Evening the score

The stress test is broken into three 3-minute stages, with each stage done at a slightly faster speed and treadmill elevation. The electrocardiogram monitors heart rate and rhythm during and after the test is completed.

In the presence of a “normal” study, showing no significant arrhythmias or compromised blood supply (ischemia) to the heart, no further treatment is usually indicated, with the exception of possible dietary changes, more exercise, or medications for blood pressure or lipid control to reduce risk factors. For an “abnormal” study that shows arrhythmias or ischemia, the next step may be a nuclear exercise perfusion study (SPECT) that has a higher “sensitivity/specificity,” meaning it is a more reliable indicator of possible underlying coronary artery disease.

If your cardiologist sees a significantly abnormal stress ECG or nuclear perfusion scan, a visit to the catheterization lab for a heart catheterization with coronary angiogram will identify the extent of obstructive plaque accumulation in the coronary arteries. With that roadmap, a treatment plan may involve placing a stent to the culprit lesions or, for more extensive disease, coronary bypass surgery.

Another tool for evaluating risk for heart disease is coronary artery calcification (CAC) scoring and Coronary CT Angiography (CCTA). These tests may be done prior to a cardiac catheterization to assess the presence of “soft” plaques (the deadly kind that can break free within the artery and travel to places like the brain) and provide an estimate of the extent of coronary obstruction.

CCTA often includes a measurement of “fractional flow reserve” (FFR). FFR is similar to studies that hydrologists use to measure the flow of river or stream water. If the flow rate across a potentially critical lesion in a coronary artery is low, it may be an indication of significant disease.

A coronary calcium score is assigned based on the preliminary findings and is often confirmed by the CCTA. The Ca score and the CCTA data combined provide the cardiologist with an algorithm to determine next steps. The FAA recognizes these diagnostic tools in determining eligibility for special issuance consideration. These studies are not necessarily required as part of an FAA evaluation for special issuance, but if the tests are done, you will need to provide the results as part of the medical records provided to the FAA.