Navigating Coronary Artery Disease in Aviation Cardiology in Australia and New Zealand.

BACKGROUND: Cardiologists will commonly assess patients who hold an aviation medical certificate and require unique assessments and communications with national civil aviation authorities (in Australia, the Civil Aviation Safety Authority [CASA] and in New Zealand, the Civil Aviation Authority of New Zealand [CAA NZ]). Cardiac conditions are the most common reason for disqualification from holding an aviation licence, and coronary artery disease is considered a high-risk condition for pilot incapacitation. AIM: To provide a contemporary update on the aeromedical approach to the evaluation, detection, and management of coronary artery disease in an Australasian context. METHODS: A narrative view of current and historical practice in the area of aeromedical evaluation of coronary disease was undertaken. RESULTS: This review highlights the aeromedical approach to risk stratification and specific challenges of the aviation environment for patients with coronary artery disease. Scenarios of coronary artery disease screening, common and rare acute coronary syndromes, and the assessment of established coronary artery disease are examined in detail. Suggestions to facilitate communications between specialists and CASA or CAA NZ to facilitate patient re-certification are also provided. CONCLUSION: Patients who are pilots have unique requirements in terms of their coronary assessment, management, and follow-up to maintain eligibility to fly. It is important for cardiologists to be aware of relevant occupational requirements to provide optimal care to their patients.

Suicide and Murder-Suicide Involving Aircraft.

BACKGROUND: This is a systematic review of suicide and homicide-suicide events involving aircraft. In aeromedical literature and in the media, these very different events are both described as pilot suicide, but in psychiatry they are considered separate events with distinct risk factors. METHODS: Medical databases, internet search engines, and aviation safety databases were searched in a systematic way to obtain relevant cases. Relevant articles were searched for additional references. RESULTS: There were 65 cases of pilot suicide and 6 cases of passengers who jumped from aircraft found. There were also 18 cases of homicide-suicide found involving 732 deaths. Pilots perpetrated 13 homicide-suicide events. Compared to non-aviation samples, a large percentage of pilot suicides in this study were homicide-suicides (17%). DISCUSSION: Homicide-suicide events occur extremely rarely. However, their impact in terms of the proportion of deaths is significant when compared to deaths from accidents. There is evidence of clustering where pilot suicides occur after by media reports of suicide or homicide-suicide. Five of six homicide-suicide events by pilots of commercial airliners occurred after they were left alone in the cockpit. This, along with a sixth incident in which active intervention by a Japan Air crew saved 147 lives, suggests that having two flight members in the cockpit is potentially protective. No single factor was associated with the risk for suicide or homicide-suicide. Factors associated with both events included legal and financial crises, occupational conflict, mental illness, and relationship stressors. Drugs and/or alcohol played a role in almost half of suicides, but not in homicide-suicides.

Aeromedical decision making: from principles to practice.

While there is literature which describes aeromedical decision making (ADM), there is not much which describes a process identifying the steps to be taken in arriving at such decisions. A five-step algorithm is proposed to clarify the ADM process. The five steps are: 1) determine the likelihood of a clinically significant event from the health condition; 2) determine the likelihood of an undesirable aviation event from the health condition; 3) determine the acceptability of the combined risks (#1 and #2); 4) determine the risk level after clinical intervention for the health condition; and 5) determine the risk level after operational restrictions for the health condition. There are several factors which can affect the various steps in the algorithm, such as uncertainty, difficulty in generalization, power and "fit" of the studies, etc. Notwithstanding these issues, the algorithm serves a useful purpose in providing a pathway for ADM.