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Am Fam Physician. 2005;71(9):1804

Air travelers with cardiovascular disease may be at increased risk for a number of complications. Safety guidelines for these persons are varied and are backed by insufficient data. Possick and Barry reviewed the literature on evaluation and management of the cardiovascular patient traveling by air, and produced case-based safety recommendations.

Although cardiac events during air travel are rare, they are the second most common cause of in-flight incidents, after vasovagal events. An automatic external defibrillator is now required on all passenger aircraft over a minimal size with at least one flight attendant. Exposure to the moderate altitude simulated in the cabin of a modern aircraft can cause a drop in PaO2, increased sympathetic activity, and increased pulmonary artery pressure. Air travel also causes mental stress. There is no evidence to suggest, however, that these changes increase risk for myocardial ischemia.

Because the incidence of implantable cardiac defibrillator (ICD) firing has not been shown to increase in-flight, there is no suggestion of greater risk for ventricular arrhythmia. According to the American College of Cardiology and the American Heart Association, persons who have had a myocardial infarction should wait until two weeks after the event to fly or, after a complicated myocardial infarction, until two weeks after stabilization. Persons who have been treated with thrombolytics after myocardial infarction and who have not undergone cardiac catheterization or any repercussion procedure should be evaluated with exercise testing three weeks after the cardiac event to determine safety of air travel. Patients who have undergone coronary artery bypass grafting should avoid air travel for three weeks after discharge. Routine preflight stress testing is not appropriate.

A pretravel evaluation should explore the possibility of angina, volume overload, and dysrhythmia. Vital signs, oxygen saturation, electrocardiogram (ECG), and a careful history will clarify potential risks. Patients with ICDs should be evaluated on schedule, but the use of an ICD is not a contraindication to travel. Patients with any synthetic material in their chests should carry a card with the name of the device or stent. The electromagnetic security fields appear to have no effect on these devices. However, a hand search is advisable rather than a hand-held wand security evaluation because of potential brief inhibition of an ICD’s output. Exposure to wands should be minimized. Contraindications to air travel include myocardial infarction within the past two weeks, angioplasty or coronary stent placement within two weeks, unstable angina, recent coronary artery bypass, poorly compensated heart failure, and uncontrolled cardiac arrhythmias.

Inflight oxygen generally is unnecessary, except for patients who customarily use supplemental oxygen and those whose in-flight PaO2 level is likely to drop below 50 mm Hg. All injectable medications should be labeled, and patients with abnormal ECGs should bring a copy on the flight. In-flight calf venous thrombosis is common, although the risk for embolism is low. Below-the-knee compression stockings may be useful to prevent calf thrombosis. Low-molecular-weight heparin, one dose subcutaneously before travel, may be helpful in high-risk persons.

In summary, the authors advise that a history of multiple cardiac events, as long as the conditions are stable, is no contraindication to air travel. Travelers with a cardiac background should walk in the cabin, use below-the-knee compression stockings, stay well-hydrated, and avoid alcohol.

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