Airtravel in MCI

I K Rina
Dept of Cardiology/ Internal Med
Med Fac / UNUD
AMI
Air Ambulance Transport an
d Acute Coronary Syndrome
Management
Air ambulances --- service and treatme
nt---- a significant impact on ACS outc
omes.
More recently -----air transport ---- tra
nsfer patients back to their country of
residence,
Economic and social pressures.
Safety of Air Transfer ACS

The complication of an untreated AMI ris

es significantly ---- the occurrence of car
diogenic shock and fatal arrhythmias.
Safe transport to a hospital---- PCI is ess
ential to ensure survival.
Air ambulance ----- for interfacility transfe
rs.
Air ambulance ------ concern raised in the
past of the safety of transferring patients
Safety of Air Transfer ACS

Short distance transported before 12 to 36 ho

urs ----did not suffer any deaths, though com
plication of hypotension and arrhythmias occu
rred, --- managed by paramedics.
Similar data----- long distance air ambulance t
ransport----no in flight complications.
The safety of air ambulance transfer----- for el
ective PCI established, with no minor complic
ation rates between 24-48 hrs post MI or 3-7
days post MI.
Improvement in treatment t
imes in air transfer

STEMI ----shorter medical contact to balloon t

imes---- most cases in less than 90 minutes
Transfer times are critical to ensure timely int
ervention.
Air ambulance transfer is safe, with no signific
ant complication rate over ground ambulance
transfers.
Costs remain an issue, and measures must be
taken to make this an economical mode of pa
tient transfer.
ACS in Air Transfer
ACS medical emergencies ---- urgent transfer
to a hospital or between facilities.
Transfer times are critical to ensure timely int
ervention.
Air ambulance transfer is safe, with no signific
ant complication rate over ground ambulance
transfers.
Costs remain an issue, and measures must be
taken to make this an economical mode of pa
tient transfer.
High altitude, air travel, and
heart disease

High altitude ---- changes physiological functi

ons to individuals physical fitness, rate of asc
ent, severity and/or duration of exposure, cult
ural habits, geographical locations, and geneti
c variation.
While high altitude ----CVD risk complications
----tissue hypoxia and reduced oxygen deliver
y, sympathetic stimulation, increased myocard
ial demand, paradoxical vasoconstriction, and
alterations in hemodynamics
BAROMETRIC PRESSURE AN
D PO2

High altitude,---- reductions atmosphe

ric pressure, oxygen pressure, humidit
y, and temperature.
Significant changes -----beyond the cri
tical height of 2500 meters (8200 feet)
above sea level.
BAROMETRIC PRESSURE AN
D PO2

Factors influence of highly altitude,----

degree of hypoxia, rate of ascent, level
of acclimatization, exercise intensity, p
revious history of severe high-altitude i
llness, genetics, and age significantly a
ffect the physiological change that the
human body will experience during asc
ents.
 Hypoxia -----peripheral vasodilation an
d a pulmonary vasoconstriction, --- ch
anges systemic BP and Po Pressure inc
rease---- contribute pulmonary edema.
It's OK to Take a Long Plane
Trip After a Heart Attack

Flying 2 3 weeks after ACS was reas

onably safe.
A medical escort recommend --- partic
ularly if < 14 days.
Researchers ---- recommend at an ave
rage 3 weeks after returned home.
Safety of air travel following
acute myocardial infarction.
1) Examine the safety flying on comm
ercial airlines : 2 wk after AMI
2) Determine no/need use O2 for redu
ced risk in-flight adverse events; and
3) Determine the need for a medical e
scort.
Safety of air travel following
acute myocardial infarction.
Suggests that, ----provided care taken
the immediate preflight and postflight
phases supplemental O2, nor medical
escorts are needed who fly 2 wk post
AMI
Safety fly after AMI

Guidelines recommend permitted---

4 to 24 weeks convalescent period afte
r AMI
International aeromedical transport ---
- safely 2-3 wk after AMI if escorted.
Recommendations ---- delaying travel
> 4 wk after AMI without escorted
Helicopter transport of patie
nts during acute myocardial
infarction
Emergency helicopter transport with A
MI --- for PCI
Thrombolytic ---may pre or in flight.
Thrombolytic --- 30 to 120 min (+ 180
),
PCI ----- 105 to 815 minutes (+ 300).
Flight time ---- 2 to 77 min (+ 31).
Helicopter transport of AMI
--- (Problema)
Transient hypotension was the most co
mmon complication pre and inflight.
CAVB and nonsustain VT (next most c
ommon complications)
VF or sustain VT occurred before takeo
ff in 38 patients (15%)
The principal factors are considered
patients fitness for air travel are:
Reduced atmospheric pressure. Cabin air pr
essure changes greatly during 15-30 minute
s after takeoff and before landing, and gas e
xpansion and contraction can cause pain an
d pressure effects.
Reduction in oxygen tension. The cabin is at
a pressure equivalent to an altitude of 6,000
to 8,000 feet and oxygen partial pressure is
approximately 20% less than on the ground.
 Patients can safely travel unescorted a
fter AMI if their risk of ischemia is low
risk stratification examination prior t
o repatriation.
Air traveling
A decrease in saturation--- increase catechol
amines ----risk of SVT in IHD.
Recommendations -----pre-PCI period ---- fly
ing allowed 2 wk post AMI).
Risk stratification ---- the need of therapy wi
th IHD.
Risk stratificationbased --- allocate the nee
d of costly medical escort to travel safely wit
hout medical escort.
 Guidelines Suggested --- no PCI --- repatriat
ed 14 days after AMI.
Recommended ---handled AMI repatriated a
ccording to a risk stratification algorithm ---
low risk, safely unescorted.
 Take care --- immediate preflight and
postflight, neither need O2 nor medica
l escorts --- the need fly 2 wk after AM
I.
Physiology and Potential Risks of Flight

The effects of hypoxia at altitude, the

effects of gas expansion at altitude, th
e effects of anxiety about flying, and t
he potential for complications related t
o movement of patients.
Physiology and Potential Risks of Flight

The effects of altitude are generally li

mited to fixed-wing aircraft as oppose
d to rotary-wing aircraft that fly at altit
udes (eg, < 1,000 feet) --- minimal ba
rometric pressure changes.
Effects of Hypoxia at Altitude

Rotary-wing aircraft, fixed-wing engine propeller air

craft fly at altitudes of > 15,000 feet and
Jets fly at altitudes of 28,000 to 43,000 feet.
Barometric pressure progressively decreases with al
titude --- 760 mm Hg - 140 mm Hg at 40,000 feet u
pper sea level.
The partial pressure of inspired oxygen (P2) decrea
ses proportionally to the decrease in barometric pre
ssure at increasing altitude (P2 = 0.21 [barometri
c pressure water vapor pressure]).
Effects of Hypoxia at Altitude

The P2 at 40,000 feet (approximately 20 m

m Hg) is incompatible with human life.
In order to make it possible for humans to fl
y at such altitudes, aircraft are pressurized t
o achieve cabin pressures at cruising altitud
es equivalent to barometric pressures at 5,0
00 to 8,000 feet of altitude.
At a cabin pressure of 8,000 feet, P2 decrea
ses from 150 mm Hg 107 mmHg. (In nor
mal patients, this has been shown to decrea
se Pa2 from 98 to 55 mm Hg).
Effects of Hypoxia at Altitude

In healthy individuals, --- only a small

decrease in blood O2 saturation to app
roximately 90%;
However, if a patient already has a red
uced Pa2 on the ground, the decrease
in oxygen saturation at altitude will be
more significant.
 The physiologic response --- lowered Pa2 ---
chemoreceptor-induced hyperventilation, me
diated primarily by an increase in tidal volu
me.
Systemic hypoxia --- tachycardia --- increase
d CPO
Proportional to the drop in oxygen saturatio
n --- increase in cardiac output in internatio
nal air ambulance
 Altitude-related decreases in P2 --- decrease
ischemic threshold in exercise-AP, --- cardiac
ischemia occurre at the same internal workl
oad (heart rate-BP product) but lower exter
nal workload (treadmill speed and incline) at
higher altitude (10,000 feet vs 5,000 feet).
Hypoxia --- stimulus SVES.
The increased sympathetic nervous system
activity in-flight is factor predisposing to arr
hythmia.
Short-Distance Emergency He
licopter Transport
Emergency helicopter transport of AMI--- sa
fe, based on the absence of in-flight deaths
or significant morbidity.
The most frequent in-flight problems were n
onfatal hypotension and arrhythmias, mana
ged by onboard medical personnel equipped
with IV fluids and medications.
Long-Distance Elective Commercial Transport

international air medical transport of p

atients by commercial airline may be s
afely accomplished 2 to 3 weeks after
acute MI when accompanied by a phys
ician.
Current Guidelines Regarding Air Travel

The current guidelines regarding long-distan

ce flight and cardiac patients are limited to
unescorted commercial airline travel.
The American College of Cardiology (ACC) a
nd American Heart Association (AHA) recom
mend that following uncomplicated MI, patie
nts in stable condition (without fear of flying
) may travel by air within the first 2 weeks,
provided they are accompanied by compani
ons, carry NTG sl, and request airport trans
portation to avoid rushing.
Current Guidelines Regarding Air Travel

Patients unstable condition, are symptomati

c, or who experienced a complicated MI (re
quiring cardiopulmonary resuscitation, exper
iencing hypotension, serious arrhythmias, hi
gh-degree block, or congestive heart failure)
, are recommended to wait a period of at le
ast 2 weeks following stabilization before co
mmercial air travel.
Current Guidelines Regarding Air Travel

The guidelines of the Aerospace Medical Ass

ociation (AsMA) state that unescorted comm
ercial airline flight is contraindicated within 3
weeks of uncomplicated MI, within 6 weeks
of complicated MI, within 2 weeks of corona
ry artery bypass surgery, or within 2 weeks
of cerebrovascular accident.
Current Guidelines Regarding Air Travel

The American Medical Association (AMA) gui

delines indicate that travel by commercial ai
rcraft is contraindicated within 4 weeks after
MI, within 2 weeks after cerebrovascular acc
ident, and for anyone with severe hypertens
ion or decompensated cardiovascular diseas
e.
 Elective long-distance air medical transport of cardi
ac patients occurs with increasing frequency, as a r
esult of medical, economic, and social pressures to
return a patient to their country or medical system.
These risks are related to the adverse effects of hyp
oxia and gas expansion at altitude, the effects of an
xiety about flying, and the potential for complicatio
ns related to movement of the patient.
Conclusions

Short-distance helicopter flights early in the

course of ACS need emergent transfer for P
CI or CABG.
Elective long-distance air medical transport
of cardiac patients for social or economic re
asons and compare benefits against the pot
ential risks of flight.