Hypertension that is detected early is usually easily controlled, but, if left unchecked, it can lead to more serious and potentially life-threatening ailments, including heart attacks; heart enlargement, called hypertrophy, which affects the heart's pumping capability; kidney disease; and stroke, to name just a few.
As common a problem as it is, we don't know a lot about what causes hypertension, but several factors are thought to be contributors. There is probably a genetic component to many individuals' high blood pressure, and researchers are attempting to identify the specific gene or genes involved. Other factors may be environmental, and many researchers believe that the fast-paced lifestyles of Western societies tend to promote the development of hypertension, possibly because of inadequate diet and excessive stress. Whatever the reasons, the fact remains that hypertension is a fact of life for many people of all ages, and pilots aren't immune.
Defining hypertension is simple. It is the elevated pressure exerted on the arteries that transport oxygenated blood from the heart throughout the body. The circulatory system is a closed system, but the pressure inside the system varies throughout the day based on metabolic changes in our bodies and external factors, such as responses to stress and physical and mental exercise. When we have hypertension, that internal baseline pressure is elevated.
It's an insidious process that progresses over time and often presents no symptoms, although unexplained headaches and nosebleeds can sometimes be signs. That's why periodic blood pressure monitoring is so important. Electronic blood pressure monitors for home use are readily available at a reasonable price, and many pharmacies and shopping malls have monitoring machines available. Employer-sponsored health fairs or even the local fire station paramedics are also good sources for periodic checks. Have your blood pressure checked from time to time. It's painless and takes only a minute.
So how do the federal aviation regulations (FARs) deal with hypertension? If you carefully read the medical standards in FAR Part 67, you won't find a single reference to high blood pressure. Don't be surprised. Many serious medical conditions go unmentioned in the FARs. That doesn't mean that the FAA ignores them. FAR 67.313(b), titled "General Medical Condition," is the equivalent to the catch-all storage closet in your house. It covers all other pathology not referred to by name in the earlier sections of Part 67. The FAA considers hypertension a "general medical condition," and the agency has a long-established policy for certificating pilots with controlled blood pressure.
The policy sets a maximum allowable blood pressure of 155 systolic over 95 diastolic. The systolic pressure is the higher of the two numbers used to record blood pressure. It represents the internal pressure being exerted against the wall of the artery during systole, the compression stroke or beat of the heart when blood is being moved through the supply side of the circulatory system. The diastolic phase, when the heart is relaxed between beats, measures the diastole, when there is less pressure being exerted against the arterial wall.
What is normal? It varies quite a bit, but consider 120/70 to be a textbook normal for most discussions. Keep in mind, though, that a single elevated reading doesn't mean you have a problem. Rather than a single snapshot, you need a photo album of readings over a few weeks or months to really see what's going on. With that in mind, we can see that the FAA policy has some flexibility within the allowable maximum reading of 155 systolic over 95 diastolic. Some doctors would recommend beginning medication treatment with a preponderance of readings of around 140/90, while others might withhold treatment until the readings were somewhat higher.
So what about treatment? Does the FAA policy allow medications for hypertension control? Absolutely. There are five acceptable groups of antihypertensive medications: angiotensin converting enzyme (ACE) inhibitors, alpha- adrenergic blocking agents, beta-adrenergic blocking agents, calcium channel blockers, diuretics, and direct vasodilators. AOPA members can visit AOPA Online (www.aopa.org/members/files/medical/hyprtens.html ) for complete details on the reporting requirements. Each group of drugs acts differently, and your doctor will prescribe the medication or combinations of medications right for you.
Be aware, though, that for some people blood pressure control comes at a price. Many, if not most, antihypertensive medications can cause some unpleasant side effects, including coughing, drowsiness, headaches, dry mouth, and decreased sexual desire. Thanks to the number of available drugs on the market, however, your doctor should be able to find an appropriate choice that will minimize the side effects.
If you currently hold a medical certificate and start taking blood pressure medication while the medical is in effect, you may continue to exercise your privileges, as long as you comply with the provisions of FAR 61.53 and 91.17(a)(3). These regulations place upon the pilot the burden for determining if an underlying medical condition or medication usage is a basis for voluntary grounding.
At the time of your next FAA physical examination when you report the medication on item 17(a) of the application form, a cardiovascular evaluation will be required. This fairly simple evaluation includes a resting electrocardiogram, done within six months before the flight physical. A blood chemistry profile is also needed. The panel should include plasma glucose, or blood sugar; total cholesterol, with HDL ("good" cholesterol) and LDL ("bad" cholesterol); and triglycerides. If a diuretic (sometimes called a water pill) is being taken to increase urinary output, reports on potassium and creatinine levels are also required to monitor the possible depletion of potassium, a necessary element for cellular function.
Finally, your doctor should take a detailed personal and family medical history. The history is important because it reveals not only any of your personal medical problems, but also a snapshot of your genetic shortcomings, like heart disease, strokes, cancer, or hypertension in any members of your family.
Once this evaluation has been completed, you can schedule the FAA examination. Be sure to have the reports with you. If the reports are within normal limits and the aviation medical examiner (AME) finds you otherwise qualified, a medical certificate can be issued on the spot. If the AME isn't sure about the FAA policy, refer him or her to pages 96 and 97 of the FAA's Guide for Aviation Medical Examiners. If the application is deferred, it will take as long as four months before the application makes its way through the FAA bureaucracy and a certificate is mailed to you. For that reason, it's best to have everything up front, especially if you're a student pilot nearing the first supervised solo.
Don't be discouraged if your doctor wants to start you on blood pressure medication. With a little effort and education, your next FAA medical exam should be no more complicated than previous exams.
Gary Crump is the director of medical services for AOPA and a commercial pilot. AOPA members who have questions about hypertension or any other medical certification issues can visit www.aopa.org or call the AOPA Pilot Hotline at 800/872-2672.
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