Does cardiovascular risk assessment of pilots detect cardiovascular disease and prevent sudden clinical presentations?
ASMA 2012 MEETING ABSTRACTS
total) were for changes in Inferior leads. Only 4 out of the 26 cases
were detected to have perfusion defects and later underwent
coronary angiography followed by revascularization. Three MPIs
were done for patients who underwent primary PTCA to check for the
success of revascularization. Nine cases were follow up cases of
CAD. There were 7 cases referred for atypical chest pain out of which
one case turned out to have RPD in inferior segments There were 5
cases referred for having positive TMT to exclude false positivity.
Only one out them (20%) was detected to be positive with reversible
perfusion defect in the apical segments. DISCUSSION: MPI has the
advantage of detection of CAD at a very early stage when only flow
heterogeneity is present. MPI has a much better diagnostic accuracy
than stress ECG alone. Although coronary angiography provides
clinically valuable information, its invasive nature and costs
precludes its routine use in the evaluation of patients after intervention. MPI with its ability to provide information about the physiological significance of stenosis, extent of ischemia and scar, global LV
function, viability and prognosis is ideally suited to assess patients
after intervention.
Learning Objectives:
1 Conclusion- The aviators are a special group of people in whom we
need to use MPI more liberally due to its high negative predictive
value, non-invasive nature and lower costs.
5:00 pm
[138] AEROMEDICAL DECISION MAKING IN CORONARY
ARTERY DISEASE REVISITED
P.D. NAVATHE, D. FITZGERALD, M. DRANE AND
M. DODSON
Office of Aviation Medicine, Civil Aviation Safety Authority,
Canberra City, ACT, Australia
INTRODUCTION: Coronary Artery Disease (CAD) is a common
condition in the pilot population, and presents as a difficult aeromedical problem. METHODS: The spectrum that this condition can present
is impressive, ranging from asymptomatic pilots who are detected to
have CAD, asymptomatic CAD which has been detected, or pilots with
symptomatic CAD who have had a multiplicity of surgical cardiological or medical interventions. The number of aviators affected by this
condition is more or less stable, but with new treatment and new
diagnostic methods being evolved, there is a plethora of different
situations that can apply in otherwise similar cases. RESULTS:
Appropriate and consistent aeromedical decision making is becoming
an increasingly difficult process. DISCUSSION: CASA has proposed a
paradigm for the assessment and follow-up of these aviators, which is
evidence based, and balances the national safety needs with the issues
of individual liberty. The paradigm is presented as a starting point for
possible harmonisation in such decision making.
Learning Objectives:
1 Understanding how to detect CAD
2 The best methods of dteceting jeopardised myocardium
3 Follow up of pilots with CAD
5:15 pm
[139] DOES CARDIOVASCULAR RISK ASSESSMENT OF
PILOTS DETECT CARDIOVASCULAR DISEASE AND PREVENT
SUDDEN CLINICAL PRESENTATIONS?
A. WIRAWAN1,4, S. ALDINGTON2,1, R.F. GRIFFITHS1,
C.J. ELLIS3 AND P. LARSEN1
1
Occupational and Aviation Medicine Unit, Department of
Medicine, University of Otago Wellington, Wellington, New
Zealand; 2Air New Zealand Aviation Medicine Unit, Auckland,
New Zealand; 3Green Lane CVS Service, Cardiology
Department, Auckland City Hospital, Auckland, New Zealand;
4
Occupational Health Department, School of Public Health,
Faculty of Medicine, Udayana University, Denpasar, Indonesia
Aviation, Space, and Environmental Medicine x Vol. 83, No. 3 x March 2012
INTRODUCTION: Due to the potential for cardiovascular
disease (CVD) to cause pilot incapacitation, screening of pilot
cardiovascular risk to detect and treat disease and prevent sudden
onset events is current practice. In New Zealand, the Civil Aviation
Authority has routinely applied an adjusted Framingham-based
cardiovascular risk prediction score to do this. This study examined
cardiovascular disease (CVD) events occurring in a commercial pilot
population, and examined the sensitivity and specificity of the current
cardiovascular risk score in predicting these events. METHODS: A
matched case-control design was applied to assess the association of
5-year cardiovascular risk score and cardiovascular events in an
Oceania based airline pilots. Cases were pilots with cardiovascular
events as recorded on their medical records. Each case was age and
gender matched with 4 controls that were randomly selected from the
pilot population. Five-year retrospective evaluations were conducted to
collect data before the events. RESULTS: Fifteen cases of cardiovascular events were identified over a 16-year study period, 9 (60%) of
which were sudden clinical presentations, and only 6 (40%) of which
were detected using cardiovascular screening. Eight cases (53%) and
16 controls (27%) had a 5-year risk of t10-15%. Almost half of the
events (7/15) occurred in pilots whose highest 5-year risk was in the
5-10% range. Cases were nearly 4 times more likely to have highest
5-year risk score of t10-15% than controls (OR = 3.91, 95% CI
1.04-16.35, p = 0.04). The accuracy of the highest risk score were
moderate (AUC = 0.723, 95% CI 0.583-0.863). The cut-off point of
10% is valid with specificity of 0.73 but low sensitivity (0.53).
DISCUSSION: Despite a valid and appropriate cut-off point, the tool
had low sensitivity and was unable to predict almost half of the
cardiovascular events. The majority of CVD events remain sudden
onset clinical presentations.
Learning Objectives:
1 The association between the cardiovascular risk score and cardiovascular events in airline pilots is described
Monday, May 14
Ballroom C
4:00 PM
SLIDE: DECOMPRESSION SICKNESS AND
HYPOXIA
4:00 pm
[140] DCS IN THE SWEDISH AIR FORCE. A SURVEY AND
EXPERIMENTAL STUDY
L.G. HÖK1, R. WETTERHOLM1, B. WALL1 AND
D.R. LEMMING1,2
1
Dept of Aerospace and Naval Medicine, Swedish Armed
Forces, Linköping and Gothenburg, Sweden; 2Rehabilitation
Medicine Dept of Clinical and Experimental Medicine, Faculty
of Health Sciences, Linköping University, Sweden
INTRODUCTION: High altitude aircraft operations with
unpressurized cabin or hypobaric chamber demonstrations are well
known high risk activities for decompression sickness (DCS). Results
of a recently distributed questionnaire in the Swedish Air Force
indicated symptoms of DCS Type 1 (joint and skin symptoms) among
personnel during normal high altitude operations, despite compliance with current regulations and preventive measures. The results of
the survey will be discussed. The primary aim of the experimental
study was to establish the presence and magnitude of venous- and/or
arterial bubble formation during a simulated flight mission at 8000
meters (26,247 feet). The secondary aim was to evaluate the
simultaneous use of the two ultrasonography techniques in chamber.
METHODS: A questionnaire concerning history of hypoxia and
decompression symptoms was sent to C130 crew members. The
survey confirmed that DCS symptoms occurs among the crew. Six
subjects were recruited. Transthoracic Echocardiography and
transcranial Doppler were used for evaluation of bubble formation at
ground level and after three periods of standardized arm work and
249
total) were for changes in Inferior leads. Only 4 out of the 26 cases
were detected to have perfusion defects and later underwent
coronary angiography followed by revascularization. Three MPIs
were done for patients who underwent primary PTCA to check for the
success of revascularization. Nine cases were follow up cases of
CAD. There were 7 cases referred for atypical chest pain out of which
one case turned out to have RPD in inferior segments There were 5
cases referred for having positive TMT to exclude false positivity.
Only one out them (20%) was detected to be positive with reversible
perfusion defect in the apical segments. DISCUSSION: MPI has the
advantage of detection of CAD at a very early stage when only flow
heterogeneity is present. MPI has a much better diagnostic accuracy
than stress ECG alone. Although coronary angiography provides
clinically valuable information, its invasive nature and costs
precludes its routine use in the evaluation of patients after intervention. MPI with its ability to provide information about the physiological significance of stenosis, extent of ischemia and scar, global LV
function, viability and prognosis is ideally suited to assess patients
after intervention.
Learning Objectives:
1 Conclusion- The aviators are a special group of people in whom we
need to use MPI more liberally due to its high negative predictive
value, non-invasive nature and lower costs.
5:00 pm
[138] AEROMEDICAL DECISION MAKING IN CORONARY
ARTERY DISEASE REVISITED
P.D. NAVATHE, D. FITZGERALD, M. DRANE AND
M. DODSON
Office of Aviation Medicine, Civil Aviation Safety Authority,
Canberra City, ACT, Australia
INTRODUCTION: Coronary Artery Disease (CAD) is a common
condition in the pilot population, and presents as a difficult aeromedical problem. METHODS: The spectrum that this condition can present
is impressive, ranging from asymptomatic pilots who are detected to
have CAD, asymptomatic CAD which has been detected, or pilots with
symptomatic CAD who have had a multiplicity of surgical cardiological or medical interventions. The number of aviators affected by this
condition is more or less stable, but with new treatment and new
diagnostic methods being evolved, there is a plethora of different
situations that can apply in otherwise similar cases. RESULTS:
Appropriate and consistent aeromedical decision making is becoming
an increasingly difficult process. DISCUSSION: CASA has proposed a
paradigm for the assessment and follow-up of these aviators, which is
evidence based, and balances the national safety needs with the issues
of individual liberty. The paradigm is presented as a starting point for
possible harmonisation in such decision making.
Learning Objectives:
1 Understanding how to detect CAD
2 The best methods of dteceting jeopardised myocardium
3 Follow up of pilots with CAD
5:15 pm
[139] DOES CARDIOVASCULAR RISK ASSESSMENT OF
PILOTS DETECT CARDIOVASCULAR DISEASE AND PREVENT
SUDDEN CLINICAL PRESENTATIONS?
A. WIRAWAN1,4, S. ALDINGTON2,1, R.F. GRIFFITHS1,
C.J. ELLIS3 AND P. LARSEN1
1
Occupational and Aviation Medicine Unit, Department of
Medicine, University of Otago Wellington, Wellington, New
Zealand; 2Air New Zealand Aviation Medicine Unit, Auckland,
New Zealand; 3Green Lane CVS Service, Cardiology
Department, Auckland City Hospital, Auckland, New Zealand;
4
Occupational Health Department, School of Public Health,
Faculty of Medicine, Udayana University, Denpasar, Indonesia
Aviation, Space, and Environmental Medicine x Vol. 83, No. 3 x March 2012
INTRODUCTION: Due to the potential for cardiovascular
disease (CVD) to cause pilot incapacitation, screening of pilot
cardiovascular risk to detect and treat disease and prevent sudden
onset events is current practice. In New Zealand, the Civil Aviation
Authority has routinely applied an adjusted Framingham-based
cardiovascular risk prediction score to do this. This study examined
cardiovascular disease (CVD) events occurring in a commercial pilot
population, and examined the sensitivity and specificity of the current
cardiovascular risk score in predicting these events. METHODS: A
matched case-control design was applied to assess the association of
5-year cardiovascular risk score and cardiovascular events in an
Oceania based airline pilots. Cases were pilots with cardiovascular
events as recorded on their medical records. Each case was age and
gender matched with 4 controls that were randomly selected from the
pilot population. Five-year retrospective evaluations were conducted to
collect data before the events. RESULTS: Fifteen cases of cardiovascular events were identified over a 16-year study period, 9 (60%) of
which were sudden clinical presentations, and only 6 (40%) of which
were detected using cardiovascular screening. Eight cases (53%) and
16 controls (27%) had a 5-year risk of t10-15%. Almost half of the
events (7/15) occurred in pilots whose highest 5-year risk was in the
5-10% range. Cases were nearly 4 times more likely to have highest
5-year risk score of t10-15% than controls (OR = 3.91, 95% CI
1.04-16.35, p = 0.04). The accuracy of the highest risk score were
moderate (AUC = 0.723, 95% CI 0.583-0.863). The cut-off point of
10% is valid with specificity of 0.73 but low sensitivity (0.53).
DISCUSSION: Despite a valid and appropriate cut-off point, the tool
had low sensitivity and was unable to predict almost half of the
cardiovascular events. The majority of CVD events remain sudden
onset clinical presentations.
Learning Objectives:
1 The association between the cardiovascular risk score and cardiovascular events in airline pilots is described
Monday, May 14
Ballroom C
4:00 PM
SLIDE: DECOMPRESSION SICKNESS AND
HYPOXIA
4:00 pm
[140] DCS IN THE SWEDISH AIR FORCE. A SURVEY AND
EXPERIMENTAL STUDY
L.G. HÖK1, R. WETTERHOLM1, B. WALL1 AND
D.R. LEMMING1,2
1
Dept of Aerospace and Naval Medicine, Swedish Armed
Forces, Linköping and Gothenburg, Sweden; 2Rehabilitation
Medicine Dept of Clinical and Experimental Medicine, Faculty
of Health Sciences, Linköping University, Sweden
INTRODUCTION: High altitude aircraft operations with
unpressurized cabin or hypobaric chamber demonstrations are well
known high risk activities for decompression sickness (DCS). Results
of a recently distributed questionnaire in the Swedish Air Force
indicated symptoms of DCS Type 1 (joint and skin symptoms) among
personnel during normal high altitude operations, despite compliance with current regulations and preventive measures. The results of
the survey will be discussed. The primary aim of the experimental
study was to establish the presence and magnitude of venous- and/or
arterial bubble formation during a simulated flight mission at 8000
meters (26,247 feet). The secondary aim was to evaluate the
simultaneous use of the two ultrasonography techniques in chamber.
METHODS: A questionnaire concerning history of hypoxia and
decompression symptoms was sent to C130 crew members. The
survey confirmed that DCS symptoms occurs among the crew. Six
subjects were recruited. Transthoracic Echocardiography and
transcranial Doppler were used for evaluation of bubble formation at
ground level and after three periods of standardized arm work and
249