents, angiotension converting enzyme (ACE inhibitors) agents, and direct vasodilators.
• The following are NOT ACCEPTABLE to the FAA:

  • Centrally acting agents (such as reserpine, guanethidine, guanadrel, guanabenz, and methyldopa).
  • A combination of beta-adrenergic blocking agents used with insulin, meglitinides, or sulfonylureas .
  • The use of flecainide when there is evidence of left ventricular dysfunction or recent myocardial infarction.
  • The use of nitrates for the treatment of coronary artery disease or to modify hemodynamics.
• The AME must defer issuance of a medical certificate to any applicant whose hypertension has not been evaluated, who uses unacceptable medications, whose medical status is unclear, whose hypertension is uncontrolled, who manifests significant adverse effects of medication, or whose certification has previously been specifically reserved to the FAA.