1. Pilots on Coumadin (Anticoagulation therapy)
The FAA is going to be more stringent in the use of anticoagulation in chronic or paroxysmal atrial fibrillation (AFIB). AFIB and a history of stroke, transient ischemic attack, moderate to severe left ventricular dysfunction, mitral valve disease, coronary heart disease, prosthetic heart valve or age >75 are considered high risk.
Lesser risks are hypertension, diabetes mellitus, thyrotoxicosis, and age 65-74. With age <65 and absent risk factors, aspirin is acceptable and if risk factors are present, then warfarin is required. In ages 65 to 75 with absent risk factors, aspirin or warfarin is acceptable. If the risk factors are present, warfarin is required. In age >75, warfarin is required.
We want the INR levels to be between 2.0 and 3.0. We are now going to allow the AME to send in the monthly values (we want the airman to have the INR level determined monthly) every 6 months for first-class and every 12 months for second and third. The airman is required to bring all these values into the AME. The way we look at the INR’s is that we want 80% of the values to be between 2.0 and 3.0. We will be satisfied with values as low as 1.6 or as high as 3.5. If they are not within that range, then we shall withdraw the authorization for a special issuance.
2. AFIB treatment
In chronic AFIB, when we request a 24 hr. Holter monitor and there are sinus pauses >2.5 sec., we will withdraw the authorization. Likewise, if the resting heart rate is 100 or there are episodes where the heart rate exceeds 130-140 BPM with minimal exertion, we will withdraw the authorization. This is regardless of whether the airman is being treated with digitalis, beta-blockers, or calcium channel agents.
3. Heart valve replacement
Follow-up for a simple heart valve replacement when there is no evidence of coronary heart disease will be a clinical status report, CVE, standard ECG, and Doppler echocardio-gram every 6 months for first- and second- class and annually for third-class.
4. Heart valve replacement and warfarin
In mechanical heart valve replacement where the airman is taking -warfarin, there will be the requirement for 80% of the INR’s to be between 2.5 and 3.5.
5. Multiple heart valve replacements
Multiple heart valve replacements will be denied all classes of medical certificates. We do grant medical certification to airmen who have had the Ross Procedure. This is where the pulmonic valve is transplanted to the aortic position and the pulmonic valve is replaced with a bioprosthesis.
6. Coronary recovery and testing
In the medical certification of myocardial infarction, angina pectoris, coronary bypass grafting, -coronary angioplasty, coronary atherectomy, and coronary stent placement, we still require a 6-month observation or grounding period. First- and second-class airmen are required to have a 6-month post-event heart catheterization.
If you recall, we had been requesting the follow-up recertification material every 6 months for first-and second-class airmen and every 12 months for third-class. We are now going to require a CVE and maximal Bruce Protocol Stress test every 12 months and a CVE and maximal Bruce Stress Radionuclide Scan every 24 months.
Please note that our cardiology consultants reserve the right to request 6- and 12-month follow-up reports, as before, depending on the airman’s particular case. We will extend the follow-up requirements when the airman demonstrates stability.
Please be aware that we are not legally allowed to place any restrictions on a first-class medical other than eye, hearing, color vision, or a time limitation. We can place restrictions on second- and third-class medical certificates. In other words you/we cannot place a restriction of SIMULATOR DUTIES ONLY on a first-class medical. We can, for example, place the restriction NOT VALID FOR CARRYING PASSENGERS OR CARGO FOR COMPENSATION OR HIRE on a second-class medical.
8. Pacemaker dependency
We have not been granting medical certification to first- and second-class airmen with pacemaker dependency. We define this as a heart rate of no less than 40 BPM when the pacemaker is turned down to its lowest rate or completely off.
9. Pacemaker observation period
We are now going to grant medical certification in cardiac pacemakers after a 2-month observation period, -instead of the previous 6-month observation period. This assumes that there is no evidence of coronary artery disease or the need for heart valve replacement. This will include replacement of generator, lead system, or both.
10. Epilepsy, seizures, brain injury
Applicants with epilepsy will now be considered after a 10-year seizure-free period and 3 years of being off anticonvulsant medications.
Airmen with a single seizure will be considered after a 4-year seizure-free period and 2 years off anticonvulsants.
11. Requip (ropinirole) no longer allowed
Since Requip (ropinirole), which is used in the treatment of Parkinson’s disease, now carries the same warning as Mirapex (pramipexole), we are no longer allowing it in airmen. These medications have been associated with the sudden falling asleep of individuals. This falling asleep has occurred up to 1 year after the initiation of therapy, many times without warning. The events have occurred while operating a motor vehicle. I recently performed a literature search because some of our AMEs said that if the dose is reduced, this side effect would not occur. However, I could find no studies or literature to support this claim.
12. Provigil (modafinil) no longer allowed
Provigil (modafinil), a wakefulness-promoting agent that is utilized in excessive daytime somnolence, is not allowed in aviation duties.
Two answers – One question
At the recent aviation medical examiner seminar an AME raised a common concern that the FAA needs to advise AME’s more frequently about FAA policy changes: “Let us know about recent regulatory changes, e.g., the prior use of Ritalin-like drugs under [question] 18m and psycho tests now needed”
The following details the way the Aerospace Medical Certification Division typically handles ADD cases.
If a young airman reports the diagnosis of ADD and is taking any of the common medications —Ritalin -(methylphenidate hydrochloride), Adderall (combination dextroamphetamine and amphetamine), or Dex-edrine (amphetamine)—he or she will be denied medical certification. The condition and the medications are incompatible with aviation duties for any class.
If the applicant reports being off the medications for 90 days and the FAA receives evidence from the treating physician or counselor of good performance in school and the applicant is not demonstrating any attention deficit-related issues, the FAA will likely grant medical certification. In all cases, the applicant should provide the FAA with an eloquently detailed statement from the treating physician as to how the diagnosis was made, the response to the treatment, and how the prospective airman currently performs while off the medications.
If there is any question as to whether the airman still is having the difficulties associated with this condition, then the FAA shall require the airman to be off the medication and have three psychologic tests: the Trail-Making Test, the Wisconsin Card Sorting Test, and the Paced Auditory Serial Addition Test (PASAT). These test the individual’s capabilities of performing in a multitasking situation. The FAA will also accept, in lieu of the above tests, the TOVA – Test of Variable Attention — or the Conner’s Continuous Performance Test.
The question raised by this AME also underscores an important point. The FAA does require continuing education to maintain designation status. Unfortunately most Aviation Medical Examiners do not attend these frequently and AME’s perform a limited number examinations. Since there are constant changes in FAA aeromedical certification standards, it is impossible for the FAA to notify all AME’s for every change in FAA policy. AME’s are private physicians designated, and not employed by the FAA. Moreover, the busy practice of medicine makes it difficult if not impossible for AME’s to be sufficiently familiar with the nuanced documentation or testing which may be required by the FAA in each particular case. There are virtually infinite amounts of medical conditions and scenarios.
Pilot Medical Solutions works with pilots throughout the U.S. and abroad and we collaborate with the FAA and private physicians on multiple cases daily. We have assisted pilots and their private physicians since 1995. Having this unique level of experience we are exceptionally familiar with the FAA’s requirements.