Aeromedical Newsletter - Vol. 25, Issue 2

President's Corner

FAA Policy and Personnel Updates

FAA Staffing Updates

AMAS bids farewell to the Great Lakes Regional Flight Surgeon (RFS), Dr. Joy Holmes.  Dr. Marvin Jackson is the Acting Great Lakes RFS.  Additionally, there are three other Regions with Acting RFS while the FAA selects the permanent replacements: Dr. Zhang as the Acting Eastern RFS, Dr. Craig-Gray as the Acting Central RFS, and Dr. Oh as the Acting Northwest Mountain RFS.

Medical Certification Backlog Improvements

The Federal Air Surgeon reports that the agency is making significant strides in reducing individual case review backlog while at the same time experiencing an unprecedented number of FAA medical applications.  There were approximately 450,000 applications last year and the number of submissions for possible Special Issuance has doubled since 2019 with the majority of those being for class 1 exams.

FAA Reauthorization Act Sections 411/413

AMAS continues efforts assisting the FAA meet requirements of the FAA Reauthorization Act of 2024 and specifically Section 411 – “Aeromedical Innovation and Modernization Working Group” and Section 413 - “Medical Portal Modernization Task Group”.    As noted in our 1^st quarter newsletter, Dr. Snyder and Dr. Northrup co-Chair this monumental effort in improvement of aviation safety and excellence in service to the aviation community.  Dr. Parker is serving as a subject matter expert and along with AMAS’ staff physicians will work to promote the interests of professional and individual airmen and air traffic controllers while focusing on aviation safety.  Those with specific questions or suggestions should speak with an AMAS physician to ensure their voice is heard.    

FAA Medication Updates

Androgel (topical testosterone) is allowed by the FAA without restriction as long as there are no adverse effects.   Air traffic controllers do have to report use to their supervisor or the Regional Flight Surgeon.  If an airman or controller requires oral or injectable forms of testosterone, then there are additional requirements such as providing a detailed clinical progress note and current blood count before the AME or FAA will clear back to aviation duties.

Orencia (abatacept) is an immunobiological medication that is used to treat autoimmune diseases such as rheumatoid arthritis or psoriatic arthritis.  The FAA allows an airman taking this medication for arthritis to return to flying under the CACI program after a two week ground trial without adverse effects.  After that, each future dose requires a 24 hour wait before flying.  The CACI program requires the airman to provide a detailed clinical progress note to the AME once annually.  Controllers would clear use through their respective Regional Flight Surgeon.

Airman & Controller's "Ask the Doc"

with Dr. Phil Parker, Director of Clinical Services

Question: I have been told I need to do a stress test, but apparently there are several kinds. What are the differences and what does the FAA want?

Answer: In these situations, it is important to know who is advising you to get testing. If this is a clinical recommendation from your treating specialist, AMAS recommends you do what is best for your health.  On the other hand, some well-meaning specialists try to anticipate what might be a regulatory requirement of the FAA leading to unnecessary testing which can lead to false positive findings.  If the FAA requires testing, they generally will put that specific request in writing. If not sure, you should contact an AMAS physician for more guidance.

If required, there are several types of stress tests. The most basic is a plain exercise treadmill test.  For this an ECG is monitored continuously while the heart rate is raised with progressively more challenging workloads – meaning increased speed and incline on the treadmill.  The most common method preferred by the FAA is called a Bruce Protocol (named after American cardiologist, Robert Bruce) where effort is increased every three minutes.  Occasionally a bicycle ergometer is used instead, but this would require an explanation why the individual could not run on a treadmill and why this would not present an aviation safety risk (e.g. can you still sufficiently egress an aircraft if you can’t run). Certain changes on the ECG can indicate blockage of the coronary blood vessels.  Symptoms such as chest pain, dizziness or severe shortness of breath can also lead to the conclusion of a positive test. This test is not terribly accurate, so a positive result is generally followed up with a more detailed study such as a stress echocardiogram or a nuclear stress test.

A stress echocardiogram is performed in the same manner as the Bruce Protocol but adds an ultrasound of the heart before and immediately after exercise. The key finding would be what are called “wall motion abnormalities.” This just means you can see that the heart muscle is not contracting effectively in a certain area during exercise. This is further indication of a potential blockage. 

A radionuclide or “nuclear” stress test is usually the next step after a positive plain stress test or stress echo.  Instead of an ultrasound, it adds a scan of the heart to the plain stress test. A radiotracer is given intravenously which allows the blood perfusion of the heart muscle to be imaged before and after exercise. Areas that never “light up” either at rest or after exercise indicate scar tissue. This is actually OK so long as the heart is otherwise functioning well and the reason for scarring has been reported and cleared by the FAA.  The problem is any “reversibility” which is where an area lights up fine at rest but “washes out” with exercise. This suggests some healthy heart muscle is not getting all the blood flow it asks for when the demand goes up.  This is a fairly reliable indication of a blockage, though some factors such as obesity can make interpretation more difficult.  Reversibility typically requires a cardiac catheterization or angiogram to directly assess the extent of potential coronary artery blockages.   

What type of stress test you need for FAA purposes depends upon the circumstances. In many instances a plain stress test will suffice. In other cases, a higher-level test may be necessary. If in doubt call your AMAS flight surgeon for advice. With any treadmill stress test done for the FAA, the minimum performance standards are that you obtain at least 85% of your maximum predicted heart rate (calculated as 220 minus your age) and complete stage three of a standard Bruce Protocol if safe to do so. As mentioned above, each stage is three minutes, so that means AT LEAST nine minutes of exercise. Those aged 70 or over only need to complete stage two (six minutes). If there is a good reason someone cannot exercise, the FAA will usually accept what is called a pharmacologic stress test. This is where a drug is administered to increase the heart’s demand for blood flow, as opposed to doing so with exercise. Most commonly this is done for orthopedic issues. For example, those with knee replacements may be able to perform their crew duties fine but not do well with the steep incline of the treadmill. As noted with cycle ergometry, this situation would require clinical clarification that an airman is still reasonably expected to be able to perform all crew duties.

Recently the FAA dropped the mandatory annual requirement for stress testing for many who are monitored under the Special Issuance program for coronary artery disease. This should be reflected in FAA correspondence. If you have questions about stress testing and/or if it’s required in your particular circumstances, an AMAS physician can assist you.

Question: My doctor has recommended that I get a calcium score. Should I get one? How will this impact my medical and what are the FAA reporting requirements?

Answer: The short answer to your question is we recommend you discuss the clinical need for this type of screening with your treating provider. Typically, we recommend against screening that isn’t clinically indicated because of the potential for false positive results leading to a requirement for some additional, potentially invasive, follow-up testing. There is also a risk of false negative results giving someone an inappropriate sense of confidence potentially missing a clinical concern.  In the case of suspected coronary artery disease, a better alternative screening and that preferred by the FAA is exercise treadmill stress testing. 

Ultrafast CT scans, now called electron beam computed tomography (EBCT), can detect calcium deposits of atherosclerosis in coronary arteries. The test can be done on almost anyone in 10-15 minutes. People with high degrees of calcium in the artery have increased risk for heart disease. The weaknesses of the test include the lack of correlation between the location of the calcium and the degree of narrowing of the coronary arteries. Some degree of stenosis comes from soft plaque that has not formed calcium. Therefore, an individual may have significantly more narrowing than indicated by the EBCT. The EBCT also does not give any information about actual blood flow to the myocardium.

Although heavily advertised in some areas, ultrafast CT for routine screening in someone without symptoms or significant risk factors isn’t recommended by the American Heart Association. The FAA requires that a positive test result (those showing ANY calcium in the coronary arteries, even if “low-risk”) should be further evaluated using other techniques. Though formal policy has not yet been released, the FAA has recently provided Aviation Medical Examiners (AMEs) with a suggested protocol for dealing with calcium screening. A positive EBCT/UFCT can be considered disqualifying for FAA certification by some AMEs pending evidence from exercise stress testing that here is no evidence of ischemia.   Internally the FAA requires specific follow-up requirements depending on the calcium score.  For a score of <100, no follow-up testing is required. A score between 100-400, the FAA requires a nuclear treadmill stress test for follow-up for 1^st and 2^nd class and a regular treadmill stress test for 3^rd class. A score > 400 requires a cardiac catheterization for 1^st and 2^nd class. An abnormal stress test generally requires a cardiac catheterization to rule out coronary artery disease.  AMAS recommends pilots and controllers to carefully consider the effects of this screening on both health and FAA certification. The evaluation visit to health care providers within the last three years does generate a reporting obligation on the next FAA physical exam, even if no disease was found.

This is a very broad overview of a complex subject with many nuances. The AMAS aerospace medicine physicians work with hundreds of pilots and controllers with cardiovascular disease each year, working to obtain FAA medical certification at the earliest possible time.

For a more specific personal explanation to your questions or those concerning aeromedical certification, contact AMAS for a private consultation. For help in reporting treatment for and obtaining clearance from the FAA to fly or control with these conditions, refer to the AMAS Confidential Questionnaire. If you are an AMAS Contracted Member, these services are FREE to you.

AMAS in the News & Updates

Publications – Recent publications on aviation mental health initiatives that Dr. Snyder is a co-author on, include a resolution by the Aerospace Medical Association for ICAO to recommend peer support programs for all aviation safety personnel and incorporate mental wellness into aviation Safety Management Systems.

He is also a co-author on "Utilizing Decision Analysis to Assess the Safety of Providing Medication for Addiction Treatment to Professionals with Substance Use Disorder"  in the Journal of Addiction Medicine  and on “A proposed framework to regulate mental health in airline pilots.” In Aerospace Medicine and Human Performance.

4^th Annual Mental Health in Aviation workshop – Dr. Snyder and Dr. Billy Hoffman conducted a 9-hour workshop on progress in aviation mental health at the Aerospace Medical Association’s annual scientific meeting. The workshop was attended by 70 physicians, mental health specialists, regulators and pilots from a dozen countries.  Subjects included setting up peer support programs in culturally challenging situations, generational differences in communicating about mental health efforts to integrate mental wellness into aviation safety management systems and possibly regulatory design innovations to encourage healthy behavior and safety.

Aviation Medicine Advisory Service