What advice should I give patients about driving and flying after myocardial infarction?

Compared to other forms of international travel, flying presents fewer demands on the invalid passenger than the alternative modes of travel. Airlines have a duty of care to other passengers who may be inconvenienced by emergency diversions, unscheduled stops and delays in the event of a medical emergency.

Recertification of drivers and pilots following myocardial infarction depends upon their subsequent risk of incapacitation whilst at the controls. All pilots and all professional drivers have a duty to inform the relevant licencing authority as soon as possible following myocardial infarction.

There are no international regulations governing the prospective passenger who has recently suffered a myocardial infarction and no statutory duty to inform the airline concerned. Most will be guided in the decision whether to fly or not by their cardiologist or family doctor. Modern passenger aircraft have a cabin atmospheric pressure equivalent to 5–8,000 feet, and alveolar oxygen tension falls by around 30%. This may exacerbate symptoms in any patient who experiences angina or shortness of breath whilst walking 50 metres or climbing 10 stairs. The enforced immobility of the passenger on a long flight, airport transfers and the crossing of time zones should be
considered.

If fewer than 10 days have elapsed since myocardial infarction, or if there is significant cardiac failure, angina or arrhythmia the patient may require oxygen or suitable accompaniment. The airline should be informed, and will request a report on a standard medical information form (MEDIF).

Professional pilots are disqualified from flying for nine months after myocardial infarction, but may subsequently be allowed to fly in a multi-pilot aircraft provided that investigations, carried out by a cardiologist acceptable to the licencing authority, are satisfactory, as follows:

• Exercise ECG to Bruce protocol stage 4 reveals no evidence of ischaemia
• 24 hr ECG reveals no abnormality
• Echocardiogram shows ejection fraction greater than or equal to 50% and normal wall motion
• Coronary angiography reveals no stenosis greater than 30% in any vessel distant from the infarction
• Any underlying risk factors must have been appropriately treated, and certification will be subject to annual cardiology review, with further coronary angiography within 5 years.

Private pilots are subject to the same regulations but may fly with a suitably qualified safety pilot in a dual control aircraft without undergoing angiography. Symptomatic or treated angina, arrhythmia or cardiac failure disqualifies any pilot from flying.

Professional drivers may be relicenced 3 months after myocardial infarction provided that there is no angina, peripheral vascular disease or heart failure. Arrhythmia, if
present, must not have caused symptoms within the last 2 years. Treatment is allowed provided that it causes no symptoms likely to impair performance.

• Exercise ECG to Bruce protocol stage 3 must reveal no symptoms or signs of ischaemia.
• Recertification will be subject to periodic satisfactory medical reports.

Private drivers need not inform the licencing authority after myocardial infarction, but should not drive for one month. If arrhythmia causes symptoms likely to affect performance, or if angina occurs whilst driving, the licencing authority must be informed, and driving must cease until symptoms are adequately controlled.