Your Health: Another Kind Of Pressure

Unlike the non-flying population at large, when it comes to blood pressure (an important indicator of cardiac health), any pilot pretty much already knows what their score is. And any pilot who is on the borderline between ho-hum normal and mildly elevated probably knows it, too. But here’s something you probably didn’t know…

Disclaimer: The information contained in this article may be misleading or inaccurate due to the passage of time or other factors and should not be substituted for direct consultation with a medical professional.

Blood pressure is an important metric; when it gets too high, it becomes a major risk factor for heart disease, stroke, brain damage, kidney failure, and even some kinds of blindness. You probably already knew that cardiovascular disease (often called the “silent killer“) represents the largest cause of death and disability among the American population. You may also know that high blood pressure (hypertension) is a common medical condition affecting over 50 million n Americans. It accounts for about 200,000 deaths in America each year. Part of the problem is that only about a fifth of those with this condition are under proper treatment; the rest are unaware that they even have it. I just this afternoon attended a gathering of relatives, friends, and neighbors for a memorial service honoring our former neighbor, Norm Siegel. The week before last, he suffered a sudden and massive heart attack. He was folk dancing.

We actually have two blood pressures: the systolic pressure when our hearts contract, and the much lower diastolic pressure, when our hearts relax. When your heart contracts, it pushes blood into your arteries, which are supposed to expand somewhat to accept the blood and prevent your blood pressure from rising too high; if your arteries are stiff or somehow constricted, your blood pressure will be higher. The FAA’s definition has been a resting systolic blood pressure over 155 mm of mercury, or a diastolic pressure over 95. Have anything over either, and you are disqualified from any and all medical certificate classes.

Warning: That border between what’s okay for a pilot and what’s not may be getting both a little blurry, as well as even more stringent. I’ll explain this in a minute.

Cardiovascular issues represent a significant fraction of all pilot inquiries to physicians. About 25,000 pilots are already dealing with this problem (because that’s about how many are already on blood pressure medication). If there is any good news, it’s that hypertension is controllable with a variety of available medications, and the vast majority of them are approved for use when flying (after an appropriate evaluation). Now if you’re already flying with medication to control blood pressure, that doesn’t make you unsafe; in fact, you’re certainly safer and wiser than those who ignore the condition and who avoid monitoring and treatment. The FAA even allows an AME to issue a medical certificate without requiring a pilot to use blood pressure medication, if a cardiovascular evaluation is otherwise (aside from blood pressure) normal. This plan of action is meant to encourage pilots to get their elevated blood pressure evaluated and treated if necessary.

What comprises a cardiovascular evaluation, or CVE? First, it can be performed by any physician, not necessarily an AME or cardiologist. See FAA Form 8500-19, Specifications for Cardiovascular Evaluation. (Be advised not to have tests that are not medically indicated “just because the FAA might want to see it.” Extra testing can cause significant problems, administrative delays, and expense.) The cardiovascular evaluation includes:

  • pertinent personal and family medical history
  • assessment of risk factors for heart disease
  • clinical exam with at least 3 BP readings
  • resting ECG
  • lab reports including fasting glucose, cholesterol, triglycerides, potassium and creatinine
  • exercise stress test, if clinically indicated (this is not always required)
  • report of medications, dosage, and any side effects

Generally, the lower your blood pressure is, the lower is your risk of suffering from heart disease. One current set of standards is summarized in this table:

The American Heart Association recently redefined blood pressure standards. To be exhaustively specific, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, and approved by the National Heart, Lung, and Blood Institute (a division of the Department of Health and Human Services and NIH) has recently updated guidelines for the prevention and management of hypertension (as of May 14, 2003). These new recommendations advocate even lower levels than those presently in use.

The New Standards: A new category of “pre-hypertension” has been added to the updated guidelines as a warning signal (and stages 2 and 3 hypertension have been combined). Patients with pre-hypertension (120/80 to 139/89 mm Hg) are at increased risk of progression to hypertension. Initially, lifestyle modifications are recommended, rather than drug therapy. These modifications include weight reduction, dietary modifications such as lowering sodium, fat, and cholesterol intake (and increasing dietary fiber), increasing physical activity, ceasing the use of tobacco products, and consuming alcohol only in moderation. There are many other elements that can also contribute to raising blood pressure, such as that morning cup of coffee, or in a more serious vein (ouch), sleep apnea. Here’s another table that lists the newest classifications:

Another change has to do with excuses for age: they’re going away. The FAA’s upper limit for blood pressure used to allow for a pilot’s age and class of certificate. The standards now allow certification for pressures up to 155/95, without an evaluation. Pilots with blood pressures above this level may still be certified after a cardiovascular evaluation. The standards set by the FAA should not be construed as healthy or “safe” levels. Like the “FARs“, they are just guidelines; blood pressure near these limits should still probably be evaluated and treated.

What classes of medication might be prescribed depends on many factors, including findings during the exam, existing medical conditions, lifestyle issues, and even insurance coverage. Among these are diuretics (which work to lower blood pressure by lowering blood fluid volume); alpha blockers (which dilate blood vessels, increasing circulatory volume and thus lowering blood pressure); beta blockers (slowing heart rate and therefore blood pressure); ACE inhibitors or A-II blockers (which block the formation of compounds produced in the kidney that raise blood pressure); and calcium channel blockers (which impede the flow of calcium into the muscles of the cardiovascular system, reducing the contraction of blood vessels and slowing electrical activity in some parts of the heart).

THE BOTTOM LINE: Pilots can often fly (according to the FAA, with any class of medical) while using such medications, singly or in certain combinations, following completion of the CVE and documentation that their blood pressure is controlled (without side effects). So there’s hope. But the best thing we can do to prolong our years on earth, as well as our hours flying over it, is to take care of ourselves. It doesn’t get much simpler than that.

For further reading, the FAA has a good web site with information of certification of individuals with hypertension.