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 of Canada bound for Rochester, Minnesota.  Considering that I’d suffered two horrific cardiac events on another long flight just five months earlier made this trip just a wee bit terrifying for me.

Only the reality that I was headed to the world-famous Mayo Clinic in Rochester helped propel me onboard. I told myself that if anything happened to me and my heart during this flight, the 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 with low oxygen content, 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 now 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) explained it like this:

“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 conditions are 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 two weeks.
• Those who have had coronary artery bypass grafts (open heart bypass surgery) can usually fly after about six weeks (longer if they have had pulmonary complications).

Generally speaking (and after chatting with your physician about your specific case), 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 to request an airport wheelchair or a ride to connecting gates on the airport golf cart, and to limit the weight and size of your carry-on bag.

Plan ahead and arrive at the airport significantly early for any flight to minimize rushing or stress. Warn the airline and/or airport authority of any requirements for assistance (like in-flight oxygen)  well in advance of your departure date. Make sure you have an appropriate supply of prescribed medications to last your whole trip plus a clear list of the medications and doses.

While you may not need an explanatory letter from your doctor regarding the condition, drugs, allergies and devices (e.g. a pacemaker or defibrillator), you might want to request this letter if you have a particularly complicated cardiac history.  Some women have encountered alarmingly ignorant airport gate staff or onboard flight crews (read the Oregon woman’s story below, for example; she was ordered off her flight after boarding a United Airlines plane because she carried nitroglycerin in her carry-on bag, which a flight attendant arbitrarily interpreted as being unfit to fly).

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’s hardly surprising that you might feel far worse now.  Ask your own doctor about advice on taking a mild sedative just before you board the plane.

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. Doing so may interrupt your therapy.

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 affect 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 1/6,000 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?

Dr. David Smith adds:

“Even those considered at high risk – those who have already had a DVT, recent surgery lasting more than 30 minutes, known thrombophilia, pregnancy, and those who are obese (BMI>30) – can still fly.”

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 – VERY IMPORTANT!
  
• 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), next of kin, 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:

 Q:   How did you prepare for your first flight after a cardiac event?