Polite discussion about EASA, the CAA, the ANO and the delights of aviation regulation.
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By Remosflyer
#1830925
Some questions for 'Flyin Dutch' who I believe is an AME...?

I apologise if some find them inappropriate but I think the answers could be interesting for us all:

Given the pilot's age and licence category one assumes that he had undergone an ECG in the previous 5 months. Could you comment on the relevance of this procedure relating to this case?

Would you support 'Stress ECG's' (ie riding a friction loaded training machine for 5 minutes) for aircrew with known heart conditions?

Is there any other procedure such as X-Ray or MRI that could help to detect a weak heart?

Do you support the use of drugs to alleviate hypertension?
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By ChampChump
FLYER Club Member  FLYER Club Member
#1830978
Richard's medical was as you surmised, Remos. There had been 'something' noticed on a previous Class II (over a month after it was issued!), resulting in some expensive investigation. That yielded 'nothing to affect', except a concern about blood pressure. Right branch block is the phrase I remember; whichever side it was, when he answered the medio's query on 'which side?' the answer was 'Good choice.' His father had had a pacemaker and thus there was some family history. The result of all this, though, was nothing: a Class II so he could continue with his CRI activity, plus a PMD in the back pocket.

I think I have the details of that investigation if polysyllabic terms are required.

You can tell my knowledge of matters cardiac is subminimal, but I'm happy to air my ignorance if it helps at all.

It does not upset me if people wish to discuss Richard's interior. He would be chuffed to think how useful he is still.
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By MattL
#1831166
Having been through the system myself recently I am told by my cardiologists that an echocardiogram is one of the best investigation / diagnosis means, and ECGs are quite an accessible but blunt tool. Indeed some of my 60+ flying friends have recently paid for private echo scans as a personal reassurance.

As for hypertension medication, again I am told that a low dosage of two drugs in combination is now favoured. Many GPs are still prescribing one drug and increasing the dose until control though (my GP said he would have done this if I hadn’t gone direct to the cardiologist)

Overall though, sadly there are still too many people brushing off those ‘not feeling quite right’ feelings that could get earlier intervention.

[I am not a clinician]
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By PaulSS
#1831173
I am told by my cardiologists that an echocardiogram is one of the best investigation / diagnosis means, and ECGs are quite an accessible but blunt tool


I was told the same thing by people who know their stuff. AN ECG is a pretty good indication of what your heart is up to at that very moment. If there is something wrong with the pump at that time then the wiggly lines can give the docs a good idea of what part of the ticker could be misbehaving. However, an ECG is not a very good predictor and, apparently, this is where the stress ECGs come in. By making the heart work for its money the people that know their stuff can look at the wiggly lines and better predict problems that may not be obvious as you lie on the oh-so-comfy bed with an octopus planted on your various pulse points.

Combining the stress ECGs with one of those isotope scans that looks at your arteries etc can give the people in white coats an even better idea.

Not an expert but been on the receiving end. Luckily all was well :thumleft:
By Dominie
#1831231
ChampChump wrote:Right branch block is the phrase I remember; whichever side it was, when he answered the medio's query on 'which side?' the answer was 'Good choice.'

I recall being told that a right bundle branch block (which I have) is OK, but a left bundle branch block is a no-no.
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By Flying_john
FLYER Club Member  FLYER Club Member
#1831263
Dominie wrote:
ChampChump wrote:Right branch block is the phrase I remember; whichever side it was, when he answered the medio's query on 'which side?' the answer was 'Good choice.'

I recall being told that a right bundle branch block (which I have) is OK, but a left bundle branch block is a no-no.


Strange - I have Left Bundle Branch Block (LBBB) and as it was explained to me its not an inherant physical problem of the heart but is an electrical problem where the "trigger" signal from the brain, to beat faster or slower to syncronise the natural rhythm of the heart muscle , does not get through the "bundle of hiss" properly and the electrical signal takes a circuitous route to trigger the beating heart muscle. This causes a delay of the beat, or sometimes additional or missing heartbeat .

I am a layperson as far as medicine is concerned but that's how it was explained to me and I then had a full cardiac workup after diagnosis and was given the all clear.
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By Flyin'Dutch'
FLYER Club Member  FLYER Club Member
#1831274
Sorry for the delay in getting back. I was on call until 0800 this morning then had to get the vaccine, do the week's shopping and sorting out general things before having a snooze. Back up now.

The aim of aeromedical testing is to a) ensure that people meet certain standards (e.g. vision) and b) that their risk of incapacitation is sufficiently small.

The most consistent indicator to judge risk of cardiac events against by far is age. Just age. Cardiac events at a young age are very rare and rise from middle age onwards for ever more:

https://www.ahajournals.org/cms/asset/b ... /24ff6.jpg

In order to stratify the risk of incapacitation due to an acute cardiac event all aviation authorities use a variety of tests and a commonly accepted test for this purpose is the ECG.

a) it is quite sensitive, if someone has coronary artery disease or a cardiac rhythm disorder it is likely to pick it up
b) it is quite specific, if it shows an abnormality it is commonly a fair indication that there is something going on
b) it is easy to apply
c) it is easy to interpret
d) it is cheap
e) there are no side-effects
f) there is no morbidity or mortality associated with the test

Some of the things it isn't

Perfect:

a) there are stories galore that people had a normal ECG and stepped off the couch only to have a fatal event - these of course 'popular' for the drama - in reality these is extremely rare - I must have done a few thousand of them and never ever had it happen even though I have done them on loads of people
b) a fair few people have an abnormal ECG only to be found not to have cardiac disease after a whole host of further involved and costly investigations
c) guarantees - the positive predictive value is not great; a normal ECG is no guarantee there is no cardiac disease or that cardiac disease will not develop.

Taking that into account the ECG can and is used as a screening tool and attached to it are periods of validity,

Remember what I wrote about risk of incapacitation?

Therefore for

a) a LAPL medical no ECG is required to meet the acceptable risk of incapacitation due to a cardiac event for LAPL medical certification.

b) for people who have a Class 2 medical at the initial medical there is no need to repeat that ECG, in the absence of symptoms, before they hit 50.
After that you need an ECG every 2 year.

c) for Class 1 Medical certification - which has a much lower acceptable risk of incapacitation that means they need an ECG after the initial one much more frequently - see the table below:
Image

Does the current system work.

The aviation authorities would argue it does - and I would agree with that, yes there are fatalities associated with cardiac events but they are rare and definitely below the accepted risks.

Could it be improved no doubt but not with the current state of medical science.

Yes you can put everyone on the treadmill but:

It is costly both in time, resource and money; it is also not a perfect test with another number for false positive and false negative tests and there is a definite morbidity and mortality associated with it.

Yes you can let everyone have an angiogram (looking into arteries to see if there is any arteriosclerosis - furring up of the arteries) of the coronary arteries but what goes for the treadmill test goes for the angiogram too.

There are still false negatives and false positives and it is even more resource intensive procedure and now you are looking at a mortality of about 1% and a morbidity of about 1% - these are people who are going to be ill after one or don't get off the table at all. All for a test that is still not perfect.

So how about the 'Gold Standard' the stress echo or stress MRT - there are very few false positives and false negatives - so very much WYSIWYG but you are now looking at £800 to £1200.

There is not the capacity to undertake these at the intervals required to meet the incapacitation prevention numbers and at those prices the number of pilots is going to be vanishingly small.

It is also worth to realise that the opportunity cost at those levels are very much at a level that the money, invested at other areas in aviation would prevent a lot more accidents and fatalities. The whole GA fleet can probably be fitted with the latest kit and TCAS, and free flying to avoid LOC accidents at the value of the budget required.

I hope that goes some way to explain what a non-perfect test can bring to aviation safety.

If there are any comments or questions, feel free to fire away.
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By Flyin'Dutch'
FLYER Club Member  FLYER Club Member
#1831281
Remosflyer wrote:Do you support the use of drugs to alleviate hypertension?


Of course!

Why not?

There is a host of evidence which makes it abundantly clear that managing blood pressure at acceptable levels is a great way to avoid cardiovascular disease.

Our design life is really only to the mid 40-50s and after that problems start to crop up which cause us to become ill and/or die.

One of those is raised blood pressure:

Image

Raised blood pressure causes cardiovascular events:

Image

And lowering raised blood pressure is directly related to reducing cardiovascular events:

Image

Note - especially in avoiding stroke disease.

The problem with blood pressure is that:

a) it is asymptomatic until: 1. there is an event 2. it is off the scale

That means:

a) in the absence of a screening opportunity many people have high blood pressure without knowing it and being treated
b) it is difficult to engage people for treatment both initially and ongoing - nobody with a bacterial pneumonia needs reminding taking their antibiotics until they are better, but for an asymptomatic condition that may or may not come?

Therefore you require a a clear understanding by the person of what the plan is and engagement with:

a) cheap medication - you need to treat many folks and for a long time to have benefit
b) no or little side-effects - nobody is going to take tablets if they feel cr@ppy or have side-effects which means not able to fly or other fun-activities (yes those!)
c) easy compliance - ideally once a day medication.

Luckily all first, second and most third line medication meets those standards.

Most people with established high blood pressure require 2 or 3 medications to get good control; it often is better to have several medications in low doses rather than fewer in higher.

That stands to reason, blood pressure is regulated at various places and managing those various places and systems works better.

If anyone has any questions feel free to ask.

Below the link to the NICE guidelines on managing high blood pressure.

https://www.nice.org.uk/guidance/ng136/ ... 1722710213
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By Flying_john
FLYER Club Member  FLYER Club Member
#1831313
Thats an interesting read esp the Hypertension part.

My GP issued me a prescription for raised blood pressure, just because I said my AME had commented on it. No lifestyle advice, just take these for the rest of your life with no explanation. Took one had a raging migrane and never took another one !.

Went to the hospital the other day to see about a chest Xray and was put through a mini data collection, weight, height, blood pressure etc and the nurse said oooh high blood pressure.

SO my question is should I trouble my GP and ask for some advice or safe medication I can still fly with, or should I become a stroke/heart failure patient in later life ??