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
