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channelopathies, catecholaminergic polymorphic ventricular tachycardia, aortic stenosis, possibly mitral
leaflet prolapse, anomalous origin of the coronary arteries, myocardial bridging, Wolff-Parkinson-White
syndrome1, atrioventricular (AV) conduction disturbances, myocarditis and certain medications. Many of
these causes are rare and their disposal in the aviation context is beyond the scope of this chapter; others
are covered below.
Medical certification in the presence of known coronary artery disease
1 W-P-W syndrome: is classically the association of atrio-ventricular reciprocating tachycardia and an ECG
showing a short P-R interval and a wide QRS complex which includes a delta wave. Experience has indicated
greater breadth to the syndome and related atrioventricular nodal reciprocating tachycardias, atrial flutter and atrial
fibrillation are also seen. After Louis Wolff, American cardiologist (1898-1972), Sir John Parkinson, English
physician (1885-1976) and Paul D. White, American cardiologist (1886-1973).
ICAO Preliminary Unedited Version — October 2008 III-1-17
Myocardial infarction disqualifies, at least initially, from certification to fly. Predictors of an adverse
outcome after myocardial infarction include previous history of the same, reduced ejection fraction,
angina pectoris, smoking (current or ex-), history of hypertension, systolic hypertension, diabetes,
increased heart rate and reduced effort tolerance.
The best-risk subject, by comparison, will be asymptomatic, non-diabetic and normotensive, with a
normal ejection fraction and with coronary artery disease restricted to the vessel subtending the infarction
(which should, preferably, be patent). Subjects with single-vessel disease subtending a completed
infarction may be considered for restricted certification, although in one study of 262 patients with a
mean age of 52.3 years, there was no difference in five- and ten-year survival regardless of whether the
infarct-related artery was patent. At 96.9 per cent versus 93.8 per cent for five-year survival, and 90.7 per
cent versus 92.7 per cent for ten-year survival, for patent and non-patent vessels, respectively, such
outcomes in an asymptomatic individual are likely to be satisfactory for certificatory purposes but only if
the ejection fraction is normal. The ten-year survivals were 94.8 per cent, 90.6 per cent and 74.8 per cent
with ejection fractions > 60 per cent, 40 to 60 per cent, and < 40 per cent, respectively.
It is well established that left ventricular function powerfully predicts both cardiovascular events and
outcome. Data from the Cleveland Clinic first demonstrated five-year survival with single-vessel disease
at 89 per cent and 77 per cent in the absence and presence, respectively, of wall-motion abnormality.
CASS registry data revealed six-year survival in two-vessel disease spanning 49 to 88 per cent, the best
outcome being predicted by normal left ventricular function. CASS registry data further confirmed the
excellent outcome in males without ventricular damage who had undergone coronary artery bypass
grafting (CABG) whose survival was significantly better than that of their Framingham peers. Reduction
in left ventricular function rendered the prognosis less favourable, mild to moderate impairment function
being associated with a significantly poorer outcome at five years.
Revascularization of the myocardium
Coronary artery bypass grafting (CABG)
The long-term outcome following CABG is now well established, although proof of benefit over medical
treatment depends largely on the outcome of three studies completed in the 1980s. Subsequent
developments include more generalized use of arterial conduits, including the internal mammary arteries,
and radial artery as a graft in addition to, or instead of, saphenous vein grafts. These have been
demonstrated to have enhanced late patency. Off-pump grafting and minimally invasive off-pump bypass
(minimally invasive direct coronary artery bypass, MIDCAB) have less morbidity, but long-term outcome
has yet to be determined with confidence.
There are important differences between CABG and percutaneous transluminal coronary angioplasty
(PTCA) in terms of early and late morbidity. One early meta-analysis contrasting outcome of the two
techniques identified mortality and non-fatal myocardial infarction at 10.1 per cent versus 9.8 per cent at
2.7 years, but the additional intervention rate in the first year was 33.7 per cent in the PTCA group, ten
times that in the CABG group. Surgery bore a prolonged period of rehabilitation, while PTCA was
burdened by repeated late hospitalisation. This was in the pre-drug-eluting stent era, the technique having
transformed the early outcome, the expected MACE event rate now being of the order of 3 - 4 per cent in
　
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