I have had several pilots request a reprint of an article I wrote a couple years ago on hypertension.
Hypertension) (high blood pressure) is certainly the most commonly encountered problem I see in my aviation medical practice. Sometimes a pilot just has “white coat syndrome” which means whenever he or she comes into a doctor’s office, anxiety sets in and it drives up the blood pressure. However, more often than not, the pilot really does have unhealthy blood pressure and is just not willing to accept the diagnosis. The prevailing attitude seems to be “As long as the pressure is low enough to pass, I am OK!” Not! Read on….
There is a great misunderstanding among pilots in that treating hypertension (high blood pressure) with medications will result in loss of their medical certificate, or at least that this requires some huge paperwork hassle and just isn’t worth it. This flatly just isn’t true! This attitude makes it seems that many pilots with hypertension (HTN) would prefer to cut their lives shorter than to get treatment, which is just about the most twisted logic I have encountered in aviation medicine.
Not a day goes by that I don’t have at least one conversation with a pilot in my office about his high blood pressure (sorry ladies…this isn’t sexist…it just affects men more often than women!) And it is happening at a greater frequency than in years gone by, due primarily to our unhealthy sedentary lifestyle. To make matters more confusing, the medical community is recognizing that the traditional definition of HTN is wrong, and the numbers that should cause concern have been considerably lowered. Let me put this in perspective.
For eons, physicians have been taught that HTN begins at a blood pressure (BP) of 140/90 mm Hg (millimeters of mercury). Unfortunately, these values had not been based on scientific evidence, but rather on an educated guess. In all fairness, these numbers were derived at a time when the medications available to treat HTN were fairly limited and often with disagreeable side effects, so it was always a question of what is worse…the treatment or the disease! Nonetheless, new data coupled with much better treatment options have resulted in a greater understanding of this disease. HTN is the leading cause of cardiovascular disease, including heart attack and stroke, and can easily be prevented either by lifestyle changes or drugs, and sometimes, both.
Just as with any other piece of fine machinery, the heart (pump and valves) and its blood vessels (pipes and tubing) will not last as long if run at the high end of specifications rather than at the low end of specs. Physicians are becoming increasingly aware of this, and are targeting their patients to be at optimal pressures rather than just staying below an arbitrary red line.
As long as the definition of HTN has been140/90, people who had been keeping their BP just under those numbers had not routinely been offered therapy. Unfortunately, it has been found that all those people who have been just under the “red line” do not live as long as people in the “green arc” which seems to be closer to 120/70…or less! The current thinking is to target for optimal BP, not just to stay below a known dangerous upper limit.
So, how does one achieve an optimal blood pressure? If you are not genetically blessed with a low blood pressure, the options are lifestyle changes and/or medications. (By the way…there are very few people whose BP is too low. As long as you don’t faint every time you stand up, your BP isn’t too low!)
The tendency toward elevated BP is from 2 causes. Some people are genetically predisposed to HTN, and no matter how fit or aerobically conditioned they are, they have “essential HTN.” These people need to be on medications, tailored to their individual physiology.
Many people with mild to moderate HTN can attribute this problem to lack of exercise, being overweight, or both. The neat thing here is that most of these people can drop their pressure 8-9 mm Hg within 3-4 weeks of mild, albeit REGULAR exercise. If that brings an individual from the 130’s to the 120’s, they have reached their goal without chemicals. The other neat thing is that this response can occur even before weight loss! Although weight loss is desirable for other reasons, the most important of which is the prevention of adult onset diabetes (more on that topic in a later column) it is clear that the simple fact of getting off the couch and moving one’s rear end regularly is enough to make a huge difference.
So how much exercise is needed? Studies show that it isn’t really that much! The minimum seems to be about 30 minutes a day, and although walking isn’t quite enough (better than nothing, though) it does require a bit of huffing and puffing in order to be aerobic. However, the biggest benefit occurs on the front end of the exercise program. In other words, the biggest bang for the exercise buck occurs when going from doing nothing to doing something! After that, the benefit continues (to a point) with increasing exercise, but at a lesser rate. The exercise/benefit curve actually flattens out for those at the high end, and actually turns a bit negative for the super-aerobic fitness folks, because injuries and high cardiovascular stress begins to take its toll. So the couch potatoes out there…rejoice! It doesn’t take much to get the greatest benefit…just get off the couch for 30 minutes a day and sweat a little! And another interesting fact is that these 30 minutes of exercise do not have to occur all at once. It seems that one can divide it up into three10 minute intervals, and have the same benefit. Now, there is NO EXCUSE for anyone to not have three10 minute periods throughout the day that they can’t jump rope, jog, get on the treadmill, run up stairs, etc. And it doesn’t count if you have a “physical” job…heavy lifting, construction work, etc doesn’t cut the mustard. You have to raise your heart rate, breathe hard, and sweat a little for it to be of benefit (get your minds out of the gutter!)
Now let’s say that you are one of those mildly hypertensive people, who has started a mild-moderate exercise program, and you still can’t get into the optimal zone of 120/70. You have even lost some weight, but you can’t get any lower in your BP. It might be time for medications. And there is a wide variety out there that your doctor can offer you. Most of the modern anti-hypertensive medications have little or no side effects, and these should be tailored to your physiology and response to therapy. It is not the intent of this column to go into the various drug therapies available, but just to say that all the normally prescribed medications are approved by the FAA for pilots to use. One caveat: as with all medications, you should politely refuse any brand new medications that your physician might want to prescribe. The FAA usually wants to see a new medication being used by land lubbers for at least a year before they will approve use in pilots.
Let’s say your doctor places you on a BP medication. What are your obligations as a pilot? First of all, whether it is for BP or any other reason, it is a good idea to not fly for several days when taking a medication you have never used before in the event you experience an adverse effect. It is best to experiment when not in the cockpit!
Secondly, for any class of Medical Certification, the FAA requires the pilot to provide a hypertension evaluation from their treating physician. This can either be mailed in to the FAA or supplied to your AME, preferably at the initiation of treatment. Certainly, by the time your next flight physical is due, the proper documentation needs to be provided. Here are the guidelines:
To determine a pilot’s eligibility while talking blood pressure medications, the FAA requires a current status report from the treating physician. If this report includes all the following requirements, then the AME may issue the certificate.
The treating physician determines that the condition is stable and the pilot has been on current medication regimen for at least two weeks and no changes are recommended.
- The pilot has no symptoms as a result of hypertension.
- The pilot has no side effects of the medication(s).
- Blood pressure is less than or equal to 155 systolic and 95 diastolic. Although 155/95 is acceptable for certification, the airman should be referred to their primary care provider for further management if the blood pressure is above clinical practice standards.
- Acceptable medications are combinations of up to three of the following:
- Alpha blockers
- Ace inhibitors
- Calcium channel blockers
- Angiotensin II receptor antagonists
NOTE: Centrally acting anti- hypertensive agents are NOT allowed
Hypertension follow-ups are required annually for first and second class medical applicants and at the time of renewal for third class certificate applicants.
Now….what is acceptable to the FAA? Remember what I stated above: the classic definition of HTN is 140/90, optimal is 120/70…yet the FAA allows up to 155/95 as “adequate” control. This horrible number is allowed because of problems associated with “White Coat Syndrome.” You know what that is…as soon as someone in a white lab coat passes by, your BP goes up!
HTN is a major risk factor for death and disability. Take care of it, and you will live longer to enjoy flying even after retirement! You can’t fool Mother Nature in weather, nor in your health!
Here’s to healthy and safe flying!