Stents are not always needed for CAD

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Gary F

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Gary F
I have been corresponding with a professional pilot who has been diagnosed with coronary artery disease. He had a cath last year which showed a couple of blockages. His cardiologist stented the one that really needed to be fixed but left a blockage near the end of the artery alone for medical management. Unfortunately, he has been advised that the FAA medical consultants will probably deny his medical due to this blockage that was not stented. This pilot had an imaging stress test with very good exercise tolerance and the pictures showed that all areas of the heart are getting good blood flow. A study has been published recently that shows it is very reasonable to treat certain blockages with medication only. I think the FAA medical consultants should allow physicians this option for at least those who only require a 3rd class certificate.

The common practice of inserting a stent to repair a narrowed artery has no benefit over standard medical care in treating stable coronary artery disease, according to a new review of randomized controlled trials published on Monday. http://www.nytimes.com/2012/02/28/h...enefits-for-coronary-artery-disease.html?_r=1

Conclusion Initial stent implantation for stable CAD shows no evidence of benefit compared with initial medical therapy for prevention of death, nonfatal MI, unplanned revascularization, or angina. http://archinte.ama-assn.org/cgi/content/short/172/4/312
 
Gary, I seriously need to suggest you become an AME. I've spent about 3 hours on this man's situation. The title of this string reflects lack of understanding of how the process really works, and is misleading. In short, I object to the title and to the use of his material in this vein.

The crux of this situation is NOT that FAA wants it stented. It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized. I have advised him to not apply. It was essentially probono including document review (I got suckered), but I repeat, "It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized".

I agree that RIGHT AT THIS MOMENT he's just fine. But he will be denied and he cannot afford to be.There is no mechanism to certify over a time period when the time performance of the setup is uncharacterized.
 
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bbchien said:
Gary, I seriously need to suggest you become an AME. I've spent about 3 hours on this man's situation. The title of this string reflects lack of understanding of how the process really works, and is misleading. In short, I object to the title and to the use of his material in this vein.

The crux of this situation is NOT that FAA wants it stented. It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized. I have advised him to not apply. It was essentially probono including document review (I got suckered), but I repeat, "It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized".

I agree that RIGHT AT THIS MOMENT he's just fine. But he will be denied and he cannot afford to be.There is no mechanism to certify over a time period when the time performance of the setup is uncharacterized.
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Sorry Dr. Bruce. I am not blaming you for this unfortunate pilot's predicament.

It should be apparent that it is my humble opinion that the FAA has unreasonable standards for at least 3rd class. I admit that I am not an expert in aviation medicine but understand cardiac physiology very well. It is not your fault that the FAA cardiology consultants are being too conservative. If the FAA medical department is concerned about the lack of data of the effects of hypoxia on pilots with coronary artery disease then they can require supplemental O2 above a certain altitude or based on pulse oximetry readings in flight. The >70% stenosis by itself is meaningless unless interpreted in the context of size of vessel, extent of disease, LV function, amount of myocardium at jeopardy, current medical therapy and several other factors. I have no doubt that plenty of pilots are flying around with undiagnosed coronary artery disease. If you don't believe me randomly take a bunch of 50+ year old airline pilots to a cardiac CT scanner and cath anybody with a calcium score over 400. I betcha that some of them will have totally occluded arteries who never knew (or admitted) that they had a problem. I know of someone who was diagnosed with very advanced CAD (really needed bypass surgery) fairly soon after retiring from a major airline.

In terms of the pilot discussed in my initial post I did advise him to contact you but never implied that you would provide service for free. I will be glad to take you out to dinner somewhere nice if you ever find yourself in this neck of the woods. I'll make it up to you one way or another.

I inquired about becoming an AME a couple of years ago but the FAA was not interested. I realize that I would probably not agree with a lot of the rules but would still carry them out precisely. I had orders for Army flight surgeon school at Ft. Rucker in 1990 but got diverted to SW Asia instead. At this time I am really too busy but will still inquire about the AME course if one of the local guys retire. I have recently started working on a project in the area of quality improvement and medical systems engineering. I intend to adapt the principles of Lean Six Sigma to the practice of medicine. I believe that the FAA medical department could use some help in that area. Perhaps some day I can help them improve the efficiency of that operation.
 
So the FAA wants a vessel stented that we know does not need to get stented :confused:
 
bbchien said:
The crux of this situation is NOT that FAA wants it stented. It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized. I have advised him to not apply. It was essentially probono including document review (I got suckered), but I repeat, "It is that the behavior of narrowings >70% even with TIMI, over time periods is not well characterized".

I agree that RIGHT AT THIS MOMENT he's just fine. But he will be denied and he cannot afford to be.There is no mechanism to certify over a time period when the time performance of the setup is uncharacterized.
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He can't fly with the lesion but if it was stented then there would be no >70% stenosis so he could conceivably get approved? It appears that his only hope is to get it fixed. Am I missing something here?

The research referenced in my initial post suggests that we do understand the behavior of single vessel disease. Coronary artery disease is very common and has been exceptionally well studied for decades.
 
No, the proper thing for him to do is get the LSA DPE-ship. Teach in LSAs.

He's going to try the (Dean Ornish) alfalfa diet. No way I'd advocate stenting a 1.5 mm vessel. We all know that's asking for trouble. Maybe make it look better- but you know the perils of angioplasty in a low flow vessel.

FAA's policy deals with when they say "no" but does not tell you what to do affirmatively.
 
bbchien said:
He's going to try the (Dean Ornish) alfalfa diet. No way I'd advocate stenting a 1.5 mm vessel.
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Would the FAA be happier if he got it over with and have the vessel embolized ?
 
Oddly, if his Ejection fraction survived above 40% and he did not develop papillary muscle dysfunction (that's really what's likely hanging by that 80-90%-er), yes.

In the operating theater we use to do an assessment that was essentially: "Has the patient completed his MI or is it yet to be completed, because, if it's the latter, we aren't going, today".
 

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weilke said:
Oh the things you can justify with the 'founding fathers' :rolleyes: .

That news piece looks like it is from the Onion, including the 'anti meat advocacy group'. The customer in question probably had reflux.
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I ate at the Heart Attack Grill in Arizona before it closed. The burger and shake were excellent, the fries not that great.
 
Gary F said:
I ate at the Heart Attack Grill in Arizona before it closed. The burger and shake were excellent, the fries not that great.
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It closed, eh? Darn... was going to make that a stop "one of these days"...

Ohhhh well...
 
Gary F said:
I ate at the Heart Attack Grill in Arizona before it closed. The burger and shake were excellent, the fries not that great.
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How many weeks of 'no sugar' did that require for penance.
 
denverpilot said:
It closed, eh? Darn... was going to make that a stop "one of these days"...

Ohhhh well...
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They opened a new restaurant in Las Vegas, where else.

weilke said:
How many weeks of 'no sugar' did that require for penance.
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I went there about a year ago. I started my low carb diet in mid October. If I go to Las Vegas I will eat there again. This time I will remove the unhealthful bread first and forgo the fries and shake.
 
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