How soon are heart patients safely fit to fly?

by Carolyn Thomas   ♥  @HeartSisters

Five months after my heart attack, I boarded a plane from the West Coast bound for Rochester, Minnesota.  Considering that I’d suffered two terrifying cardiac events on another long flight just five months earlier made this trip just a wee bit scary for me.

Only the reality that I was headed to the world-famous Mayo Clinic helped to propel me onboard. I told myself that if anything happened to me and my heart during this flight, the board-certified cardiologists at the Mayo Women’s Heart Clinic would know exactly what to do for me. If I survived the flight, that is . . .            .      . 

Like many freshly-diagnosed heart attack survivors, my fear of having a heart attack on a plane was very strong. (Note: many survivors experience a very strong fear of having another heart attack just walking down the street).

So being strapped into a metal box 35,000 feet up in the sky, hour after endless hour, inhaling stale air, in a pressurized germ-infested environment, with reduced circulating oxygen levels in my blood, risking the onset of hypobaric hypoxia, and with no guarantee at all that my seatmate would be a board-certified cardiologist seemed just plain crazy.

But apparently there is good news about heart patients and flying from the British Cardiovascular Society.

Most people with heart disease who are not critically ill can safely fly on commercial aircraft, according to a U.K. report.(1) Lead author Dr. David Smith (Royal Devon and Exeter NHS Foundation Trust) told Heartwire:

”   The overwhelming conclusion is that the cabin environment poses very little threat. It’s not the flying that’s the problem for heart patients, but the stability or instability of someone’s underlying condition that indicates the probability of a spontaneous cardiac event occurring while they are in the air.”

The passengers who might feel some minor physical effects of low blood oxygen (hypoxia)  include those already at risk of:

• angina
• myocardial infarction (heart attack)
• heart failure
• abnormal heart rhythms

But according to Dr. Smith, the blood oxygen levels induced by flying “appear to have little or no adverse circulatory effects, certainly not for short- and medium-haul flights.”

However, some heart patients at high risk are advised to “defer travel” until their condition is stable, including those:

• having an ejection fraction <40%
• showing signs and symptoms of poorly controlled heart failure
• with unstable angina or uncontrolled arrhythmias
• awaiting further investigation, revascularization, or device therapy

And here’s how soon after a cardiac procedure you are generally safe to fly:

• After uncomplicated elective (non-emergency) cardiac catheterization (angioplasty, with or without stent implants), patients can fly after a few days.
• If patients suffer from stable angina with infrequent attacks, they should be able to fly. It is safe to use nitroglycerin spray in a pressurized aircraft cabin.
• Patients with pacemakers implanted can fly after a few days, unless they have suffered a pneumothorax, in which case they should wait until two weeks after it has fully healed.
• Those with ICDs (Implantable Cardioverter Defibrillators) can fly after a few days, with the added recommendation that they should not fly after the ICD has delivered a shock until the condition is considered stable again.
• Those who have experienced a heart attack (myocardial infarction) can fly after 10-14 days. If you are older than 65 or if you’ve had another heart attack in the past, you’re statistically more likely to have one again. The U.K. Civil Aviation Authority recommends that if you have no symptoms or other heart conditions and no further cardiac treatment is planned, you’re considered to be at low-medium risk to fly. But if further cardiac treatment is planned, you’re considered to be at higher risk of another heart attack – best not to fly at this time.
  
• Those who have had heart valve repair or replacement surgery or coronary artery bypass grafts (open heart surgery) can usually fly after 4-6 weeks (longer if they have had pulmonary complications).

Generally speaking, if you can walk briskly for 100 metres on the flat without being breathless or in pain, you can fly.

But even when your physician has officially given you the green light to fly again, remember that severe fatigue can continue to be a serious issue for heart patients long after the other physical effects of cardiac procedures have healed.

Anticipating this fatigue may influence your decision, for example, to request an airport wheelchair or a ride to connecting gates on the airline golf cart, and to limit the weight and size of your carry-on bag. Please plan ahead and arrive at the airport significantly early for any flight to minimize rushing or stress.

The anxiety surrounding air travel can be debilitating even for non-heart patients. If fear of flying has ever been a serious issue even before your own cardiac event, it may indeed feel worse now.  If you really must fly, ask your own doctor about managing this anxiety before your flight.

Long flights can mean crossing time zones, sleep deprivation and jet lag. Probably the most important effect of changes in sleep patterns for passengers with cardiovascular disease is the potential disruption in taking daily medications. It can be difficult to stick to a normal meds routine when that routine is altered, especially if we’re confused about what time it really is. The U.K. report warns that it’s especially important for passengers with stable heart failure, angina or arrhythmia to maintain the regularity of their medications.

If you’re planning an out-of-country flight in the near future, remember that most major insurance companies will not provide travel medical insurance earlier than 90 days after a cardiac event, or even after a change in your medical treatment. In some cases, just a doctor’s appointment in the past 90 days at which your medication dosage is changed (either increased OR decreased) can mean your condition can be considered “unstable” and thus grounds for denial when you file a travel medical insurance claim.

Each airline has its own policy for allowing flying passengers after a cardiac event – and as you’ll see from the Oregon heart patient’s experience with Alaska Airlines (described below), some of these policies appear to defy accepted medical guidelines. So call both your insurance broker and the airline before you book a flight to double-check all details relevant to your own travel and clinical circumstances. 

For heart patients who sport implanted medical devices, it may be comforting to know that the amount of metal used in most implanted heart devices like pacemakers, heart valves or ICDs is very small, according to cardiologists at St. Jude Medical. It is usually not enough to set off airport security metal detectors; if it does, simply show security personnel your patient identification card. Passing through a metal detector should not hurt your device. However, do not linger near the security system arches or poles.

Dr. Clemens Jilek and his team of researchers from the German Heart Center in Munich recently did a study on 388 heart patients, published in the journal Annals of Internal Medicine.  They concluded that metal detector security screening appears safe for those with pacemakers or ICDs implanted.

What about those new full body scans at airport security gates and people with implanted pacemakers or ICDs?  According to cardiologist Dr. Richard Fogoros, there are few if any controlled clinical studies or even written information about the safety of these full body scanners for heart patients:

“I called the technical support departments of two major pacemaker manufacturers. I was told that they regard the full body scanner as completely safe for those with implanted  pacemakers and ICDs, and this is what they tell patients and doctors when they call for advice (which apparently they do frequently, since there is no written advice anywhere).  I was told that:

• 1) their engineers have determined it is extraordinarily unlikely that these scanners are capable of negatively affecting implantable medical devices
• 2) many thousands of people with pacemakers and ICDs have used total body scanners over the past several years, and there has been no allegation of any problems.
  

“So, both engineering theory and a large volume of real-world experience indicates they are safe, according to them.

“There is no reason to believe that a full body scanner will effect a pacemaker or ICD, and medical device companies are willing to say that verbally (but not in writing).

“If you want to wait until some authority is willing to make a definitive written statement about this, you can opt for a pat-down instead when you go through airport security. Since this issue is in the hands of bureaucrats, however, don’t hold your breath waiting for a resolution.”

A serious health problem you may have also heard linked with air travel, particularly long flights, is deep vein thrombosis (DVT) and venous thromboembolism.

Although a long-haul flight doubles the risk of DVT, it is actually similar to that incurred during car, bus, or train travel for a similar period, the U.K. researchers state. And the absolute risk of DVT for a fit and healthy person is one in 6,000 for a flight of more than four hours, they note, pointing out that pilots are at no greater risk than the general population, a statistic that is not particularly comforting.

Now I have to worry not only about myself, but about my pilots.  Why not take the advice of my heart sister Jaynie, who always harps at us to wear compression knee-high stockings while flying?

There are some recommended common sense flight precautions for those at risk of DVT:

• consume plenty of fluids
• exclude caffeine and alcohol
• wear compression stockings
• take a dose of low-molecular-weight heparin (a blood thinner)
• wear a MedicAlert bracelet or dogtag necklace at all times
• talk to your doctor to confirm that your cardiac disease is stable
• carry adequate supplies of all prescribed medicine
• carry a copy of your medical history
• carry emergency phone numbers for your doctor(s), family members and destination contacts

Having memorized these precautions, you might want to also consider the alarming case of one Oregon heart patient who describes her “very interesting flight” to Rochester, Minnesota to see cardiologist Dr. Sharonne Hayes at the Mayo Women’s Heart Clinic. Here is the transcript of her complaint against Alaska Airlines filed with the FAA:

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(1)  Smith D, Toff W, Joy M, et al. “Fitness to fly for passengers with cardiovascular disease. The report of a working group of the British Cardiovascular Society“. Heart 2010

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COVID-19 UPDATE 2020:  “Should I avoid plane travel just to be safe?”

“Planes tend to be low humidity, but the air’s actually pretty clean. It gets re-circulated through these HEPA [high-efficiency particulate air] filters that really are very good at clearing stuff out,” said Dr. Vicki Hertzberg, a biostatistician at Emory University, who co-led a study on flights and disease transmission with scientists at Boeing. “Also, they suck in about 50% clean air with every re-circulation. So in some aspects, the air on a plane is cleaner than what’s going on in your new office buildings.”  

Remember that Dr. Hertzberg’s advice applies only to passengers while the plane is in the air. As soon as that aircraft lands, passengers exit the plane and are no longer protected by HEPA filters while walking through the airport, or waiting at the baggage carousel, or shopping or dining in the airport, or getting onto airport transportation vehicles.

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NOTE FROM CAROLYN:   I wrote more about my fateful five-hour flight in Chapter One of my book, A Woman’s Guide to Living with Heart Disease . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 30% off the list price).