After a Cardiac Event

Under 14 CFR Part 67, a history of myocardial infarction (heart attack), angina, coronary heart disease that has required treatment, cardiac valve replacement, permanent pacemaker implantation, or heart replacement is disqualifying for all classes. That doesn't end your flying. Most pilots return through an Authorization for Special Issuance. Your AME must defer your first exam after a heart attack, stent, or bypass (CABG), and the FAA makes the initial decision. For first- and second-class applicants, the Federal Air Surgeon's cardiology consultants review the case.

The rules depend on your certificate class. For first and second class, you must wait out a recovery period before any post-event testing: 3 months after a heart attack or a stent (including the left main artery), and 6 months after CABG. Then you'll need a post-event nuclear (radionuclide) stress test with images on CD. A stress echo or a routine Bruce treadmill test is not acceptable for these classes. First class and full (unrestricted) second class also need a post-event heart catheterization with images on CD. For new applicants, that cath must be from within the last 5 years. A limited second-class certificate, which carries a restriction such as no carrying passengers for hire, doesn't require the cath. You also submit a CAMI Limited Certificate Petition to tell the FAA whether you would accept a lower class.

For third class, there is no mandatory recovery period (Public Law 114-190), but your treating physician should release you first. Instead of a nuclear study, you need a post-event exercise stress test with ECG tracings, done within 90 days of your AME exam. To pass without further questions, you must reach at least 85% of your predicted maximum heart rate, exercise at least 9 minutes (6 minutes if you're 70 or older), and show less than 1 mm of ST depression, unless nuclear or stress echo imaging shows no ischemia. Every class needs hospital records, a detailed cardiology clinical progress note, and labs within 90 days of the exam. After a stent, you're expected to follow ACC/AHA guidelines for dual antiplatelet therapy. Long-acting nitrates and ranolazine (Ranexa) are on the FAA's Do Not Issue list.

Once you're approved, you can usually renew under the AME Assisted Special Issuance (AASI) for coronary heart disease. At each renewal, your cardiologist completes the CHD/CAD Recertification Status Summary within 90 days of the exam. As of May 29, 2024, routine renewals no longer need a follow-up stress test. Your AME must defer if you have chest pain, a new event or procedure, bleeding that required intervention, poorly controlled risk factors, or a new long-acting nitrate. Other heart conditions have their own FAA paths. Atrial fibrillation, pacemakers, valve replacement, and left atrial appendage closure (such as Watchman) are summarized below. An active implantable defibrillator (ICD) is disqualifying for all classes.