The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident

Abstract

Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.

Keywords: cardiac imaging and diagnostics; cardiac risk factors and prevention; health care delivery.

Figure 1

HFM-251 generic screening and evaluation algorithm (Adapted from DeJohn et al [1]). (1) This algorithm should be modified/revised for use by specific agencies as required. (2) Aggregate stenosis is the sum of quantified stenoses found on invasive coronary angiography (ICA). Adapted from Davenport et al [53]) (3) Functional imaging refers to stress myocardial function (eg, MUGA), stress nuclear perfusion studies stress echocardiography or perfusion CMR. Functional imaging should be performed based on the results of anatomical imaging studies and/or clinical decision. CAD, coronary artery disease; CACS, Coronary Artery Calcium Score; CTCA, CT coronary angiography; MUGA, multigated acquisition.