Flying with Heart Failure
It’s the holiday season and before we go on talking through this frequently asked question the information in this post is purely opinion and you must always discuss with your clinician. In fact the stipulation of many travel insurance companies means that you must be certified to fly usually by a consultant. Irrespective whether you need certification we would recommend you speak to your consultant. In our opinion we feel it is crucial. Anyway here goes –
Over one billion people travel by air each year.The information in this post refers to considerations regarding fitness to fly as a passenger. This is not about assessing your ability to fly but it includes the measures which are taken into consideration when assessing your ability to fly.
The information given is general and not exhaustive; individual patients may need to have several conditions taken into account and different airlines have varied policies. The sources of advice used are only guidelines and clinical judgement should always be used in their interpretation.
Some airlines require medical certificates confirming that a patient is currently stable and fit to fly. Most have medical advisors who provide advice and ‘clear’ passengers as fit to fly. They may ask for a medical information form (MEDIF). The British Medical Association (BMA) advises doctors ‘to word statements on a person’s fitness to fly carefully, indicating the information on which the advice is based, rather than positively certifying a person’s fitness’. For example:
- ‘I know of no obvious reason why this person should not fly’; OR
- ‘There is nothing in the medical record to indicate that flying is risky for this patient’.
This ensures that the doctor is not guaranteeing in any way that this patient can travel without any problem but rather saying that, on the available evidence, there is nothing to indicate a greater risk for this person than for others. However, the doctor is partly dependent on what the patient chooses to disclose to them about past health problems.
The main factors to take into account are whether air travel could adversely affect a pre-existing medical condition and whether or not a patient’s condition could adversely affect the comfort and safety of the other passengers, or the operation of the flight. Regardless of a doctor’s opinion on this latter question, the ultimate sanction to refuse travel lies with the airline and captain of the flight. If they consider there is a risk to the aircraft or its passengers, they may refuse to carry a particular passenger.
Modern aircraft are not pressurised to sea level. Cabin altitude equivalent is usually between 5,000 and 8,000 feet which means that there is a reduction in barometric pressure and a reduction in the partial pressure of alveolar oxygen. Sometimes during flight, although not usually for long periods, oxygen saturation levels can fall to around 90%. A healthy individual can usually tolerate this with no problems but it may not be the same for someone with Heart Failure.
Basic considerations when assessing a patient’s fitness-to-fly include:
- The effect of mild hypoxia (deprivation of oxygen) and decreased air pressure in the cabin.
- The effect of immobility.
- The ability to adopt the brace position in emergency landing.
- The timing of regular medication for long-haul/transmeridian travel.
- The ability of the patient to cope mentally and physically with travel to and through the airport to reach the flight and on disembarkation.
- Will the patient’s medical condition adversely affect the comfort or safety of the other passengers and the operation of the aircraft?
- What health insurance cover does the patient have in case of problems?
Cardiovascular contra-indications to commercial airline flight include:
- Unstable angina.
- Decompensated congestive cardiac failure.
- Uncontrolled hypertension.
- Coronary artery bypass graft within 10 days.
- Uncontrolled cardiac arrhythmia.
- Severe symptomatic valvular heart disease.
- Uncomplicated percutaneous coronary interventions (e.g. angioplasty with stent placement) within 5 days – individual assessment is needed after that to ensure fitness and stability.
The decrease in oxygen saturated during air travel may affect those with cardiovascular disease. Indications for in-flight oxygen in cardiovascular disease include:
- Need for oxygen at baseline altitude.
- Heart failure – New York Heart Association’s (NYHA) Class III-IV
- Angina Canadian Cardiovascular Society (CCS) Class III-IV.
- Cyanotic congenital heart disease.
- Primary pulmonary hypertension.
- Other cardiovascular diseases associated with known baseline hypoxia (deprivation of oxygen)
It is unusual for patients to be allowed to take their own oxygen supply and oxygen is usually arranged by the airline who must be aware in advance. A fee is usually charged. This may change in the future and there are ongoing discussions regarding this.
Patients with pacemakers and implantable cardioverter defibrillators can fly once medically stable