AvWeb: Pilot Suffers In-Flight Heart Attack

DJTorrente

DJTorrente

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DJTorrente
Gary F said:
Maybe we should get daily checks by an AME. That should fix the problem.
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Why not just add a medical monitoring panel to the panel. Hook up EKG pads, blood pressure monitor, and pulse oximetry, and if you do not pass the plane does not start.
 
douglas393 said:
Why not just add a medical monitoring panel to the panel. Hook up EKG pads, blood pressure monitor, and pulse oximetry, and if you do not pass the plane does not start.
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Don't forget the blood alcohol monitor.
 
Greg Bockelman said:
Better yet, do away with them altogether. :rofl::rofl::rofl:

Like THAT would ever happen.

I am not really advocating that anyway.
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In reality, the ATP who died may have been able to pass a 1st class physical an hour before the flight. The really bad hearts attacks (ST elevation MI) often occur in coronary arteries that are not badly blocked until a plaque ruptures and causes a blood clot. The resting ECG can be normal for the first few minutes of a heart attack.
 
Gary F said:
In reality, the ATP who died may have been able to pass a 1st class physical an hour before the flight. The really bad hearts attacks (ST elevation MI) often occur in coronary arteries that are not badly blocked until a plaque ruptures and causes a blood clot. The resting ECG can be normal for the first few minutes of a heart attack.
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Gary, what is considered "CAD"? Symptoms? "Events"? "Any" amount of atherosclerosis? It seems like CAD is written about in way that makes it sound like one either has it or doesn't have it.

dtuuri
 
dtuuri said:
Gary, what is considered "CAD"? Symptoms? "Events"? "Any" amount of atherosclerosis? It seems like CAD is written about in way that makes it sound like one either has it or doesn't have it.

dtuuri
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Depends on who you ask and for what purpose. Definitions are often driven by billing codes or CMS rules.
 
Gary F said:
Depends on who you ask and for what purpose. Definitions are often driven by billing codes or CMS rules.
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As far as the FARs go, coronary artery disease is a disqualifier for any class. Lots of doctors, though, say we all have it in some degree because of autopsies of young soldiers who died in combat. So, everybody is illegal if that's true. Should a doctor "discover" this illegality we're at the mercy of the Federal Air Surgeon's special issuance standards, which is about 20 years behind the times as far as I can tell.

dtuuri
 
dtuuri said:
As far as the FARs go, coronary artery disease is a disqualifier for any class. Lots of doctors, though, say we all have it in some degree because of autopsies of young soldiers who died in combat. So, everybody is illegal if that's true. Should a doctor "discover" this illegality we're at the mercy of the Federal Air Surgeon's special issuance standards, which is about 20 years behind the times as far as I can tell.

dtuuri
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How are you defining coronary artery disease?

I'm betting every male in America in the 50's has SOME level of atherosclerotic heart disease. And they get certified to fly every day.

As someone else said, the sudden infarcts like this guy had are usually caused by a clinically insignificant, non-obstructive plaque that bursts/ruptures for various reasons. That then causes a clot. Then you have a total occlusion and you go from "meh, I feel fine:dunno:" to.. Oh SNAP:yikes:

Right up until that moment you are free of symptoms, and there is no stress test, EKG or echo that will pick up on that. You might see it on angiogram, but nobody is going to do one without an abnormal stress test, EKG or echo... And I'm sure Gary will correct me on current AHA/ACC guidelines if I have it wrong but I believe the driving indication for those three tests is SYMPTOMS.

If you dont have symptoms, you dont go looking for disease that causes the symptoms.
 
Doggtyred said:
How are you defining coronary artery disease?

I'm betting every male in America in the 50's has SOME level of atherosclerotic heart disease. And they get certified to fly every day.

As someone else said, the sudden infarcts like this guy had are usually caused by a clinically insignificant, non-obstructive plaque that bursts/ruptures for various reasons. That then causes a clot. Then you have a total occlusion and you go from "meh, I feel fine:dunno:" to.. Oh SNAP:yikes:

Right up until that moment you are free of symptoms, and there is no stress test, EKG or echo that will pick up on that. You might see it on angiogram, but nobody is going to do one without an abnormal stress test, EKG or echo... And I'm sure Gary will correct me on current AHA/ACC guidelines if I have it wrong but I believe the driving indication for those three tests is SYMPTOMS.

If you dont have symptoms, you dont go looking for disease that causes the symptoms.
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I don't know a definition of coronary artery disease that makes any sense for pilots. Like you say, "...every male in America in the 50's has SOME level of atherosclerotic heart disease." I don't believe Part 67 allows any level. So the rule was made before the knowledge of just how common it is.

The SI "exception" to the rule seems to, likewise, allow CAD based on outdated notions of the character of plaques. Again, like you say, "...the sudden infarcts like this guy had are usually caused by a clinically insignificant, non-obstructive plaque that bursts/ruptures for various reasons." Those are the very ones, ironically, the FAA will certify under the SI program. Go figure.

Now, "symptoms" seems like a great way to differentiate between younger CAD (the sort most likely to rupture) and the older plaques that were tough enough to grow up without bursting until they can finally signal their owner by causing angina. Here's the rub: When the owner hears this wake-up call he or she can change for the better without intervention and with only lifestyle changes. The FAA, though, requires an intervention even though statistically there's no advantage. More irony: The ones with symptoms, but change going forward, are less risky than those without, but the FAA certifies the riskier ones.

The FAA also appears to base their ideas about how CAD progresses on a database of those who did not make significant lifestyle (read "dietary") changes after their diagnosis. Dietary habits have been shown to arrest CAD and I've not seen any published study that refutes the claimed effects of a 10% fat diet in doing so. I suspect in a couple weeks there may be yet another study announced that makes that claim.

dtuuri
 
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Doggtyred said:
How are you defining coronary artery disease?

I'm betting every male in America in the 50's has SOME level of atherosclerotic heart disease. And they get certified to fly every day.

As someone else said, the sudden infarcts like this guy had are usually caused by a clinically insignificant, non-obstructive plaque that bursts/ruptures for various reasons. That then causes a clot. Then you have a total occlusion and you go from "meh, I feel fine:dunno:" to.. Oh SNAP:yikes:

Right up until that moment you are free of symptoms, and there is no stress test, EKG or echo that will pick up on that. You might see it on angiogram, but nobody is going to do one without an abnormal stress test, EKG or echo... And I'm sure Gary will correct me on current AHA/ACC guidelines if I have it wrong but I believe the driving indication for those three tests is SYMPTOMS.

If you dont have symptoms, you dont go looking for disease that causes the symptoms.
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True. Otherwise it is the physicians job to identify and treat risk factors for coronary artery disease. I think that certain persons in high risk occupations should have a simple exercise stress test every year or two.
 
Gary F said:
True. Otherwise it is the physicians job to identify and treat risk factors for coronary artery disease. I think that certain persons in high risk occupations should have a simple exercise stress test every year or two.
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Insurance companies that write 'key man" policies for corporations will give a considerable break on the premium if the executive the policy is written on agrees to a biennial nucular stress test. It is my understanding that the predictive value for that strategy is quite high. It won't catch the nonobstructing plaque that ruptures, but it will pick up most of the others in time (in time to increase the premium, they don't care about your health, they care about the math).
 
weilke said:
Insurance companies that write 'key man" policies for corporations will give a considerable break on the premium if the executive the policy is written on agrees to a biennial nucular stress test. It is my understanding that the predictive value for that strategy is quite high. It won't catch the nonobstructing plaque that ruptures, but it will pick up most of the others in time (in time to increase the premium, they don't care about your health, they care about the math).
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Predictive value for what? Why not a non-imaging plain 'ol treadmill stress test?
 
Gary F said:
Predictive value for what? Why not a non-imaging plain 'ol treadmill stress test?
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Predictive value for the insurance company not having to pay out over the term of the next two years.

They dont care whether you are healthy. They care whether you are likely to die during the term of the coverage they have agreed to. It seems to work for the insurance company, I just do what they ask for.
 
weilke said:
Predictive value for the insurance company not having to pay out over the term of the next two years.

They also dont care whether you are healthy. They care whether you are likely to die during the term of the coverage they have agreed to. It seems to work for the insurance company, I just do what they ask for.
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I don't screen the studies I interpret for appropriateness either although the clinical information provided with the study often has me scratching my head.

I agree that a negative cardiac stress nuclear imaging study has a good predictive value for low risk of cardiac events over a 1 to 2 year period. There are better ways to do this but I can see how this approach may have utility for the life insurance company. The biggest advantage is that some people lie about not having symptoms or unconsciously reduce their level of activity to compensate for disease. Pilots might fall into that category as well.
 
Gary F said:
I agree that a negative cardiac stress nuclear imaging study has a good predictive value for low risk of cardiac events over a 1 to 2 year period. There are better ways to do this but I can see how this approach may have utility for the life insurance company. The biggest advantage is that some people lie about not having symptoms or unconsciously reduce their level of activity to compensate for disease. Pilots might fall into that category as well.
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The insurance company is not worried about a false positive, it just allows them to jack up their rate :wink2: Worst case, they loose a premium on the false positive. They worry about the false negative that carries the risk of paying out whatever amount the policy is for.

Of course, this is an awful workup strategy for a pilot and probably not what a unbiased physician would do if he has the patients best interest in mind.
 
weilke said:
Insurance companies that write 'key man" policies for corporations will give a considerable break on the premium if the executive the policy is written on agrees to a biennial nucular stress test. It is my understanding that the predictive value for that strategy is quite high. It won't catch the nonobstructing plaque that ruptures, but it will pick up most of the others in time (in time to increase the premium, they don't care about your health, they care about the math).
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Yup, exactly right. When I was working for a company that bought it, it was actually the "full day executive physical" at the local hospital (at their expense). Not much you can hide.

You're double right, it's an annually renewable policy and they could care less if you die at 366 days but they sure want to make sure you live for a year. They are very good at math.
 
jbarrass said:
Yup, exactly right. When I was working for a company that bought it, it was actually the "full day executive physical" at the local hospital (at their expense). Not much you can hide.
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Oh, those tests were part of 'executive physicals'. The company doesn't just send you for the stress test, they also want to know whether you have developed diabetes, have cholesterol/lipids off the charts etc.

More stringent than a first class medical. If this UAL incident was more than an isolated incident, it may be necessary to revise the first class standards for that 60+ contingent.
 
weilke said:
Oh, those tests were part of 'executive physicals'. The company doesn't just send you for the stress test, they also want to know whether you have developed diabetes, have cholesterol/lipids off the charts etc.

More stringent than a first class medical. If this UAL incident was more than an isolated incident, it may be necessary to revise the first class standards for that 60+ contingent.
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A regular treadmill. Must do at least 9 minutes on a standard Bruce with no ECG change or more tests will be required.
 
I have long been a proponent of 5th yearly stress treadmills and NO EKGs for part 121 flight crews. At least that has predictive value (circulation Res 1998).
 
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