In this subsection we will refer to ischaemic heart disease (IHD) when ischaemia is present and coronary artery disease (CAD) when there is known CAD but ischaemia is absent or has resolved.
Ischaemia may be diagnosed following an acute coronary syndrome, the development of angina or arrhythmia, an abnormal ECG or through routine screening for elevated CV risk.
An applicant with a history of cardiac ischaemia should be considered as having ongoing elevated cardiovascular risk, even if full revascularisation has taken place.
Demonstration of absence of ischaemia, adequate cardiac function (LVEF 50% or above), and adequate control of risk factors have to be demonstrated, initially and recurrently. In particular:
- Smoking cessation if the applicant is a smoker; and
- Use of antithrombotic agents: Aspirin lifelong and another agent (i.e.: Clopidogrel, Ticagrelor) for twelve months post event; and
- Use of a Statin for plaque stabilisation; and
- Satisfactory blood lipids profile; and
- Use of a beta-blocker or other cardio-protective medication if advised by the treating cardiologist.
Operational restrictions are generally imposed on medical certificates Class 1 and occasionally on medical certificates Class 2 and 3, in order to mitigate third party risk.
Information to be provided
On the first occasion that an applicant presents with a history of acute coronary syndrome or coronary artery disease with or without revascularisation.
- All discharge summaries;
- All specialists reports;
- Any angiography report and images, including an electronic copy;
- Any echocardiogram report and images, including an electronic copy if available;
- All stress ECGs, including complete tracings and reports;
- Any other investigation reports, for instance myocardial perfusion scan or stress echocardiography, with all tracings/ images/ videos;
- Any Holter monitoring tracing and report,
- Blood lipids, glucose or HbA1c and renal function.
On subsequent occasions that an applicant presents with a history of coronary syndrome or a history of coronary artery disease, at least annually.
- Recent cardiologist report;
- Copy of any interim investigation report;
- Demonstration of absence of ischaemia by stress ECG or stress echocardiography or as advised by CAA;
- Blood lipids, glucose or HbA1c, and renal function.
Note: Applicants applying six monthly, should provide the above information annually, all things being equal, or as required otherwise by CAA or the ME.
- An applicant with a history acute coronary syndrome or any history or symptoms suggestive of cardiac ischaemia should be considered as having a condition that is of aeromedical significance.
Under the flexibility process, many applicants with a history of ischaemic cardiac disease are able to be certificated. CAA generally requires the following medical evidence:
- 6 months have lapsed since the acute coronary event and any re-vascularisation procedure;
- Satisfactory cardiac vascularisation;
- Satisfactory cardiac function: LVEF 50 % or above;
- Absence of ischaemia, demonstrated at 6 months post event and then annually. The acceptable tests to demonstrate absence of ischaemia may vary on a case by case basis;
- Control of risk factors: Non-smoking, favourable blood lipid profile;
- Compliance with optimum medication.
Under the flexibility process, an applicant who has undergone coronary artery stenting to be considered for certification earlier than 6 months post re-vascularisation, provided that:
- There has been no myocardial infarction;
- Three months have lapsed since stenting;
- The cardiac function is normal;
- There is single vessel disease, not affecting the main coronary artery or the proximal LAD;
- Absence of ischaemia is demonstrated at three months post stenting;
- There is control of risk factors: Non-smoking, favourable blood lipid profile;
- There is compliance with optimum medication.