Evaluation and management of the cardiovascular patient embarking on air travel

Abstract

This case-centered review summarizes the risks of air travel and available studies and recommendations for air travel among patients with cardiovascular disease. General Considerations: Although overall risk is small, cardiac events are the second most common cause (after vagal events) of in-flight medical incidents. Several mechanisms could predispose travelers to myocardial ischemia and arrhythmia during air travel, including cabin pressurization to less than that at sea level (median cabin altitude on modern aircraft was found to be 2259 m in one study), and mental stress associated with flying. In theory, increased sympathetic tone and decreased oxygen tension found at altitude could lead to myocardial ischemia, or atrial or ventricular arrhythmias. Although the occurrence of ectopy has been correlated with altitude among healthy volunteers, altitude has not yet been associated with sustained ventricular tachycardia among patients at risk. Specific Recommendations: The American Medical Association, American College of Cardiology, and Aerospace Medical Association advise abstention from flying for 2 to 3 weeks after uncomplicated myocardial infarction (or the same duration after stabilization following complicated myocardial infarction). Although preflight stress testing has not been specifically addressed, reliance on history and physical examination appears to be appropriate for preflight screening. There are no data that suggest air travel interferes with pacemaker or internal cardiac defibrillator (ICD) function. However, these devices (but not intracoronary stents) will trigger preflight security metal detectors. Because the alternating magnetic field associated with hand-held metal detectors could trigger ICD discharge, patients should request a “hand search” if possible. Supplemental oxygen is not routinely required for patients with cardiovascular disease. However, patients requiring supplemental oxygen at sea level will require supplemental oxygen during air travel. Finally, owing to venous stasis and hemoconcentration associated with dehydration, there is an increased risk of deep vein thrombosis and pulmonary embolus associated with air travel of long duration. One small study found fewer thrombotic complications among patients receiving low molecular weight heparin as a single dose 2 to 3 h before air travel. This should be considered for patients at high risk who are not chronically anticoagulated. DB