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the context of aviation. Some 70 per cent of lesions undergoing the percutaneous approach are now
stented.
It is likely that the early hopes for drug-eluting stents will be sustained although there may be
performance differences, and other, unforeseen, complications may arise. However, in a meta-analysis of
14 trials using paclitaxel and sirolimus-eluting stents, there was no significant improvement in rates of
death or non-fatal myocardial infarction when compared with the bare metal stent. Current guidelines by
the National Institute for Clinical Excellence (NICE) in the United Kingdom state that “stents should be
used routinely where percutaneous coronary intervention (PCI) is the clinically appropriate procedure”
but they do not endorse unlimited use of drug eluting stents.
In the context of aviation, a very low post re-vascularisation MACE rate is needed before certification can
be considered. Graft angioplasty and angioplasty in diabetic patients should not be acceptable due to the
high subsequent event rate. Furthermore, in multi-vessel disease, the technique is relatively less good than
surgery in obtaining “full” revascularization. In some Contracting States, pilots are certificated following
stenting of one or more coronary arteries, provided there is not evidence of reversible ischaemia (judged
by exercise ECG and/or thallium scintigraphy) in spite of an annual MACE rate which may very
significantly exceed 1 per cent per annum.
Intervention against vascular risk factors
There is now massive published evidence that intervention against the major vascular risk factors —
hypertension, hypercholesterolaemia, smoking and diabetes — is associated with a significant reduction
in fatal and non-fatal cardiovascular events. This holds good in both primary (i.e. before declared disease)
and secondary prevention (i.e. after a cardiovascular event), across all ages, especially if there are
multiple risk factors present. With such convincing evidence, the requirement that a reduction of risk
factors must be undertaken in the presence of known coronary artery disease represents best clinical
practice.
• Targets in the treatment of hypertension should be <90 mm Hg diastolic, taken to D51 with an
appropriate sized arm cuff (<85 mm Hg on a 24-hour ambulatory recording); 80 mm Hg in the
context of diabetes
• Targets for the treatment of hyperlipidaemia (with a statin, if tolerated) should be at least a
reduction of 30 per cent in the level of total cholesterol or <5 mmol/L total, and <3 mmol/L low
density (LD) or better.
• Diabetes should be managed as indicated in Part III, Chapter 4
• Smoking must be avoided completely
• Programmed exercise should be undertaken
• Weight reduction is beneficial with increased consumption of fruit and vegetables and
substitution of saturated fats by mono-unsaturated fats such as olive oil
3 ARTS study: The Arterial Revascularization Therapy Study: a large randomized, controlled trial that compared
percutaneous coronary intervention (PCI) with stent placement to coronary artery bypass graft (CABG) surgery in
patients with multivessel disease. ARTS was designed in Salzburg in April 1996 and was performed at 67 centres in
Australia, Europe, New Zealand, and South America.
1 D5: fifth phase Korotkoff sound, i.e. no sound, for the determination of diastolic blood pressure
ICAO Preliminary Unedited Version — October 2008 III-1-20
In summary, an applicant may regain a Class 1 Medical Assessment to fly as/with a suitably qualified copilot
(OML) no sooner than six months following the index event (i.e. myocardial infarction / revascularisation
procedure in the presence of known coronary artery disease), provided that:
• he/she is asymptomatic and requires no anti-anginal medication
• vascular risk factors have been addressed, including smoking cessation, lipid lowering (with a
statin, unless contraindicated), and treatment of hypertension (with an angiotensin-converting
enzyme inhibitor (ACE inhibitor), an angiotensin receptor blocker (ARB) and/or a calcium
channel blocker (CCB), and the administration of aspirin and/or clopigogrel, if indicated.
Subjects with an abnormality of glucose metabolism demand special scrutiny and management.
Diuretic agents and the beta-blocking agents are better avoided
• left ventricular function is normal (> 50 per cent) as measured by echocardiography (Simpson’s
rule1), multiple-gated acquisition (MUGA) study, or contrast ventriculography
• exercise ECG to stage IV of the Bruce treadmill protocol can be achieved without evidence of
myocardial ischaemia, significant rhythm disturbance or symptoms
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Manual of Civil Aviation Medicine 1(83)
