I am currently self-grounded
Votes
Answered By AOPA
I am currently self-grounded and need some direction.
History: 67 y/o male. Class 3 medical, expires in October. Risk factors: Hypertension, Acquired Hypothyroidism, Dyslipidemia all previously under control with meds (below). No family history of heart disease.
Event(s): In Fall 2019 experienced light headedness on several occasions, associated with warm weather and outdoor physical exertion. Resolved with sitting or lying down, fluids, ice pack, etc.  
 On April 2, 2020 with similar symptoms experienced brief syncope, while seated following large meal. Spontaneous recovery in about 20 seconds. EMS called and transport to ER. EKG/chest x-ray/BNP were all normal. Discussion with doctor regarding possible dehydration, received IV fluids and discharged. BP medications, at the time: valsartan320mg, HCTZ12.5mg, amlodipine 10mg, Coreg CR 40mg.
PCP requests BP diary, notes high percentage of resting pulse rates below 55, many below 50, and as low as 46.  PCP suspect bradycardia as a factor, reduces COREG from 40mg to 20mg daily and refers to Cardiologist. 
Cardiologist test results summarized:
BP: 130/62
EKG: Normal, w/RBBB. (HR 58)
ECHO: 1. Good quality, normal dimensions, no abnormalities. 2. Doppler/color Doppler, no regurgitation or stenosis. 3. Ejection fraction 65%
7-day HOLTER & MCT: (46- - 63- -86) Normal sinus rhythm with sinus bradycardia 44% of time. Occasional PVC/PAC’s, no sustained arrhythmia.
TREADMILL SESTAMIBI STRESS TEST: 4min 15sec, 84% max rate. This is a long report so summarized: Study good, adequate count density. Uniform distribution myocardium. Rest images unchanged. Normal contractility and wall thickness. LVEF calculated 54%. LV not enlarged. No artifact noted. No transient dilation seen. CONCLUSIONS: 1.reduced aerobic capacity 2. Attainment of adequate HR making test reliable. 3. [Test] does not elicit evidence of exercise induced myocardial ischemia by symptoms, EKG, or Sestamibi imaging. 4. Normal LV contractility. The EF was 54%.
Cardiologist Impression and Plan: (excerpts due to length) No spontaneous syncope. Hot weather and dehydration preceded any dizziness and syncopal episode. Coreg reduced and symptoms ceased. Will also stop HCTZ since dehydration likely cause.  
Revised medications: Cardura 1mg, Irbesartan 300mg, amlodipine 10mg, Coreg CR 20mg.
I feel great, it has been 6 weeks without any symptoms.  Given this information, how do I go about getting clearance to fly?
 
15 Replies
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AOPA Staff Answer
To avoid the risk of denial you may want to consider becoming qualified under BasicMed. If you have had a loss of consciousness without satisfactory medical explanation of the cause, BasicMed requires a one time approval from the FAA. Only you with the help of your physician can determine if this applies. It has been determined the cause was dehydration, you have completed testing, and had favorable medication adjustments.

T help you decide if BasicMed is the way to go, it gives you the privileges of a 3rd Class medical with the exception of the aircraft you fly can weigh up to 6000 lbs, have up to 6 seats, speeds below 250K, up to FL180 within US, Bahamas, and Mexican airspace. Here is a link to provide you with details and the process:
https://www.aopa.org/advocacy/pilots/medical/basicmed


 
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You can’t. First you had to make 85% of max heart rate. 85 is the mandatory denial line. You made 84 % (cutoff has to be somewhere), and so they can’t approve you. And the trouble is, insurance won’t get you another run for a year. With new Rt. BBBlock, you have to prove to FAA’s satisfaction it isn’t one of the ~7% of these that is coronary in origin. A 4.5 minute run is also disqualifying. You have to go at least eight minutes (they want 9) NINE minutes to qualify.  “Missed it by that much”. Sigh.

You have low end rate troubles. Do you have any pauses on the holter/zio...above 2.5 seconds. You are only allowed ONE. And that one, at night. If you have two, you need another  holter on the reduced cocktail which doesn’t have low-end problems.2.5 seconds between beats is a long time to be coasting, for BP maintenance.

if the conclusion is “repeated dietary abuse” what do you think the appropriate response of the FAA will be? It will be, “show us an extended period in which you have shown no recurrence and no dietary abuse”. After all, “We don’t want habitual dietary abusers, who will pass out at the stick, do we?”

Lastly, you are on 4 meds for hypertension. That right there is a special issuance right in and of itself.

Not warm and fuzzy :(.

WILL YOUR DOC give you a BASIC med? I would not apply until you have (1) demonstrably fixed the low end, and have (3) fixed The “CAD proof” insufficiency. This one gets denied, as-is.

😧
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Bruce Chien:
This one gets denied, as-is.
 

...and that would close the door on both Basic Med and Sport Pilot options.  Make sure you will be issued before you make another application -- and the advice of someone like Bruce will guide you on the path to that goal.

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Dr Chien,
Thanks for taking the time to respond.  I knew it was going to be a challenge, but at least I now have the information to create a plan. 
As far as the stress test, I can do nine minutes without a problem. I have no idea why the technician stopped after 4:15.  I need to have a discussion with the Cardio doc and get an explanation.
You asked a couple of questions about my tests that I don’t know the answer yet.  I will post them when I get a response from the Cardio doc.
The Cardio doc suggested going completely off the COREG, so I will continue that discussion. If that happens it would resolve the “three drug to control” issue.  Is it wishful thinking that eliminating the COREG might also fix the “low end rate” troubles?  
Assuming my PCP agrees that the issues mentioned are “fixed”, can I go straight to Basic Med without an SI?
Thanks again.
 
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Thanks Ron.
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Thomas De Witt:
Assuming my PCP agrees that the issues mentioned are “fixed”, can I go straight to Basic Med without an SI?
 

Take a good look at the list of SI-required conditions in 14 CFR 68.9 or Chapter 8 of AC 68-1 with your PCP.  If you don't have any of those, you can go straight to Basic Med.  If you do, you'll need to get the SI first.  And from Bruce's posts, I gather he thinks you do.

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See the attached, the original enabling legislation, bottom of page 5 and top of page 6.   ThirdClassReform(Short.Final)07.14.16.pdf   
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Scratch,
Thanks for your input on my situation.  When the worlds of medicine and legal intersect, sometimes it’s hard for us laypeople to really know what we need to do.  The law says “unexplained”.  I suppose that comes down to how strident the doctors are when they say the cause was “low heart rate” and “dehydration” both brought on by specific medications is an “explanation”, along with a satisfactory resolution following elimination those medications.


My current airplane does not qualify for operating under Basic Med, so if that is the route that befalls me then I will, of course, take it and sell/buy to an airplane that does qualify.  

My plan is to follow Dr. Chien’s advice and get the “low-end” fixed, get stable on the new med regime, and get a new valid stress test.  I may also need a new Holter, I haven’t seen the tracings yet.

At the end of all that, I will seek advice on the quality of my case and assess the odds of getting an SI for the third class.  If the quality of my case is not very close to 100%, then I won’t risk Basic Med and won’t make the application.   
 
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Sounds like a good plan.
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Dr Chien,

You asked about pauses recorded during the Holter test.  See the attached photo. (Sorry about the sizing). 
The test was taken approximately 21 days after reduction of Coreg from 40 mg to 20mg.

Thank you.