CARDIOVASCULAR

DISEASE

CPT DONALD C PALMA MC

FLIGHT SURGEON
DIPLOMATE, PHILIPPINE SPECIALTY BOARD OF
INTERNAL MEDICINE
FELLOW, PHILIPPINE COLLEGE OF PHYSICIANS
 OBJECTIVE

• To provide the students with the basic

knowledge on the management of patients with
Cardiovascular disease during Aeromedical
evacuation
 SCOPE OF PRESENTATION

• STRESSES OF FLIGHT
• CARDIOVASCULAR DISEASE AND
MANAGEMENT
• PRE-FLIGHT/ IN-FLIGHT CONSIDERATIONS
• CONTRAINDICATIONS TO FLIGHT
 STRESSES OF FLIGHT

• Decreased Partial Pressure of Oxygen

• Increases myocardial workload, predisposing

compromised patients to arrhythmias, chest pain and
may lead to myocardial infarction.

• Consider cabin pressure altitudes less than 6000 feet for

cardiac patients and patient with increased FiO2
requirements.
• Increased atrial arrhythmias due to hypoxia
inducing cellular changes
 STRESSES OF FLIGHT

• Barometric Pressure Changes

• Gas expansion in the GI tract may cause diaphragmatic

crowding and decrease in tidal volume.
 STRESSES OF FLIGHT

• Gravitational Forces

• Take - off may increase returning blood flow and cardiac

workload for some cardiac patients.

• Use a backrest for cardiac patients on a litter.

 STRESSES OF FLIGHT

• Thermal Changes

• Excessive heat may cause patients on cardiac

medication to become hypotensive.

• Hyperthermia and hypothermia may increase cardiac

oxygen requirements.
 STRESSES OF FLIGHT

• Fatigue

• Cumulative effect of stresses may exacerbate the

patient’s condition.
 CARDIOVASCULAR DISEASE

• CORONARY ARTERY DISEASE

• CARDIAC ARRHYTHMIA
• CONGESTIVE HEART FAILURE
• HYPERTENSIVE URGENCY / EMERGENCY
 CORONARY ARTERY DISEASE

 Range of conditions wherein the demand for myocardial

oxygen exceeds the supply

 Reduction in oxygen supply and/or by an increase in

myocardial oxygen demand

 ANGINA- most commonly reported manifestation of

cardiac pain, typically retrosternal pain, chest discomfort
and heaviness
CORONARY ARTERY DISEASE
CLINICAL PRESENTATION
 Stable Angina

 Typical exertional angina pectoris

 Usually precipitated by exertion and relieved by rest

 VARIANT OR PRINZMETAL’S ANGINA

 episodes of chest pain occuring at rest, associated

with ST segment elevations by ECG due to coronary
vasospasm without evolution to MI
 Unstable Angina

 Angina pectoris or equivalent ischemic discomfort with at

least one of three features:

1) It occurs at rest, usually lasting > 10min;

2) It is severe and of new onset;

3) It occurs with a crescendo pattern

Myocardial Infarction
 MANAGEMENT

 Monitoring of vital signs and oxygen saturation

 Do a 12-Lead ECG

 Give supplemental oxygen

 Establishing IV access

 Treat underlying cause (ischemia, hypertension)

 Give nitrates
 MANAGEMENT

 Give Aspirin if there are no bleeding tendencies

 Give Morphine if entertaining possible MI

 Drawing blood specimens: CBC, blood chemistry, serum

electrolytes, coagulation studies, cardiac markers (CK-MB,
troponin)

 Take a targeted history

 Inotropes (dopamine), if necessary

 CARDIAC ARRHYTHMIAS

 CAUSES

• Disturbances in automaticity

• Disturbances in conduction

• Combinations of altered automaticity and conduction

 CARDIAC ARRHYTHMIAS

• SUPRAVENTRICULAR ARRHYTHMIAS

• ATRIAL FIBRILLATION

• ATRIAL FLUTTER

• VENTRICULAR TACHYARRHYTMIAS

• VENTRICULAR TACHYCARDIA

• PREMATURE VENTICULAR
CONTRACTIONS
ATRIAL FIBRILLATION
 ATRIAL FIBRILLATION

• Common etiologies:

• Acute coronary syndromes, coronary artery disease,

congestive heart failure

• Disease at mitral or tricuspid valve

• Hypoxia, acute pulmonary embolism

• Drug-induced: digoxin or quinidine; β-agonists,

theophylline
 ATRIAL FIBRILLATION

• Sepsis

• Hypertension

• Hyperthyroidism
 ATRIAL FIBRILLATION

• Most common atrial arrhythmia

• Irregularly irregular rhythm

• Clinical manifestations:

• Dyspnea on exertion

• Shortness of breath, Acute pulmonary edema

• Palpitations
 MANAGEMENT

• Treat underlying cause

• If unstable : Cardioversion

• If stable: digoxin, verapamil, diltiazem, beta blockers

 VENTRICULAR TACHYCARDIA

• 3 or more beats of ventricular origin in successive at a rate

> 100 BPM

• May be well tolerated or may be life-threatening

• May be pulseless or not

VENTRICULAR TACHYCARDIA
 VENTRICULAR TACHYCARDIA

CLINICAL MANIFESTATIONS

• Typically, symptoms of decreased cardiac output

(orthostasis, hypotension, syncope, exercise limitations) do
develop.

• Monomorphic VT can be asymptomatic despite widespread

belief that sustained VT always produces symptoms.

• Untreated and sustained VT will deteriorate to unstable VT

and often to VF.
 VENTRICULAR TACHYCARDIA
COMMON ETIOLOGIES

• An acute ischemic event with areas of ventricular irritability

leading to PVCs

• Low ejection fraction due to chronic systolic heart failure

• PVCs that occur during relative refractory period of cardiac

cycle (R-on-T phenomenon)

• Drug-induced prolonged QT interval (tricyclic

antidepressants, procainamide, sotalol, ibutilide, dofetilide,
some antipsychotics, digoxin, some long-acting
antihistamines, certain antibiotics)
 MANAGEMENT

• Treat underlying cause

• If unstable : Electrical cardioversion or defibrillation

• If stable: Lidocaine, amiodarone

 CONGESTIVE HEART FAILURE

 Heart failure describes an inability of the heart to keep up

its work load of pumping blood to the lungs and to the rest
of the body.
 CONGESTIVE HEART FAILURE

 SIGNS AND SYMPTOMS:

 Orthopnea

 Dyspnea

 Bipedal edema

 Distended neck veins

 MANAGEMENT

 Monitoring of vital signs and oxygen saturation

 Give supplemental oxygen

 Establishing IV access

 Treat underlying cause first

 Give necessary medications

 HYPERTENSION

• commonly known as High Blood Pressure

• Chronic medical condition

• Occurs when blood is forced through the heart and

arteries under excessive pressure
 HYPERTENSION

• Hypertensive Urgency

• No end organ damage

• Hypertensive Emergency

• With end organ damage

• Presence of changes in sensorium, heart failure

 MANAGEMENT

1. Lifestyle Modification

2. Adherence to medication

3. Regular BP monitoring

4. Regular consultation
 MANAGEMENT

 Monitoring of vital signs and oxygen saturation

 Give supplemental oxygen

 Establishing IV access

 Treat underlying cause first

 Give necessary medications

 COMPETENCIES

- Perform a detailed cardiovascular assessment before,

during and after air transport.

- Recognize potential for lethal events and institute

appropriate interventions and therapeutic modalities.

- Identify and provide treatment for patients experiencing

an acute cardiac event such as AMI, CHF, Cardiogenic
shock, arrhythmias and hemodynamic instability.
 PRE-FLIGHT ASSESSMENT

• History

• Medications needed

• Laboratory and
diagnostic work up
 PRE-FLIGHT ASSESSMENT

• Carry a copy of the most

recent ECG

• Equipment to carry for

possible resuscitation

• IV access / O2
supplementation
 IN-FLIGHT ASSESSMENT

• Monitor VS and Neurovital signs

• Regulate the IVF

• O2 saturation

• Emergency medicines (anti-

angina, anti-arrhythmia)

• Prepare for resuscitation

 ASSESSMENT OF
CARDIOVASCULAR EMERGENCIES
DURING AIR TRANSPORT

- Place the patient on a cardiac monitor and monitor the vital

signs and oximetry readings.

- Make sure to have an IV access. Continue the physical

assessment of the patient while all the necessary
equipment is being applied.

- Should the patient become unconscious, check circulation,

airway and breathing then proceed with ACLS if necessary.
CONTRAINDICATIONS TO FLIGHT

• 1. Uncomplicated myocardial infarction within 2–3

weeks

• 2. Complicated myocardial infarction within 6 weeks

• 3. Unstable angina

• 4. Congestive heart failure, severe, decompensated

• 5. Uncontrolled hypertension
CONTRAINDICATIONS TO FLIGHT

• 6. CABG within 10–14 days

• 7. CVA within 2 weeks

• 8. Uncontrolled ventricular or supraventricular

tachycardia

• 9. Eisenmenger syndrome

• 10. Severe symptomatic valvular heart disease

QUESTIONS?
THANK YOU
and
GOOD DAY!!!