Ask the Flight Surgeon / By CPT Karl Swinson, MD, MPH: Q: I am a male 39-year-old active duty UH-60 pilot.My time in service is 17 years, and I anticipate transitioning to civilian aviation once I retire. I am in excellent health and have no waivers.
I do not drink or smoke, and I take no medications. My father had coronary artery disease diagnosed at 62. I was worried when I heard that I will be screened for cardiovascular disease at my next flight physical. What does that mean?
FS: Cardiovascular events are the single largest risk factor for adverse medical events in aviation, and the risk rises significantly with age. Consequently, all aviation services have some form of cardiovascular screening, with annual screening starting at age 40 in the Army. Studies have shown that positive family history in a first order relative (parents or siblings) increases your heart attack risk as you age by almost double. Screening involves history, physical exam, laboratory, and imaging results and, sometimes, consults with heart doctors (cardiologists). For our purposes, we are going to focus on your specific concerns regarding Army cardiovascular screening as well as how the FAA would perform similar screening post retirement.
Workup
In the Army you will receive cardiovascular screening with an EKG and blood labs. These tests estimate the cardiovascular risk level. Higher cardiovascular risk is worked up further and can include the use of a treadmill stress test, a chemical test of your heart’s function, and/or imaging with ultrasound. An “event monitor” as well as cardiology consult may be necessary.
Aviators who fail Level 1 Coronary Artery Disease (CAD) screening (the most basic level) may remain on flight status for 60 days pending completion of Level 2 CAD screening (treadmill stress test). If Level 2 CAD screening is abnormal but the crew member is asymptomatic, a restricted dual status with a second rated pilot only may be approved by USAAMA for up to 60 days, while going through additional testing. Failure of Level 2 CAD screening results in Level 3 CAD screening with an echocardiogram (an ultrasound of the heart). Failure of level 3 CAD screening requires invasive cardiac evaluation with a heart catheter, which is usually performed by a cardiologist.
Of note, civilian ATCs failing Level 1 are normally counseled on risk factor modification only. However, the ATC may require further screening if other risks are identified. Military ATCs failing Level 1 will be evaluated the same way as other military crew.
Prevention
Multiple measures can reduce one’s risk of failure of the cardiovascular screening. A lower calorie diet high in fruits and vegetables and low in simple sugars, saturated fat, and sodium is strongly correlated to lower cardiovascular risk. Moderate to vigorous physical activity up to 180 minutes per week correlates with better cardiovascular health, as does smoking cessation. Your flight provider may also recommend additional interventions such as medications.
Waivers
Per Army Aeromedical Policy, full flight status is authorized with a negative Level 1 CAD screening workup and does not require a waiver or affect your flight status. Asymptomatic positive Level 2 CAD screening requires stress tests every three years to monitor your cardiovascular disease risk. Failure to undergo required testing will usually result in termination of aviation duties until testing is completed.
If you fail cardiovascular screening and require further workup, then you will likely need to provide records supporting that your underlying heart and cardiovascular system is sound, such as EKGs, stress tests, and cardiology consult records. Normally no follow up is required annually for normal results of CAD screening workups. If you get a waiver for a certain abnormality, it will require scheduled follow up as outlined in the Aeromedical Policy Letters.
For Your Future (Including FAA Guidance)
If your Army Aviation workup is negative, then no waiver is necessary. Any positive results will require further evaluation of the underlying disease state.
For your civilian career, the FAA has no specific CAD screening protocol. However, a resting 12 Lead EKG is required for an initial license application. An EKG is also required by the FAA for pilots after reaching their 35th birthdays and on annual basis after reaching the 40th birthdays. While no specific lab or other cardiac workup is associated with the EKG, the aeromedical examiner (AME) will still likely ask about personal and family medical history, perform a heart and general physical examination, and review your clinical status. If any concerns are noted, the AME will further evaluate your fitness for duty with similar tests as Army Aviation. Any findings will require further workup, typically as per FAA protocols for specific heart disease conditions. These findings will have to be completed within 90 days of your initial physical and may require further FAA evaluation and a special issuance certificate.
Fly Safe!
Questions?
If you have a question you would like addressed, email it to This email address is being protected from spambots. You need JavaScript enabled to view it.; we’ll try to address it in the future. See your unit flight surgeon for your personal health issues. The views and opinions offered are those of the authors and researchers and should not be construed as an official Department of the Army position unless otherwise stated
MAJ (Dr.) Joseph R. Adams is a flight surgeon at the School of Army Aviation Medicine, Fort Rucker, AL.
