Disposal of IHD Cases for Pilots Medical

Reference : AIC 28/ 99 dated 26 Aug 1999

Classification and Diagnosis:

IHD - Angina Pectoris

IHD - Myocardial Infarction

IHD - Post PTCA / CABG

Assessment of IHD –

Aircrew with asymptomatic IHD clinical group (a) will be referred to AFCME only for complete cardiac evaluation. The following investigations will be carried out as considered necessary:
- Biochemical Profile
- Treadmill Stress Test (TMT)
- Holter monitoring
- Echo Cardiography including Stress Echo
- Stress MUGA
- Stress Thallium Scan
- Coronary anglography (CART).

Disposal -

IHD Asymptomatic–
- If coronary angiography is normal and there is no associated abnormality, e.g. Hypertension, Hypertrophic Cardiomyopathy, Aortic valvular disease, Myocarditis etc. the aircrew will be certified fit.
IHD - Angina -
- All cases of angina will be observed on ground for a minimum period of 12 months. Certification will be considered only after 12 months of the initial diagnosis provided the following criteria are met:
  - Individual is asymptomatic and effort tolerance is normal.
  - Modifiable risk factors and complications, if any, are under control/stablised.
  - Maximal TMT, Stress MPI Scan do not show evidence of reversible myocardial ischaemia.
  - Holter monitoring does not reveal any episode of silent myocardial ischaemia or significant arrhythmia.
  - Echo shows normal left ventricular function and no significant regional wall motion abnormality.
  - Not on cardioactive drugs.
  - Coronary angiography and other haemodynamic studies show coronary arteries to be normal or with minimal/insignificant lesion.

IHD: Myocardial Infarction (Non-transmural Myocardial Infarction as well as Transmural Myocardial Infarction) :
- Aircrew with Myocardial Infarction will be grounded. However, AFCME may on a case to case basis recommend cases of Myocardial Infarction for award of P1status to fly along with a qualified P2 only (with any other specified restrictions) not less than 12 months after the initial episode provided all the following criteria are met:
  - Individual is asymptomatic and his effort tolerance is normal.
  - Modifiable risk factors and complications, if any, are corrected/stablised.
  - Maximal TMT, Stress MUGA, Stress Thallium scan do not show evidence of recersible myocardial ischaemia.
  - Holter monitoring does not reveal any episode of silent myocardial ischaemia or significant arrhythmia.
  - Echo shows normal LV functions and no significant regional wall motion abnormality.
  - Not on any active cardiac drugs for last six weeks.
  - Coronary angiography and other haemodynamic studies show coronary arteries other than the infarct related vessel to be normal or with minimal lesion and
  - h) These cases will be reviewed every six months at AFCME only.

Disposal after Myocardial Revascularisation Procedures

Percutaneous Transluminar Coronary Angioplasty (PTCA)

A minimum period of nine months should have elapsed since PTCA. He should have remained asymptomatic and maintained functional class I (MYHA) for at least 6 months.

They should not have any associated disease like Diabetes mellitus, Hypertension, Peripheral vascular disease or metabolic disorder. The modifiable risk factors should have been corrected.

There should be no evidence of significant reversible myocardial ischemia/arrhythmia/conduction defects appearing on TMT.

24 hours Ambulatory monitoring (Holter) should not reveal any significant Arrhythmia, conduction defect or silent ischaemic episode.

2 D Echo should reveal normal ventricular size, shape and functions. Global left ventricular ejection fraction should be normal (more than or equal to 50%) showing further rise with exercise.

Repeat coronary Arteriography not earlier than 8 months following the procedure should show results of successful coronary angioplasty with no evidence or restenosis. There should be no lesion restricting the luminal diameter to 50% or more in any epicardial artery.

Stress MPI Scan should reveal normal left ventricular size, absence of stress induced perfusion defect or washout abnormality in any part of myocardium.

Those cases who fulfill the above criteria will be considered fit for flying as P1 along with a qualified P2 only. They will be reviewed at least once in 12 months at AFCME. Investigations including Stress MPI Scan and Coronary Angiography will be carried out as considered necessary by the Cardiologist of the Establishment. Cases who have suffered a myocardial infarction will not be considered for flying till 12 months after the episode of infarction.

Coronary Artery Bypass Surgery (CABGS)

Minimum period of twelve (12) months should have elapsed since CABGS. He should have maintained functional class I (NYHA) for at least 6 months and had been on no cardioactive drugs except dispirin or persantin.

There should be no associated disease like Hypertension, Diabetes mellitus, Peripheral vascular disease or metabolic disorder. All modifiable risk factors should have been corrected.

There should have been no significant left main stem stenosis (50% or above).

The subject should be able to complete a symptom limited exercise ECG satisfactorily (usually Bruce stage 3 or more). It should not reveal reversible myocardial ischemia, left ventricular dysfunction, significant arrhythmias or fresh conduction defect.

Colour Doppler Echocardiographic evaluation should reveal no structural disease of the heart, left ventricular dysfunction or significant regional wall motion abnormality. Ejection fraction should be more than 50 %.

A Thallium Scan should show no perfusion defect or LV dysfunction.

Hotler Monitoring for 24 hours should not reveal any abnormality of rate/rhythm/silent ischaemic episodes.

Cases considered fit based on the above criteria will be certified fit for P1 status to fly with a qualified P2 only (with any other restriction). They will be reviewed at AFCME at least once in 12 months. Investigations including stress MPI Scan and coronary angiography will be carried out as considered necessary by the Cardiologist of the Establishment.

Cases who have successfully undergone myocardial revascularisation procedures and have been returned to P1 status to fly along with a qualified P2 only, may after a three year period of follow up, be recommended for grant of P1 status, without restrictions on a case to case basis. If the recommendation is approved by DGMS (Air) such cases will continue to be followed up at AFCME only.

The disposal of cases who have undergone procedures like Rotablator, coronary atherectomy, stents, etc. will be the same as for PTCA. Similarly, the disposal after Minimally – Invasive Coronary artery Bypass Surgery/total arterial grafting etc. will be the same as for CABGS.

Aircrew declared unfit for flying due to Ischaemic Heart Disease will have to apply to DGCA for reconsideration, after the specified period of observation as laid down in their circular. Original records or authenticated video recordings of angiography, ultrasonography, Doppler study etc. will have to be produced at the time of review at AFCME/IAM.