by Dr. Bill Blank, MD
Copyright 2021. All rights reserved!
Published in Midwest Flyer Magazine – print & online April/May 2021 issue
Hypertension or high blood pressure is quite common. It is estimated that almost half of our population will develop it sometime during their lifetime. The FAA’s mission is to promote aviation safety. It develops its certification procedures with this in mind. The FAA’s time frame is, at most, two (2) years except for 3rd class medical certificates issued to pilots under 40 years of age in which case it is five (5) years. Pilots under 40 are not likely to have hypertension. When the FAA certifies someone with hypertension, they feel it is unlikely the airman will become unsafe because of hypertension-related issues during the period of certification. The hypertension certification policy needs to be seen with this in mind.
Hypertension is usually symptom free. Over time untreated hypertension can cause heart attacks, aneurysms, heart failure, kidney disease, eye disease and cerebral problems such as strokes, transient ischaemic attacks (TIA) or “mini strokes,” and memory problems. Most cases of hypertension have no known cause. This is called primary or essential hypertension. Secondary hypertension is caused by an underlying disease such as sleep apnea, kidney disease, or adrenal gland tumors. Certification with secondary hypertension will require treatment of the underlying condition to FAA satisfaction. Risk factors for primary hypertension include age, obesity, race (more common in non-Hispanic blacks), family history, tobacco use, too much dietary sodium or too little potassium, excess alcohol consumption, stress, and kidney disease.
Normal blood pressure is generally considered to be under 120/80. Treatment from a medical point of view depends upon the risk factors. Your aviation medical examiner (AME) can certify you for any class as long as your blood pressure does not exceed 155/90. This is an arbitrary level based on the likelihood of blood pressure caused safety issues during the certification period. It also takes into consideration people who have anxiety caused blood pressure elevations in the doctor’s office. This is not a healthy blood pressure, if it accurately reflects your blood pressure. When I certify someone with a blood pressure near the limit, I recommend they monitor their blood pressure and, perhaps, see their physician. I note that in the comments section of the 8500-8.
What are the options if your blood pressure is above 155/90 in the AME’s office? Your AME can wait a while, let you relax, and take it again. If it falls below the limit, he can pass you. If that doesn’t work, he can have you return three (3) times over a 7-day period and retake it. If it falls below the specified limits, he can again certify you. If not, he will need to send you to your physician. There is a 7-day no fly period if medication is started or the dosage is changed. If this can be done within the 14-day period, the AME has to transmit the exam, and he can certify you. If not, it will need to be deferred and you will need to submit to the FAA the information required in the hypertension Conditions AMEs Can Issue (CACI). They will issue the certificate. Your AME can be helpful here, by faxing the CACI report to the Regional Flight Surgeon. This will save time.
If you are being treated, your blood pressure must be controlled and stable. You must have no symptoms or medication side effects. You may take up to three (3) medications. Approved medications are Alpha and Beta blockers, calcium channel blockers, diuretics, ACE inhibitors, angiotensin II receptor blockers (ARBs), direct renin inhibitors and direct vasodilators. Centrally acting antihypertensives, such as clonidine, are not allowed. Hypertension is now handled with a CACI. It is the only CACI your AME can do himself, if he so desires. All others require a report from the treating physician. If you need more than three (3) medications, it will need to be deferred.
In the past, airman would sometimes avoid taking medications for as long as possible, because of fear of side-effects. From my point of view, the dangers of untreated hypertension outweigh the likelihood of serious side-effects. The FAA has come a long way. When I first became an AME, you could fly with high blood pressure, but not take medication for it! If you have hypertension, I recommend seeing your treating physician within 60 days of your flight physical and asking him to complete the top half of the CACI hypertension worksheet, sign it and date it. Put your name on the form. That will make it easy for your AME. A problem I frequently see is airmen reporting taking blood pressure medications, but they have not had any doctor visits in the last year. Prescriptions need to be renewed once a year! I hope this information will help you navigate certification with high blood pressure.
EDITOR’S NOTE: William A. Blank is a physician in La Crosse, Wisconsin, and has been an Aviation Medical Examiner (AME) since 1978, and a Senior AME since 1985. Dr. Blank is a retired Ophthalmologist, but still gives some of the ophthalmology lectures at AME renewal seminars. Flying-wise, Dr. Blank holds an Airline Transport Pilot Certificate and has 5600 hours. He is a Certified Instrument Flight Instructor (CFII) and has given over 1200 hours of aerobatic instruction. In addition, Dr. Blank was an airshow performer through the 2014 season and held a Statement of Aerobatic Competency (SAC) since 1987.
DISCLAIMER: The information contained in this column is the expressed opinion of the author only, and readers are advised to seek the advice of others and refer to the Federal Aviation Regulations and FAA Aeronautical Information Manual for additional information and clarification.