Drive + Fly

Driving

Coronary Artery Disease (CAD)

Syndrome	Private	Commercial
STEMI	1 mo from D/C	3 mo from D/C
NSTEMI with sig LV damage	1 mo from D/C	3 mo from D/C
NSTEMI with PCI	48 h after PCI	7 days after PCI
NSTEMI without PCI	7 days after D/C	30 days after D/C
Unstable angina with PCI	48 h after PCI	7 days after PCI
Unstable angina without PCI	7 days after D/C	30 days after D/C
Stable angina or asymptomatic CAD	No restriction	No restriction
Stable CAD with PCI	48 h after PCI	7 days after PCI
CABG	1 mo after D/C	3 mo after D/C
Any, with 50% left main		Disqualified until treated
Any, with 70% left main	Disqualified until treated

Minor/non-significant LV damage is the abscence of new wall motion abnormality

Dysrhythmias

Syndrome	Private	Commercial
VF without reversible cause	6 mo after event	Disqualified
Unstable VT	6 mo after event	Disqualified
VT or VF with reversible cause	Until cause is treated	Until cause is treated
Sustained VT, LVEF <30%	3 mo after event & controlled	Disqualified
Sustained VT, LVEF ≥30%	4 wk after event & controlled	3 mo after event
NSVT	No restriction	No restriction
Paroxysmal SVT/AF with impaired LOC	When controlled	When controlled
SVT/AF without impaired LOC	No restriction	No restriction
Symptomatic SSS	Until treated	Until treated

AF = atrial fibrillation or flutter

Heart Block

Syndrome	Private	Commercial
Isolated 1º HB	No restriction	No restriction
Isolated RBBB	No restriction	No restriction
Isolated LAFB	No restriction	No restriction
Isolated LPFB	No restriction	No restriction
LBBB	If no impaired LOC	If no impaired LOC*
Bifascicular block	If no impaired LOC	If no impaired LOC*
2º HB, Mobitz I	If no impaired LOC	If no impaired LOC*
1º HB with bifascicular block	If no impaired LOC	If no impaired LOC*
2º HB, Mobitz II	Disqualified	Disqualified
Alternating LBBB & RBBB	Disqualified	Disqualified
Acquired 3º HB	Disqualified	Disqualified
Congenital 3º HB	If no impaired LOC	If no impaired LOC**

• and no higher block on annual 24 h Holter ** and QRS ≤110, and no pauses ≥3 sec on annual 24 H holter

Pacemakers and ICDs

Syndrome	Private	Commercial
PPM	1 wk after implant*	1 mo after implant*
ICD for 1º prophylaxis	4 wk after implant	Disqualified
ICD for symptomatic VF/VT	6 mo after event	Disqualified
ICD for sustained VT	1 wk after implant	Disqualified
ICD giving shocks	6 mo after event	Disqualified

• as well as no impaired LOC, normal sensing and capture, and no evidence of PPM malfunction

Other Dysrhythmias

Syndrome	Private	Commercial
Brugada, long QT, or arrhythmogenic RV cardiomyopathy	Once investigated	Disqualified
Cather ablation	48 h after D/C	1 wk after D/C

Syncope

Syndrome	Private	Commercial
1x vasovagal	No restriction	No restriction
Treated cause (e.g. with PPM)	1 wk after treatment	1 mo after treatment
Reversible cause (e.g. dehydration)	After treatment	After treatment
Situational syncope with avoidable trigger	1 wk after episode	1 wk after episode
1x unexplained	1 wk after episode	12 mo after episode
Recurrent vasovagal in 12 mo	1 wk after episode	12 mo after episode
Recurrent unexplained in 12 mo	3 mo after episode	12 mo after episode
Due to arrhythmia	See Dysrhythmia section	See Dysrhythmia section

Valvular Disease

Syndrome	Private	Commerical
AS	NYHA I or II with no impaired LOC	Asymptomatic, NYHA I, AVA ≥1cm, EF ≥35%
AR/MS/MR	NYHA I or II with no impaired LOC	No impaired LOC, NYHA I, EF ≥35%
Mechanical valve BioMVR or MV repair with AF	6 wk from D/C No embolic, on A/C	3 mo from D/C No embolic, on A/C, NYHA I, EF ≥35%
BioAVR BioMVR or MV repair without AF	6 wk after D/C No embolic	3 mo after D/C No embolic, NYHA I, EF ≥35%

Heart Failure

Syndrome	Private	Commercial
NYHA I	No restriction	EF ≥35%
NYHA II	No restriction	EF ≥35%
NYHA III	No restriction	Disqualified
NYHA IV	Disqualified	Disqualified
Receiving inotropes	Disqualified	Disqualified
LVAD	Disqualified	Disqualified
Heart transplant	6 wk after D/C NYHA I or II, on stable Rx	6 mo after D/C EF ≥35%, NYHA I No evidence of ischemia on testing

Hypertrophic Cardiomyopathy

• Private: no impaired LOC
• Commercial: LV wall thickness <30 mm, no syncope, no NSVT on annual 24 h Holter, no FHx sudden death at young age, and no hypotension with exercise

Flying

Condition	NYHA	Travel
Angina	I/II	No restriction
Angina	III	Supplemental oxygen required
Angina	IV	Only if medically necessary and accompanied
Recent MI	I	1 to 2 weeks for repatriation if uncomplicated and revascularized 6 to 8 weeks for elective travel
Heart failure	I/II	Unrestricted
Heart failure	III	Supplemental oxygen required
Valvular disease	I/II	Unrestricted; supplemental oxygen if pulmonary hypertension
Valvular disease	III	Supplemental oxygen required
Valvular disease	IV	Only if medically necessary and accompanied
Congenital	I/II	Unrestricted; supplemental oxygen if PaO2 <70 mmHg
Congenital	III	Supplemental oxygen required
Congenital	IV	Only if medically necessary and accompanied
Recent CABG/valve surgery	I/II	4 days post-surgery if Hb ≥90 and flight <2 h 7 days post-surgery if Hb ≥90 and flight ≤2 h
PCI/ASD closure	I/II	1 day postprocedure If PCI, following CAD guidelines, above
Post-arrhythmia procedure	I/II	Well-controlled SVT: unrestricted 1 day post-procedure for SVT 2 days post-procedure for ventricular arrhythmias
Post-arrhythmia procedure	III/IV	Uncontrolled hemodynamically significant ventricular arrhythmias should not fly
Post-PPM/ICD/loop recorder	I/II	1 day post-implant if no pneumothorax, and device is functioning
ICD patients	I/II	1 mo following last shock associated with severe presyncope or syncope

DVT Prophylaxis

Routine precautions include:

• Avoid stasis, move around cabin, isometric calf exercises
• Avoid dehydration, alcohol, and caffeine

Patient Population	Recommendations
Flight <12 h	Routine
Flight ≥12 h, low risk	Routine
Flight ≥12 h, moderate risk	Routine with pressure stockings or ASA 160-325 mg 4 h before flight
Flight ≥12 h, high risk	Routine with pressure stockings or LMWH 2 h before flight

• Moderate risk: patients aged >75 years, women >45 on estrogen, pregnant or post-partum women, age <45 years with heterozygous FVL or prothrombin mutations, patients with varicose veins, heart failure, MI within 6 weeks, or lower limb trauma within 6 weeks
• High risk: previous VTE, major surgery within 6 weeks, active malignancy, gross obesity or marked immobility due to neuromuscular or cardiorespiratory disease, people age >45 with antithrombin/protein C/protein S deficiency, people age >75 with cardiac or pulmonary disease

Further Reading

• CCS Consensus Conference 2003: Assessment of the cardiac patient for fitness to drive and fly – Executive summary