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WHSXXX10.1177/2165079917751478Workplace Health & SafetyWorkplace Health & Safety
vol. 66  ■  no. 10
Cardiovascular Risk Factors in Airline Pilots
Dana Lord, BSN, RN1 and Helen Acree Conlon, DNP, MPH, ARNP-BC, COHN-S1
Abstract: The health of an airline pilot is imperative
to the safe travels of millions of people worldwide.
Medical providers evaluate the cardiovascular risks for
airline pilots and the medical requirements to obtain
and maintain licensure as an airline pilot. It is the role
of the occupational health nurse practitioner to evaluate
and reduce the risk of cardiovascular disease in this
population.
Keywords: case management, disease prevention, medical
surveillance, government regulation, health promotion,
occupational health and safety programs, cardiovascular
disease risk factors, airline pilots
Introduction
The U.S. Department of Transportation’s Bureau of
Transportation Statistics reports that in the year 2015, U.S.
airlines and foreign airlines servicing the U.S. carried 895.5
million passengers (U.S. Bureau of Transportation Statistics,
2016). The data show that the number of U.S. passengers
continues to rise each year for domestic and international
flights. The Federal Aviation Administration (FAA) is charged
with providing safe and efficient flights for U.S. travelers. Their
role in safety includes regulation of civil aviation; issuing and
enforcing regulations and standards in manufacturing and
maintenance of aircraft; operating the air traffic control system;
developing new aviation technology; and certification of U.S.
pilots (FAA, 2014).
A large part of the FAA safety initiatives includes the
licensure of pilots, ensuring that licensed pilots are
competent in their occupation. Included in the basic
competence of licensure is a comprehensive medical
examination performed by an Aviation Medical Examiner
(AME). Cardiovascular diseases are an important medical
condition requiring careful evaluation due to the risk of
DOI: 10.1177/2165079917751478. From 1University of South Florida. Address correspondence to: Dana Lord, BSN, RN, Student, College of Nursing, Dual Degree Program AGPCNP/Occupational
Health Nursing, University of South Florida, 2400 Spring Hollow Loop, Wesley Chapel, FL, USA; email: dhamilt1@health.usf.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2018 The Author(s)
Workplace Health & Safety
Professional Pr actice
sudden incapacitation of a pilot during a cardiac event.
Evaluating the risk factors specific to airline pilots and
implementing heart healthy programs to mitigate modifiable
risk factors are an important part of the occupational health
nurse practitioner role.
Background and Epidemiology
Cardiovascular disease is the number one killer of both
men and women, with more than 600,000 people dying from
the disease in the U.S. every year (National Center for Chronic
Disease Prevention & Health Promotion, Division for Heart
Disease & Stroke Prevention, 2015). Forty-seven percent of
Americans have major risk factors for heart disease, including
a smoking history, hypertension, or hypercholesterolemia
(National Center for Chronic Disease Prevention & Health
Promotion, Division for Heart Disease & Stroke Prevention,
2015). There are many contributing factors to the
development of cardiovascular disease, including an
unhealthy diet, physical inactivity, alcohol, tobacco use,
genetics, family history, increased stress, and medical
conditions such as diabetes and hypertension. Often,
cardiovascular disease is insidious, with many people having
a sudden cardiac event prior to knowledge of having heart
disease.
Airline pilots have a responsibility to their passengers and
crew to ensure their safety while flying. According to the
FAA, pilots must meet medical standards to obtain or
maintain their license (FAA, 2011). Airline pilots are at an
increased risk of heart disease related to the requirements of
their occupation, such as extended flights, shift work,
irregular meal times, stress, and biorhythm disturbances with
changing time zones and increased light exposure (Choi &
Kim, 2013). With the insidious nature of cardiovascular
disease and the risk of a sudden cardiac event occurring
mid-flight, it becomes increasingly important to analyze the
risk factors of airline pilots and attempt to mitigate those
risks.
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Review of the Literature
Risk factors of Cardiovascular Disease
There are two types of risk factors involved in cardiovascular
disease: modifiable and non-modifiable. Modifiable risk factors
include poor diet, physical inactivity, smoking, excessive alcohol
consumption, stress, and obesity. Non-modifiable factors include
family history, genetics, gender, race, and increasing age
(American Heart Association [AHA], 2016).
Ekstrand, Bostrom, Arborelius, Nilsson, and Lindell (1996)
examined the differences in risk factors between pilots and the
general population. They found that pilots exhibited an
increased incidence of left ventricular hypertrophy (LVH) on
electrocardiogram (ECG), 29.2%, as compared with 10.9% in the
control group. It was also discovered that pilots had a systolic
blood pressure (SBP) >145 mm Hg, more frequently than the
control group, 11.5% and 4.4% respectively. Serum cholesterol
was higher among the pilots, 5.83 mmol/L, with the control
group results of 5.54 mmol/L (Ekstrand et al., 1996). These
factors, hypertension, hypercholesterolemia, and LVH, are
independent risk factors for cardiovascular disease (Mayo Clinic,
2015). It is hypothesized by the authors that pilots have an
increased risk due to their occupational exposures, such as
increased level of stress, flight schedules, nutritional factors,
noise levels, shift work, and time zone changes that disrupt
circadian rhythm.
Evaluation of Risk Factors
There is increased importance of identifying those pilots
who have a higher risk of cardiovascular disease as many pilots
with cardiovascular disease are asymptomatic until they have a
sudden cardiac event.
Wirawan, Larsen, Aldington, Griffiths, and Ellis (2012)
studied the effectiveness in using the Framingham risk chart to
predict cardiovascular events of airline pilots. This study found
that 60% of those with cardiovascular disease were not detected
with screening and initially presented with a sudden cardiac
event. Only 13.3% had an increased cardiovascular risk score
and 26.7% of pilots’ cardiovascular disease were discovered
during other routine screening, such as laboratory studies
(Wirawan et al., 2012). They concluded that the risk assessment
tool had low sensitivity and that a more comprehensive
cardiovascular workup is required for airline pilots.
Wirawan, Aldington, Griffiths, Ellis, and Larsen (2013)
performed another study to research the topic of pilots with
excessive cardiovascular risk, this time studying the cardiac
examinations performed when a pilot is determined to have an
increased risk. They compared the cardiovascular disease risk
factors between high-risk groups and low-risk groups of pilots.
They found that the high-risk group had higher total cholesterol,
increased blood pressure, higher incidence of diabetes, and a
higher incidence of smoking. They emphasized the importance
of prevention programs focused on decreasing these specific
risk factors. They discovered that there is difficulty in accurately
predicting a cardiovascular event based on utilization of risk
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models available. Forty-seven percent of those who had a
cardiovascular event had lower risk levels, never achieving a
10% 5-year risk level. ECGs were unreliable, with half of the
pilots with a positive ECG showing normal or trivial disease
with coronary angiogram. Three pilots with normal ECG
readings, but high-risk scores, had significant disease on
coronary angiogram (Wirawan et al., 2013). The current
approach relies on ECG as the diagnostic tool to investigate risk,
which may not detect disease and may place the pilot at
unnecessary risk with invasive coronary angiography as
follow-up testing. This study shows that a comprehensive
cardiac examination and view of the patient is required to fully
evaluate for cardiovascular disease.
Wirawan, Wu, Abernethy, Aldington, and Larsen (2014)
studied a specific approach in the use of coronary artery
calcium score (CACS) to improve prediction of cardiovascular
disease in asymptomatic pilots. It was noted that high calcium
scores (>400) place a pilot at a higher risk for coronary heart
disease (CHD) and can identify pilots at high risk for
cardiovascular disease. Coronary artery calcium score can be
utilized in addition to current risk assessments of Framingham
risk score and exercise stress test to assist in classifying
asymptomatic pilots into cardiovascular risk categories and
initiating primary prevention programs to reduce their risk
factors.
Strategies for Risk Reduction
Choi and Kim (2013) conducted a study to evaluate the
influence of physical examination and dietary consultation in
the reduction of risk factors associated with cardiovascular
disease. They examined the various modifiable risk factors, such
as smoking, physical exercise, obesity, and alcohol. They
specifically studied the impact of dietary counseling, combined
with an exercise program, on the reduction of these risk factors.
The group who received counseling and exercise intervention
significantly decreased their total cholesterol and body mass
index (BMI) and increased their high density lipoprotein (HDL).
Viewing the patient as an individual, providing an exercise
program and nutritional counseling specific to the individual,
will have an impact in reducing the modifiable risk factors
associated with cardiovascular disease.
Implications for the Occupational Health
Nurse Practitioner
Aviation Medical Examiner
A comprehensive medical evaluation is required by the FAA
for airmen to obtain or maintain medical certificates for
licensure. It is the responsibility of the AME to issue or deny
medical certificates or, in certain circumstances, defer to the FAA
for review (FAA, 2011). Airmen applying for medical
certification are divided into three classes. First-class certification
holds an airline transport license and must be renewed every 12
months for pilots less than 40 years of age; second-class airmen
hold a commercial pilot license and must renew every 12
vol. 66  ■  no. 10
months regardless of age; third-class airmen hold a private pilot
license and must renew every 60 months if less than 40 years of
age and every 24 months if older than 40 (FAA, 2011). The
cardiovascular requirements for all classes are to have no
history or diagnosis of myocardial infarction (MI), angina
pectoris, cardiovascular heart disease that has required
treatment, cardiac valve replacement, permanent cardiac
pacemaker, or heart transplant. In addition to this requirement,
first-class airmen must also demonstrate a normal ECG with
their first application after age 35, and on an annual basis after
age 40 (Electronic Code of Federal Regulations, 2017). The AME
must document a thorough cardiac assessment and take into
consideration the demands of flight, such as increases in heart
rate with takeoff and landing or G-forces associated with
aerobatic or agricultural flights (FAA, 2011).
Occupational Health Nurse Practitioner
Although the AME is responsible for performing the physical
examination required to issue a medical certificate for a pilot,
they can delegate portions of the testing, laboratory workup,
and history taking to a nurse practitioner (FAA, 2011). AMEs are
also in practice as physicians in family medicine, internal
medicine, and occupational health clinics. The occupational
health nurse practitioner working with an AME plays a crucial
role in the reduction of modifiable risk factors and management
of cardiovascular disease in an airline pilot. The occupational
health nurse practitioner’s role as counselor, with a holistic or
all-inclusive approach to patient care, will be an asset in the
implementation of a more comprehensive cardiac investigation,
which may include Framingham Risk Scores, CACS, ECG,
nutrition counseling, implementing a fitness program, stress
reduction techniques, evaluating cholesterol levels, and
monitoring blood pressure. It is the responsibility of the
occupational health nurse practitioner to have knowledge of the
requirements of the FAA with regard to treatment of a
cardiovascular disorder in this population. The FAA does allow
medical certificates to be issued under strict guidelines to fully
evaluate the disorder with a focus on the degree of functional
recovery and prognosis (FAA, 2011). The occupational health
nurse practitioner should also be aware of immediate
disqualifiers that must be reviewed by the FAA, such as a
medical history of coronary artery bypass surgery, permanent
cardiac pacemakers, and artificial heart valves (FAA, 2011).
The occupational health nurse practitioner may be
responsible for routine care of these pilots and must be aware
of FAA guidelines for each system of the body and treatments
allowable for an airline pilot. The Guide for Aviation Medical
Examiners provides information for exam techniques of each
system, treatments allowed, and medical dispositions depending
on the results of the exam (FAA, 2011).
One common diagnosis that leads to cardiovascular disease
is hypertension. The occupational health nurse practitioner
should be aware of current practice guidelines to treat
hypertension, while still taking into consideration the FAA
Workplace Health & Safety
requirements of treatment of hypertension. The American
College of Cardiology (ACC) and AHA’s 2017 practice
guideline begins with stressing lifestyle modifications for every
patient with hypertension (ACC, 2017). The ACC/AHA
guidelines also classify Stage 1 hypertension as having an SBP
> 130 mm Hg or a diastolic blood pressure > 80 mm Hg, and
Stage 2 hypertension as having an SBP > 140 mm Hg or
diastolic blood pressure > 90 mm Hg (ACC, 2017). Treatment
with medications for Stage 1 hypertension begins if the patient
has a high risk for a cardiovascular event or a history of a
cardiovascular event (ACC, 2017). There are medications that
the FAA states are acceptable and medications that are
unacceptable. If initiating medication therapy for hypertension,
the occupational health nurse practitioner should advise the
pilot of the FAA’s no fly rule of seven trial days to ensure no
adverse side effects from the medications (FAA, 2015).
Coronary heart disease is another diagnosis with strict FAA
guidelines. Coronary heart disease follows a very specific
protocol for medical certification that often requires the AME to
defer to the FAA for a decision. There are four categories of
CHD per the FAA, which include the following:
•• Open revascularization of any coronary artery and left
main coronary artery stenting, with or without MI
•• Percutaneous intervention with or without MI
•• MI without open or percutaneous intervention
•• MI from non-coronary artery diseases
It is important for the occupational health nurse practitioner
to keep in mind the required recovery time for open
revascularization of coronary artery and left main coronary
artery stenting is 6 months, while the other three categories
have a required recovery time of 3 months (FAA, 2011).
The occupational health nurse practitioner should be aware
of the resources and requirements of the FAA for medical
certification when evaluating a pilot at any point, even when
they are not being seen for initial certification or renewal. The
FAA requires the AME to report a thorough history and physical,
test results each time a pilot is seen for certification, and any
time there are changes in a pilot’s condition that may affect their
medical certification and ability to fly (FAA, 2011). Access to
these records is important for the occupational health nurse
practitioner to provide continuity of care, considering the
mobility of this career. The Guide for Aviation Medical
Examiners is an invaluable resource on the FAA website that
provides information on the evaluation and treatment of various
conditions, enabling the airline pilot to continue to fly safely
(FAA, 2011).
Summary
Cardiovascular disease has been identified as a leading cause
for airline pilot grounding and denial of a medical certificate
(Choi & Kim, 2013). The importance of conducting a thorough
cardiovascular evaluation for airline pilots cannot be overstated.
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A sudden cardiovascular event mid-flight can have a significant
impact on the safety of both crew and passengers, not to
mention the delay in care for the pilot. It is important to identify
the cardiovascular risk score of the pilot, identify specific risk
factors that may be modifiable, and implement programs to
mitigate these risks. The occupational health nurse practitioner
plays a significant role in the health and safety of this worker
population. The occupational health nurse practitioner has a
unique perspective of the patient as a whole and can provide
appropriate individualized interventions to reduce the risk
factors specific to this population.
ORCID iD
Dana Lord https://orcid.org/0000-0001-5994-4426
Conflict of Interest
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Author Biographies
Dana Lord is graduating from the University of South Florida’s
Dual Masters Degree Program in Nursing and Public Health,
with a concentration in Environmental and Occupational
Health. She currently works as a registered nurse providing care
to critically ill patients in the Southwest region of Florida.
Helen Acree Conlon is an Adjunct Professor at the College of
Nursing and Deputy Director of the Dual Degree Program
AGPCNP/Occupational Health.