Previously, we discussed what a pilot could do to avoid problems during the vision portion of FAA medical examination. Now, we’ll look at the Coronary and Cardiovascular portions of the exams. There are some things you can do that will help avoid problems during this portion of your flight physical.
The first thing to understand is, the FAA is not doing clinical medicine. Its concern is sudden incapacitation in the cockpit. For instance, FAA data indicates that concern is justified when at-rest blood pressure exceeds 155 over 95 and remains high during successive readings.
The average medical doctor becomes apoplectic, however, when they learn that the FAA will certify a pilot with a blood-pressure level that high, because they want to see at-rest BP readings below 120/70. They consider a person pre-hypertensive slightly above 120/80 and clinically hypertensive at a considerably lower BP level than 155/95.
Another example – this time going the other direction: Premature Ventricular Contractions (PVCs) and Premature Atrial Contractions (PACs) can cause your heart to feel as if it’s doing flip-flops and can be quite disconcerting. But doctors know they occur in both healthy and unhealthy people, sometimes at a rate of hundreds a day. Cardiologists know that since PVCs and PACs occur in both healthy and unhealthy people; so, in and of themselves, they are not predictive of heart attacks unless accompanied by other factors.
In the absence of these additional factors, most doctors will not order expensive tests solely on the basis of a few PVCs occurring as single events. (Runs of PVCs – two or more in succession – may or may not result in further testing by your regular doctor. It depends on what other factors are present and if your MD is super cautious.)
Still, regardless of current clinical practices, the FAA will require a pilot seeking a 1st class medical certificate to undergo a complete cardiac workup – including a stress test and probably a nuclear test as well – if more than one PVC appears on the annual electrocardiogram. If you pop a couple of PVCs on your 1st class flight physical ECG, you will be doing a stress test in the near future, according to current guidelines published in the AME handbook. Again – clinical medicine and sudden incapacitation medicine are not the same thing and the FAA’s main concern is investigating whether or not you’re likely to conk out while flying.
OK. On to a few suggestions about how you can avoid raised AME eyebrows.
Blood Pressure Tripwires
It’s very common for pilots to develop White Coat Hypertension when in the presence of an AME. For me, it used to mean an elevation of about 10 points on both measurements.
I had the White Coat Hypertension problem until I found an AME that left the BP measurement for last and made a show of signing the medical certificate after completing the entire exam except for the BP requirement. That simple technique did wonders to lower my BP. (I knew he could always tear the certificate up but the fact he had signed it disarmed my concern for some reason.)
That AME is retired now and I’m back to taking steps to lower it in other ways. If you’re concerned about blowing past the 155/95 limit, you might consider doing what I do now.
Drink plenty of water, cut out salt starting 48 hours before the exam and eat some bananas, because unbalanced electrolyte levels – in this case potassium – can enhance BP issues. Eight tall glasses of water each day also helps flush the toxins out of your body and, strange as it sounds, will result in less water retention, which is a very good thing.
Make sure the arm from which the BP measurement is taken is at heart level and don’t slouch in the chair. Also, don’t hold the arm up yourself; ask the person taking your BP to support your arm if they don’t do it on their own.
No Caffeine a full 24 hours before your exam – zero intake, nada, zip, none.
If there is something going on in your life that is producing stress, consider rescheduling your exam. Even something as mundane as an argument with your significant other just before an exam can make your BP rise temporarily. AMEs are instructed to not rely on just one BP measurement if an airman exceeds the limit but if you break the 155/95 barrier, that in itself will typically cause a shot of adrenalin due to fear of not passing your exam, which can cause even more BP troubles. To reiterate: Reschedule your physical if you are stressed out.
If you do these things and still have BP over 155/95, you may need to be on a beta-blocker (or certain other drugs) to get things under control. If your personal physician puts you on any of the common BP reducing drugs, the AME can issue a certificate nowadays upon written assurance by your doctor that your BP is under control along with information describing what drugs he or she has prescribed. (Your BP measure-ment in the AME’s office still has to be below the 155/95 limit, which it will be if your BP is truly controlled.)
Ectopic Beats, PVCs, PACs
and Caffeine Intake
Ectopic Beats is a generic name for variation from normal sinus rhythm – the constant and evenly spaced pulse – and are often caused by PACs or PVCs.
Depending on when they occur, they feel like an extra beat or a skipped beat when taking a pulse. If PVCs occur when the heart’s tricuspid valve is closed, you’ll feel a flutter in your chest when they occur; otherwise, you won’t feel anything and likely won’t even know they’re happening.
Since AMEs are instructed to ignore “occasional” ectopic beats, resist the tendency to obsess about them if you’re only going for a 2nd or 3rd class medical which do not require an ECG.
If you are required to have an ECG, there’s little you can do to prevent the ECG from ratting you out on your PVCs, but there’s a lot all pilots can do to eliminate PACs. PAC generation is particularly sensitive to caffeine intake, so lay off the coffee, soft drinks and energy drinks for a few days before your AME visit. Ditto for any food that contains caffeine.
The problem for those seeking a 1st class certificate is you won’t be able to tell what – PAC, PVC, or something else – is causing the ectopic beat without an ECG. All you know is your pulse appears to be irregular. If you feel extra or skipped beats happening in your pulse, your best option is to have an ECG done by your personal physician to see what’s happening prior to seeing your AME. (Your doctor will check you out for other coronary factors too, which is a very good thing.)
If the beats are PACs, lay off the caffeine and most likely they will go away. If they are PVCs and you are seeking a 1st class medical, prepare yourself for the AME’s inevitable demand for a stress test and perhaps more if the ECG catches more than one PVC.
Your Personal Physician and the FAA
Because of the disconnect between clinical medicine and sudden incapacitation medicine, pilots have to take a different approach with their personal doctors than regular folks do, because our doctors frequently must provide opinion letters to the FAA if our flight physical turns up something unusual. For that reason, we have to make sure our physicians understand how different the FAA is with respect to medical objectives and stress that it’s critical that the doctor be extremely careful how he or she documents medical facts to the FAA. Tell them it’s just like an IRS audit: address the FAA’s specific concerns truthfully but volunteer nothing else.
The root of the problem is, doctors as a group want to be helpful to a colleague, so they will often speculate about what may be happening in their correspondence. They cannot do this with the FAA. Tell your physician that he or she is not dealing with a colleague. Rather, they are dealing with the equivalent of a lawyer, who happens to be a physician.
I’ve had success showing my doctors the actual FAA AME guidelines. (The AME handbook is available online at the faa.gov website.) Once they get over the FAA’s attitude on clinical medicine versus sudden incapacitation medicine, most doctors will be very helpful when providing opinion letters – at least by the time you reach the second or third iteration.
A Final Couple of Comments
This article – and the previous one dealing with the vision portion of the FAA exam – is not intended to be medical advice; I’m a pilot and an electrical engineer by training, not a physician. But I do have 50 years of experience jumping through the FAA’s medical certification hoops and have learned a few things about their certification philosophy, which I’ve tried to pass on to you.
The suggestions I’ve made are not intended to hide anything and in fact will not hide any true problem. What they will do is help you minimize false positives during the FAA exam – and false positives can cost you time and money plus create consternation you don’t need.