Any meds to avoid after a heart attack?

[DaleB]

Paging Dr. Bruce...

My new cardiologist is talking about statin, beta blocker, yada yada yada. Are there any that I should avoid to keep from having problems getting my medical certificate back? I don't want to find out 6 months from now that something we do this week screws me.

 

[Gary F]

I'm interested in what Dr Bruce has to say but adherence to your cardiologist's medical regimen following a heart attack is probably necessary to get your medical back after an acute coronary syndrome. Standard post ACS treatment often consists of:

Dual antiplatlet therapy with aspirin and Plavix (clopidogrel) or aspirin and Effient (prasugrel)

Statin, usually high dose of a potent statin Liptor (atorvastatin) or Crestor

Beta blockers Metoprolol or carvediolol

ACE inhibitor or ARB

Cardiac rehab followed by a regular home exercise program

Healthful diet low in animal fat and simple carbohydrates.

Good luck. Your health comes first, flying is secondary.

 

[DaleB]

I totally agree with that. My only question is whether there are certain specific medications to be avoided in favor of other ones. If there are, I'll discuss that with the cardiologist But right now he gets the final say.

 

[Gary F]

I totally agree with that. My only question is whether there are certain specific medications to be avoided in favor of other ones. If there are, I'll discuss that with the cardiologist But right now he gets the final say.

As far as I know, most of the meds used for the treatment of ACS or stable coronary artery disease treatment are OK with the FAA. A few medications occasionally used to treat hypertension like clonidine are probably prohibited. If you are prescribed a problematic medication ask your physician to change it to something else if it is intended for long term use. I think you are grounded for at least 3 months.

 

[BillTIZ]

Paging Dr. Bruce...

My new cardiologist is talking about statin, beta blocker, yada yada yada. Are there any that I should avoid to keep from having problems getting my medical certificate back? I don't want to find out 6 months from now that something we do this week screws me.

Dr Bruce is on vacation to the pacific NW. I think he'll be back next week?

You can check most statin and beta blockers online with AOPA for approved meds.

 

[Doggtyred]

Paging Dr. Bruce...

My new cardiologist is talking about statin, beta blocker, yada yada yada. Are there any that I should avoid to keep from having problems getting my medical certificate back? I don't want to find out 6 months from now that something we do this week screws me.

By the way.... did you have any kind of interventional procedure, such as angioplasty and stenting?

 

[azure]

As far as I know, most of the meds used for the treatment of ACS or stable coronary artery disease treatment are OK with the FAA. A few medications occasionally used to treat hypertension like clonidine are probably prohibited. If you are prescribed a problematic medication ask your physician to change it to something else if it is intended for long term use. I think you are grounded for at least 3 months.

If I remember correctly what Bruce has said about this, if you've had a stent placed but no MI, it's 3 months. If you've had a MI, it's 6.

And I thought nitrates were verboten.

But Dr. Bruce will have the straight dope.

 

[Gary F]

If I remember correctly what Bruce has said about this, if you've had a stent placed but no MI, it's 3 months. If you've had a MI, it's 6.

And I thought nitrates were verboten.

But Dr. Bruce will have the straight dope.

Nitrates generally mean that someone has inadequately revascularized coronary artery disaese so I would not be surprised if they were on the no-go list. You may have noticed that nitrates were absent from my list of usual post ACS medications.

 

[DaleB]

By the way.... did you have any kind of interventional procedure, such as angioplasty and stenting?

STEMI, some O2, a ride to the CCU, a little nap, one stent, no nitrates. BP isn't bad, I just have bullet-proof arteries. I was on my way to preflight the 172, planned to do some night T/O and landings to get night current again. It became obvious as I drove to the airport that flying would be a Very Bad Idea (tm). Good thing it didn't happen an hour later.

So, the plan now is cardiac rehab, beta blocker, statin, clopidogrel, aspirin, lots more cardio exercise and some dietary modifications. We've already made a lot of improvements in our diet over the past couple of years, so that won't be a big adjustment. I've been exercising "off and on", so now it's fully "ON". Needless to say I plan to adhere to my doctors' advice to the letter.

 

[Doggtyred]

Please do to the line. With regards to the clopidogrel, DONT SKIP IT, and dont stop taking it without your cardiologists knowledge and consent...

Get healthy and get airborne again!

 

[bbchien]

Any anti-diabetic meds?

 

[Gary F]

Please do to the line. With regards to the clopidogrel, DONT SKIP IT, and dont stop taking it without your cardiologists knowledge and consent...

Get healthy and get airborne again!

That's right. Stents require aspirin indefinitely and Plavix or Effient for a period of time, typically a year or longer. Stop one or both of these meds early and you risk having the stent plug up with a clot possibly causing a lot of damage. STEMIs can result in significant heart damage and often an imaging study is obtained after the smoke clears a month or two later to assess pumping function unless everything looked OK when the artery was opened. If the cardiologist is worried that the pumping function is seriously compromised the pumping function is reassessed at least 90 days after the artery is opened to determine the need for a defibrillator.

 

[DaleB]

Any anti-diabetic meds?

Nope. Although I'm not exactly slim and diabetes is rampant in my family, I'm not diabetic -- or even close, really. I think the diabetes in my family is self-inflicted.

The echocardiogram they did Friday showed my EF at or a little above 50, if I recall correctly, which seemed to please everyone. And to clarify -- while I'm not on nitrates now, nor was I before, the ER did start a nitroglycerin drip after seeing the EKG. Wasn't enough to make me detonate in the ambulance, though.

My wife and I took the dog for a walk yesterday afternoon. Other than a little tenderness around the puncture site I'm feeling great, but taking it slow nonetheless.

 

[Doggtyred]

Nope. Although I'm not exactly slim and diabetes is rampant in my family, I'm not diabetic -- or even close, really. I think the diabetes in my family is self-inflicted.

The echocardiogram they did Friday showed my EF at or a little above 50, if I recall correctly, which seemed to please everyone. And to clarify -- while I'm not on nitrates now, nor was I before, the ER did start a nitroglycerin drip after seeing the EKG. Wasn't enough to make me detonate in the ambulance, though.

My wife and I took the dog for a walk yesterday afternoon. Other than a little tenderness around the puncture site I'm feeling great, but taking it slow nonetheless.

When discussing nitrates as disqualifying for a medical, they are referring to the oral medication that is prescribed for outpatient use for angina. The IV version used short term in the emergency treatment of the STEMI isn't quite the same.

Glad to hear things are going well for you.

 

[Everskyward]

My new cardiologist is talking about statin, beta blocker, yada yada yada. Are there any that I should avoid to keep from having problems getting my medical certificate back? I don't want to find out 6 months from now that something we do this week screws me.

When I clicked on this thread I didn't realize you were talking about yourself. Sorry to hear that but glad you are doing better.

 

[Gary F]

Nope. Although I'm not exactly slim and diabetes is rampant in my family, I'm not diabetic -- or even close, really. I think the diabetes in my family is self-inflicted.

The echocardiogram they did Friday showed my EF at or a little above 50, if I recall correctly, which seemed to please everyone. And to clarify -- while I'm not on nitrates now, nor was I before, the ER did start a nitroglycerin drip after seeing the EKG. Wasn't enough to make me detonate in the ambulance, though.

My wife and I took the dog for a walk yesterday afternoon. Other than a little tenderness around the puncture site I'm feeling great, but taking it slow nonetheless.

That's good to hear that your EF is still good. It may even improve with time. Since you had an event somebody needs to scrutinize your risk factors. Even if you don't meet the criteria for diabetes you may have metabolic syndrome which is a risk factor and all too common in persons who have had a STEMI.

 

[DaleB]

I'm pretty well aware of my risk factors, and have been addressing them for the past few years -- obviously not aggressively enough. Some, like the family history of heart disease, I can't do much about. Others (weight, diet, cholesterol) I can do quite a bit to fix. Needless to say, I've stepped up my efforts in those areas. I went up to the gym this morning with my wife -- she had a workout scheduled, I did some treadmill time. I have noticed that my resting heart rate is way down from what it was a week ago, like 15 BPM. I kept it within 15-20 of my new resting rate and took it easy. Knowing my habits, I think not letting inertia take over will be important for my long term success. I have no desire to try to match Dad's track record; he survived four heart attacks. I'm not doing this again -- ever.

Mari -- thanks. I'm doing fine, and will continue to do so. Tomorrow is my birthday, and I plan on another 50+ after this one.

 

[Gary F]

I'm pretty well aware of my risk factors, and have been addressing them for the past few years -- obviously not aggressively enough. Some, like the family history of heart disease, I can't do much about. Others (weight, diet, cholesterol) I can do quite a bit to fix. Needless to say, I've stepped up my efforts in those areas. I went up to the gym this morning with my wife -- she had a workout scheduled, I did some treadmill time. I have noticed that my resting heart rate is way down from what it was a week ago, like 15 BPM. I kept it within 15-20 of my new resting rate and took it easy. Knowing my habits, I think not letting inertia take over will be important for my long term success. I have no desire to try to match Dad's track record; he survived four heart attacks. I'm not doing this again -- ever.

Mari -- thanks. I'm doing fine, and will continue to do so. Tomorrow is my birthday, and I plan on another 50+ after this one.

Many of my patients with coronary artery disease have been told their blood pressure and cholesterol were always just fine. I ask them who are you going to believe, those numbers or your coronary arteries? I get their old records and it turns out the numbers weren't so good after all. The rules for those with established CAD are stricter than for those without known disease. I tell my patients that I don't want them to need another trip to the cath lab. Don't get me wrong. The cath lab is my favorite place at work. It's sort of a really cool video game but not so good when my patients end up there.

 

[DaleB]

My PCP has been complaining about my cholesterol for a while now, but not my BP or anything else. And since he started complaining I have knocked 70 points off my total cholesterol, but as I said -- obviously not early enough or fast enough.

What's going to suck about the next six weeks is having to sit through all of the rehab classes telling me the stuff I already know, just didn't pay enough attention to. It's OK -- I figure that and the pills are my penance for a couple decades of complacency. Those plus this incredibly horrible looking bruise.

Over the past few days I've been on a very, very low cholesterol, low sodium, very low fat diet -- in other words, almost identical to what I was eating last week and last month. The only real adjustment I've made is not eating eggs, and switching from coconut to olive oil until we get a clear answer on that. Depending to who you listen to, our pure, unrefined organic coconut oil is either the best oil in the world, or Satan himself trying to kill you and steal your greasy soul.

 

[bbchien]

Okay, then.
Statin and Betablocker are not an FAA issue unless you develop Atrial Fibrillation. There are restrictions on Beta Blockers and some anti-diabetics.

 

[Gary F]

Okay, then.
Statin and Betablocker are not an FAA issue unless you develop Atrial Fibrillation. There are restrictions on Beta Blockers and some anti-diabetics.

I'm a little confused here.

 

[DaleB]

I interpreted that to mean there are restrictions on beta blockers and anti-diabetics used together.

 

[Gary F]

I interpreted that to mean there are restrictions on beta blockers and anti-diabetics used together.

That makes sense since beta blockers (in theory) can make the symptoms of low blood sugar. If so I would have written beta blockers used concurrently with certain anti-diabetic medications.

 

[DaleB]

That's good to hear that your EF is still good.

Seems I didn't remember what he said exactly right. I had my first rehab appointment today, and went over some things with the nurse. When they had me on the table in the cath lab, they measured it at 45% or so. The next morning they did an echo and it was at 55-60%.

My resting heart rate is lower, and O2 sat is higher, than I've ever seen it before. Hey, one or two more of these and I'll be in perfect health! OK, maybe not - but the path is pretty clear. A1C is good, triglycerides are good, but LDL too high and HDL too low. Sodium is nice and low. Diet & exercise, diet & exercise, more diet & exercise.

 

[AggieMike88]

I interpreted that to mean there are restrictions on beta blockers and anti-diabetics used together.

This is right. I recall an FAA Safety Brief issue (the magazine) where someone from FAA Medical (Dr. Tilton?) answered the question and expained that the combo of beta blockers and anti-diabetics were not issuable.

(applies google fu)

Found the applicable reference.... See paragraph 5.a. at this link -- http://www.faa.gov/about/office_org...vs/offices/aam/ame/guide/pharm/oral_diabetes/

 

[Papa Foxtrot]

LDL too low and HDL too high

I think you might have those backwards....

 

[DaleB]

Corrected that.

 

[DaleB]

Do I need to report this to my AME and/or the FAA immediately, or is self-grounding sufficient? My 3rd class expires in March. I'll see my regular doc later this month, who is also a pilot and my AME is in the same office - so the AME will for sure know then, if he doesn't already.

 

[Gary F]

High LDL and low HDL is a bad combination. When that occurs the LDL is usually an especially nasty variety known as small dense LDL. Triglycerides are often high and this pattern of lipids can be seen with diabetes or metabolic syndrome. http://www.ncbi.nlm.nih.gov/pubmed/10499189
Diet, medication and exercise are the treatment for this problem.

 

[DaleB]

High LDL and low HDL is a bad combination.

Yeah, I know -- a guy could have a heart attack.

 

[Unregistered]

mods - please delete previous post. posted in error.

 

[BillTIZ]

Do I need to report this to my AME and/or the FAA immediately, or is self-grounding sufficient? My 3rd class expires in March. I'll see my regular doc later this month, who is also a pilot and my AME is in the same office - so the AME will for sure know then, if he doesn't already.

Doc Bruce will answer up, but if I remember correctly, self ground, no flying until a new Class III is issued, and they will want all the data. The AME in your docs office should tell you what is needed and the test that need to be completed with xx days before the appointment for the class 3.

 

[bbchien]

Statin plus beta blocker= fly to next medical.
Statin plus beta blocker plus MI-->grounded until next medical is issued. I'd just self ground.

The FAA will really stick you if you try to say, "well, I didn't know that...." EVERYONE knows that an MI is grounding.

"Hey, it was just a little MI....I'm fine".

*****
You need 6 months down, and at the end of 6 months:

Stress Treadmill to 9 minutes (if you are above 70, assay so the numbers are different).....and 90% of your age related Vmax, you have to achieve BOTH numbers.

Fasting Glucose, lipid profile, creatinine.
Letter from cardiologist summarizing your CARDIAC risk factors and what you have done about them.

Cath report
Stent report
This is a special issuance. Running the treadmill annually becomes a "fixture". If you have one while on a special issuance, though, that is "write the FAA and send in your medical" while it's sorted out.

 

[Gary F]

Statin plus beta blocker= fly to next medical.
Statin plus beta blocker plus MI-->grounded until next medical is issued. I'd just self ground.

The FAA will really stick you if you try to say, "well, I didn't know that...." EVERYONE knows that an MI is grounding.

"Hey, it was just a little MI....I'm fine".

*****
You need 6 months down, and at the end of 6 months:

Stress Treadmill to 9 minutes (if you are above 70, assay so the numbers are different).....and 90% of your age related Vmax, you have to achieve BOTH numbers.

Fasting Glucose, lipid profile, creatinine.
Letter from cardiologist summarizing your CARDIAC risk factors and what you have done about them.

Cath report
Stent report
This is a special issuance. Running the treadmill annually becomes a "fixture". If you have one while on a special issuance, though, that is "write the FAA and send in your medical" while it's sorted out.

What does the FAA consider a MI? An STEMI obviously but what about a little infarctlet with a tiny bump in the troponin but normal CK NSTEMI?

 

[bbchien]

Why is there air?
How small is the Mort Arsndorf nucleus on the "teeny tiny" MI?

 

[Gary F]

Why is there air?
How small is the Mort Arsndorf nucleus on the "teeny tiny" MI?

I don't really understand.

Depending on the FAAs definition it might be a good idea for marathon runners to avoid getting cardiac enzyme tests immediately after a race. The troponin level can be increased in otherwise apparently healthy individuals. Some ER docs get them for almost any reason and diagnose MI at the drop of a hat.

CONCLUSION: Troponin increases were relatively common among marathon finishers and can reach levels typically diagnostic for acute myocardial infarction. Less marathon experience and younger age appeared to be associated with troponin increases, whereas race duration and the presence of traditional cardiovascular risk factors were not. Further work is needed to determine the clinical significance of these findings. http://www.ncbi.nlm.nih.gov/pubmed/17145114

 

[DaleB]

Statin plus beta blocker= fly to next medical.
Statin plus beta blocker plus MI-->grounded until next medical is issued. I'd just self ground.

I have no intention of flying alone for a while. I'll still get some dual time, since I was working on some endorsements anyway. I have no desire to play chicken with a Federal bureaucracy, even if I was 100% confident in my recovery.

The FAA will really stick you if you try to say, "well, I didn't know that...." EVERYONE knows that an MI is grounding.

"Hey, it was just a little MI....I'm fine".

Not me. I'm not going to try to screw myself permanently. I'm doing what the cardiac doc says to the letter, and will err on the side of safety with the FAA. I just got my ticket less than 18 months ago, I'm not risking it now.

This is a special issuance. Running the treadmill annually becomes a "fixture". If you have one while on a special issuance, though, that is "write the FAA and send in your medical" while it's sorted out.

Jeez. SI forever? Or is there a chance of getting a normal medical after a few years? I've talked to a couple of guys who got so fed up with the SI process they finally just gave up and fly SP. One guy I talked to last night finally got his SI issued after nine months of back and forth with OKC, and it was back dated to the original application, so he had a medical for 3 months -- and started all over again. Are these horror stories typical, or the result of just not doing it the right way? I'm building an RV-7... if this is going to mean I can only keep a valid medical for a few months at a time, I may need to re-assess whether I should be building an RV-12 instead.

 

[Gary F]

Coronary artery disease is forever. It can be managed but not cured.

 

[bbchien]

Jeez. SI forever? Or is there a chance of getting a normal medical after a few years? I've talked to a couple of guys who got so fed up with the SI process they finally just gave up and fly SP. One guy I talked to last night finally got his SI issued after nine months of back and forth with OKC, and it was back dated to the original application, so he had a medical for 3 months -- and started all over again. Are these horror stories typical, or the result of just not doing it the right way? I'm building an RV-7... if this is going to mean I can only keep a valid medical for a few months at a time, I may need to re-assess whether I should be building an RV-12 instead.

The CAD SI never goes away. Neither does CAD.

However, if you use someone who really does know what to do, you can get your medical for a full year, issued at the time of exam. There are lots of guys (some here) who know about this.

I won't plug myself any more than that. Plugging around for 9 months is entirely for lack of any expertise. Pure and simple.

 

[DaleB]

The CAD SI never goes away. Neither does CAD.

However, if you use someone who really does know what to do, you can get your medical for a full year, issued at the time of exam. There are lots of guys (some here) who know about this.

I won't plug myself any more than that. Plugging around for 9 months is entirely for lack of any expertise. Pure and simple.

That's what I hoped. Thanks. I will be talking to my AME in a couple of weeks (he's in the same office as my PCP doc, and co-owns a plane with him). I'll be asking him some questions about how many of these he's done, and how long it typically takes. If I don't get really good answers, I'll probably be contacting you.