Help for Evaluating Coronary Disease in People With High-Risk Jobs

A new review aims to pull together what can sometimes be challenging information to access: best approaches to the management of coronary disease in people with two high-risk occupations—commercial drivers and airline pilots, in whom a sudden and incapacitating medical event could have disastrous results.

Nadia Sutton, MD (University of Michigan, Ann Arbor), told TCTMD she was motivated to write this document, published online recently ahead of print in Circulation: Cardiovascular Interventions, based on interactions with some of her own patients with high-risk jobs and discussions with her colleagues. Those conversations made it clear “that we don’t really have very good information about the decisions that we’re helping patients make and what that means for them, what the implications are for their profession and for their licensure,” Sutton said, noting that it’s also not always clear what the licensing agencies are looking to get from treating physicians.

Airline pilots and drivers of commercial vehicles, including trucks and passenger buses, became the focus because they are commonly seen in everyday practice and are regulated by specific licensure guidelines. However, many decisions that are made on a day-to-day basis don’t necessarily go by the guidelines, which can be difficult to track down in the first place, Sutton said.

“This is a document that contains information that took a lot of time to actually obtain and put together,” she said. “I hope that people find this useful because it contains information that’s otherwise pretty challenging to find.”

Getting Pilots, Drivers Back to Work

For commercial drivers and pilots, as well as others with high-risk occupations, “there is lower tolerance for the risk of myocardial infarction and sudden death due to the consequences for public safety,” Sutton et al note.

The authors go over what’s known about coronary disease in these populations and review existing recommendations for screening, treatment, and secondary prevention, including those from US licensing agencies like the Federal Motor Carrier Safety Administration (FMCSA) for drivers and the Federal Aviation Administration (FAA) for pilots, as well as the Civil Aviation Authority for the United Kingdom and the European Aviation Safety Agency for continental Europe. “Regulatory agencies must consider the health status of the individual but also make decisions that are consistent with a safety mandate beyond the therapeutic strategy for a single patient and are legally defensible,” they write.

Both commercial drivers and pilots need to have a medical assessment performed by a certified examiner before they’re allowed to go to work, and the paper by Sutton et al goes into details about what’s required for each occupation. They also provide summaries of what drivers and pilots are required to do in order to return to work if they’ve had an event like an MI or undergone a procedure, such as PCI, CABG, or a heart transplant, as well as what’s mandated in terms of follow-up.

Suggested Guideline Changes

Sutton et al discuss several potential changes to how drivers and pilots have their coronary risks managed.

“Future considerations should emphasize primary prevention of MI and sudden death, particularly in asymptomatic high-risk commercial vehicle drivers and pilots,” they say. “Development of risk scores which consider the widespread use of high-sensitivity troponin assays could allow medical examiners to better estimate risk.”

When it comes to assessing risk in these groups, the authors suggest moving away from the Framingham risk score toward the newer atherosclerotic CVD risk calculators from the American Heart Association and American College of Cardiology to better reflect contemporary clinical practices. Greater use of coronary CT angiography, too, may provide a better picture of a patient’s coronary status than exercise treadmill stress tests, they highlight.

In addition, Sutton et al indicate that the findings of the ISCHEMIA trial should come into play when considering how to manage coronary disease in commercial drivers and pilots.

“Because decision-making for coronary heart disease revascularization for asymptomatic pilots is driven mostly by their occupation, the threshold for revascularization may be lower than in standard clinical practice. Since these regulatory agency recommendations were initially published, recent studies have demonstrated that revascularization does not reduce the future risk of death or MI or death in stable patients with moderate or severe inducible ischemia (in a normal environment),” the authors write, pointing to COURAGE and ISCHEMIA. “This raises an important question for the regulatory agencies as to how to best incorporate these data in their guideline recommendations for revascularization in high-risk occupations, in which unusual stressors may occur.”

Overall, “Given the current evidence base suggesting the strong benefit of optimal risk factor control, optimization of medical risk factors could be more heavily weighted in future guideline updates,” and revascularization recommendations could be considered in the context of the ISCHEMIA findings, they say.

Ultimately, “I hope clinicians will refer to [this paper] to get some information for their patients so they can have educated conversations,” Sutton told TCTMD. “There’s those aspects where you can actually help your patient by being knowledgeable and sending them for the right testing, so that they don’t end up getting delayed in returning to work because you sent them for the wrong stress test or you haven’t provided them with enough detail about the PCI intervention and what other coronary disease they have, etc.”

She added: “I hope this really gets people thinking and talking about how these guidelines really are in need of an update, and I hope that this gets the attention of the licensing agencies as well. I think at least FAA already knows about this document, and I know that they have some guideline updates in mind, so I hope this sways them toward a little bit more transparency and alignment with current evidence-based clinical practice.”