air travel with heart failure

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Review Article
Published: 06 January 2022

Travelling with heart failure: risk assessment and practical recommendations

Stephan von Haehling 1 , 2 ,
Christoph Birner 3 , 4 ,
Elke Dworatzek 5 , 6 ,
Stefan Frantz 7 ,
Kristian Hellenkamp 1 ,
Carsten W. Israel 8 ,
Tibor Kempf 9 ,
Hermann H. Klein 10 ,
Christoph Knosalla ORCID: orcid.org/0000-0002-8127-5019 6 , 11 , 12 ,
Ulrich Laufs ORCID: orcid.org/0000-0003-2620-9323 13 ,
Philip Raake 14 , 15 ,
Rolf Wachter 1 , 2 , 13 &
Gerd Hasenfuss 1 , 2

Nature Reviews Cardiology volume 19 , pages 302–313 ( 2022 ) Cite this article

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Heart failure
Patient education

Patients with heart failure are at a higher risk of cardiovascular events compared with the general population, particularly during domestic or international travel. Patients with heart failure should adhere to specific recommendations during travel to lower their risk of developing heart failure symptoms. In this Review, we aim to provide clinicians with a set of guidelines for patients with heart failure embarking on national or international travel. Considerations when choosing a travel destination include travel distance and time, the season upon arrival, air pollution levels, jet lag and altitude level because all these factors can increase the risk of symptom development in patients with heart failure. In particular, volume depletion is of major concern while travelling given that it can contribute to worsening heart failure symptoms. Pre-travel risk assessment should be performed by a clinician 4–6 weeks before departure, and patients should receive advice on potential travel-related illness and on strategies to prevent volume depletion. Oxygen supplementation might be useful for patients who are very symptomatic. Upon arrival at the destination, potential drug-induced photosensitivity (particularly in tropical destinations) and risks associated with the local cuisine require consideration. Special recommendations are needed for patients with cardiac implantable electronic devices or left ventricular assist devices as well as for those who have undergone major cardiac surgery.

Patients with heart failure (HF) are recommended to schedule a specialist consultation for pre-travel risk assessment 4–6 weeks before departure.

Preparation for travel requires special considerations in patients with HF, including the choice of destination, availability of medical resources and strategies to prevent volume depletion.

Most patients with HF can travel when medically stable; patients with a ground-level oxygen saturation ≤90% or those in NYHA class III–IV might need an on-board medical oxygen supply.

All medication and important documents should be stored in carry-on luggage.

Volume depletion and dehydration are important considerations requiring meticulous attention with regards to medication adjustment and fluid intake.

Patients with implantable cardiac devices might require extra time at security checkpoints and additional documents; for some patients, remote monitoring of implantable cardiac devices might be useful.

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Introduction

Domestic and international travel are associated with increased health risks, with 20–70% of individuals reporting health issues during their travels 1 . During international travel, 1–5% of individuals seek medical attention and the rate of death among travellers is 1 in 100,000, with cardiovascular disease being the most frequent cause of death 1 . Trauma, particularly from motor vehicle accidents, is another major cause of death while travelling 1 . Health-care providers are frequently approached by patients for advice on how to prepare for travel or to determine whether travelling is advisable at all. General practitioners can provide information to healthy individuals but specialist consultation is of benefit for patients with underlying illnesses such heart failure (HF) 2 . Indeed, many patients with HF intend to travel for business or leisure. Although some guidance has been published 3 , a systematic overview of recommendations for patients with HF planning to travel is not yet available. In this Review, we aim to provide clinicians with recommendations for preparatory measures before travel to inform and educate patients with HF. We discuss factors that might increase the risk of HF symptom development, such as local climate, air pollution levels and altitude levels, and provide specific guidance for patients with a cardiac implantable device and those who have undergone major surgery.

Which patients with HF can travel safely?

To date, guidance on travel recommendations for patients with HF is limited. In general, patients with NYHA class I–III HF who are stable should be able to travel safely 4 . However, patients with NYHA class III HF who are planning to travel by air should be advised to consider on-board medical oxygen support. Patients with NYHA class IV should not travel; however, if travel is unavoidable, on-board oxygen and medical assistance should be requested. A patient with an oxygen saturation rate >90% at ground level usually will not require medical oxygen during flight 5 . An overview of whether travelling is advisable for different classes of HF 6 , 7 is provided in Box 1 . An overview of contraindications for air travel in patients with cardiovascular diseases is provided in Box 2 .

Box 1 Travel recommendations for patients with heart failure

Chronic stable heart failure

NYHA class I–II: travel advisable, if patient is stable

NYHA class III: travel advisable, if patient is stable; consider use of on-board medical oxygen during air travel

NYHA class IV: travel not advisable; if travel is unavoidable, on-board oyxgen and medical assistance are required

Acute heart failure decompensation

Travel not advisable until at least 6 weeks after discharge and rehabilitation, if patient is stable

Ventricular assist device implantation

Travel advisable after hospital discharge and rehabilitation, if patient is stable

Heart transplantation

Not advisable until at least 1 year after transplantation surgery, if patient is stable

Implantable cardioverter–defibrillator or cardiac resynchronization therapy implantation

Not advisable until at least 2 weeks after discharge, if patient is stable

Box 2 Contraindications for air travel in patients with cardiovascular disease

Myocardial infarction (ST-elevation or non-ST-elevation myocardial infarction) within the previous 2 weeks

Unstable angina without further diagnostics and treatment

Percutaneous coronary angioplasty within the previous 2 weeks; in patients who have undergone uncomplicated percutaneous coronary intervention, shorter time frames might be acceptable

Cardiac surgery or interventional valve therapy within the previous 3 weeks

NYHA class IV heart failure or any decompensated heart failure

Untreated arrhythmias (ventricular or supraventricular)

Eisenmenger syndrome

Uncontrolled pulmonary artery hypertension

Pneumothorax (such as after major cardiac surgery)

Choice of destination

The choice of destination for travel can have important health implications for patients with HF, particularly when travelling abroad. Considerations include the local climate, air pollution levels, altitude levels, the season upon arrival, the distance and time for travelling, jet lag, and vaccines required.

Effects of transitioning climates on HF

Individuals who transition through climates different to the one they reside in (such as someone living in the arctic travelling to a tropical island) are at an increased health risk. In general, people living in warmer regions tend to be most vulnerable to cold weather and, conversely, those residing in a cold climate are most sensitive to heat 8 . Exposure to extreme heat has been associated with increased morbidity and mortality from heat exhaustion and heat stroke 9 , 10 . Maintenance of homeostasis during hot weather requires an increase in cardiac output; heat tolerance is impaired when cardiac output cannot be increased to meet the requirements of heat loss. Numerous medications that are frequently prescribed for individuals with HF can also increase susceptibility to heat stroke, including loop diuretics, serotonic antidepressants, angiotensin-converting enzyme inhibitors and proton-pump inhibitors 11 , 12 , 13 . Colder temperatures are less likely to have effects on cardiovascular health but have been associated with increased morbidity among patients with respiratory disease 14 . Patients with HF should be advised to choose either spring or autumn for international travel to avoid travelling during extremities in weather and to adjust medications that can contribute to volume depletion. Appropriate clothing is required for the site of departure, the destination and for the journey itself. Given the challenges in contacting a patient’s primary care physician if the patient is in a different country or continent, distant travel destinations might only be advisable for patients who are well-informed about their medication regimen, dietary restrictions and exercise limitations.

Endemic diseases

The need for immunization for travel depends on the destination. In general, the status of routine vaccinations, such as the diphtheria, measles–mumps–rubella, pertussis, tetanus and varicella vaccines, should be checked before travelling abroad. For all patients with HF, vaccines are required for pneumococcal disease, influenza and coronavirus disease 2019 (COVID-19). Other destination-dependent vaccines are provided in Table 1 .

Air pollution and HF

Air pollution can be measured by the air quality index, which integrates measures for the five main air pollutants: ground-level ozone, particulate matter, carbon monoxide, sulfur dioxide and nitrogen dioxide. An air quality index value of 0–50 indicates good air quality, 51–100 indicates moderately polluted air, >100 indicates an unhealthy level of air pollution and >300 designates a hazardous environment 15 . Particulate matter (PM) of ≤10 µm (PM 10 ) or ≤2.5 µm (PM 2.5 ) in diameter are linked with increased cardiopulmonary mortality 16 , 17 as well as with an increased risk of hospitalization for HF 18 and death 19 . The pathophysiological mechanisms underlying this increased risk remain elusive. Accumulating evidence points towards a crucial role of PM-induced systemic oxidative stress 20 and endothelial dysfunction 21 in the development of arterial vasoconstriction and elevated systemic blood pressure 22 . In addition, PM-induced pulmonary vasoconstriction results from increases in pulmonary and right ventricular diastolic filling pressures, which affect right ventricular performance 22 . Given that the effects of air pollutants on cardiovascular performance and outcomes can occur within hours or days of exposure 23 , patients with HF should be advised to avoid travelling to locations with high levels of air pollution.

Altitude-induced hypoxia and HF

Patients with HF are more susceptible to the physiological changes induced by high altitude exposure than the general population 24 . During air travel, cabin pressure is required to be no less than the barometric pressure at an altitude of 2,438 m (8,000 ft), which is classified as an intermediate altitude 25 (Fig. 1a ). Cabin pressures usually remain higher than this altitude, particularly during long-haul flights 26 . Travel to high altitude locations that are >2,500 m above sea level triggers physiological acclimatization processes within the cardiocirculatory and pulmonary systems 27 , 28 (Fig. 1b ). These processes are initiated by a gradual decrease in barometric pressure, which in turn lowers the partial pressure of oxygen in inspired air. Hypobaric hypoxia leads to a fast increase in respiratory rate and tidal volume 29 , which leads to respiratory alkalosis and hypoxic diuresis 30 . Hypoxia induces pulmonary vasoconstriction and eventual pulmonary hypertension, an important trigger for high altitude pulmonary oedema 31 . To compensate for the lower arterial oxygen content, heart rate and stroke volume are increased via activation of the sympathetic nervous system 26 , 32 , 33 , 34 . Together, these physiological adaptations limit the exercise capacity of patients with HF and make them prone to cardiac decompensation. However, studies that assessed simulated altitude-induced hypoxia in patients with NYHA class III–IV HF showed that high altitude was not associated with angina, arrhythmia, or ischaemia 35 , 36 and that the degree of the reduction of maximum work capacity was dependent on the individual’s exercise tolerance at sea level 35 . The ESC and other professional societies recommend that the assessment of safety of high altitude exposure for patients with HF should depend on their functional capacity (that is, NYHA class) at sea level 35 , 37 . Furthermore, certain drugs that are prescribed to patients with HF can further interfere with the physiological adaptation processes at high altitudes. For example, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can reduce renal erythropoietin production, thereby hampering the compensatory rise in haematocrit mediated by altitude-induced hypoxia 38 . Therefore, diuretic therapy should be tailored to the individual to account for clinical signs of dehydration (such as through hypoxic diuresis) or fluid gain 39 . Finally, anaemia reduces oxygen delivery, and muscle loss (present in patients with sarcopenia or cachexia) reduces maximal physical workload and time to fatigue; patients with these conditions in addition to HF need to have special considerations when planning to travel to high altitude locations. To summarize, travel to destinations at an intermediate altitude (~2,000 m) is safe for patients with HF who have good exercise tolerance at sea level.

a | Definitions of height and examples of mountains and cities at different altitudes. Most aircraft fly at approximately 10,000–12,000 m (33,000–42,000 ft) above sea level, with the cabin pressurized to an equivalent of 2,438 m (8,000 ft). b | High altitude-induced hypobaric hypoxia leads to an increase in respiratory rate and tidal volume, which promotes respiratory alkalosis, hypoxic diuresis, pulmonary vasoconstriction and, ultimately, pulmonary hypertension and pulmonary oedema. Compensatory mechanisms of this hypoxia include increases in heart rate and stroke volume via activation of the sympathetic nervous system (SNS). Together, these changes can limit exercise capacity and promote cardiac decompensation.

Seasonal variations and HF

Hospitalizations owing to worsening HF show intriguing seasonality, with a substantial decline during warmer periods and an increase during colder periods 18 , 40 , especially in older patients 41 . Temperature had the greatest (inverse) correlation with hospitalizations for HF among other causative environmental factors such as humidity, precipitation or irradiation 16 . Skin cooling has been shown to increase vascular resistance 42 and plasma noradrenaline concentration 43 , which might lead to HF decompensation. Beyond neurohumoural activation and haemodynamic stress, respiratory infections, which peak during the colder months, can precipitate and aggravate HF symptoms 41 . Furthermore, vitamin D insufficiency during winter has also been linked to worsening HF 44 . Interestingly, the effect of seasonal variability on health is more prominent in elderly people and winter hospitalization is associated with both poorer short-term and long-term prognosis 41 . These observations suggest that patients with more severe HF (and worse prognosis) are prone to decompensation during winter and that these patients and older patients with more advanced disease should be advised to avoid travelling to colder regions. Of note, a study from Norway reported that the Christmas winter period was associated with the highest rates of excess all-cause and cardiovascular deaths 45 . Overall, appropriate clothing and heating strategies need to be carefully selected for optimal stabilization of body core temperatures, vitamin D levels should be measured before departure and supplemented if required, and vaccines against influenza and pneunococcal disease should be administered 40 (Table 1 ).

Preparing to travel

Any patient with a history of HF should seek medical consultation before departure, particularly when travelling overseas or when leaving for a long period. Women are generally more likely to seek pre-travel medical advice than men 46 and are also more likely to have travel-related worries 47 . A cross-sectional national survey found that a low perceived need was among the main causes for avoiding medical care, often because patients expected their illness or symptoms to improve over time 48 . For patients with HF, travel preparation should include a specialist consultation approximately 4–6 weeks before departure. This consultation should follow a structured and sequenced approach, which should involve risk assessment (including an evaluation of medical history and travel itinerary), interventions required before departure (including physical examination or setting up of remote monitoring for cardiac implantable devices) and focused education on topics such as medications and factors that can lead to volume depletion. For example, the presence of anaemia might cause lightheadedness, angina or loss of consciousness, particularly during flights 49 , 50 . Medication regimens should be optimized before departure and patients with iron deficiency should be considered for repletion therapy. Suggestions for topics to cover during this consultation are summarized in Box 3 .

Box 3 Recommendations for pre-travel assessment

Risk assessment

Full medical history (current medications, immunization history, history of surgeries or device implantation, immune status, allergies, pregnancy or breast feeding)

Previous travel experience (particularly to the same destination) or risk tolerance

Travel itinerary (destination, mode of travel, travel distance, season, air pollution levels, potential jet lag, clothing required and altitude)

Activities planned (such as adventure sports or hiking, mass gatherings)

Type of accommodation

In-office interventions

Physical examination, electrocardiogram tracing, biochemistry analysis (plasma levels of creatinine, ferritin, glucose, glycated haemoglobin, N-terminal pro-B-type natriuretic peptide, potassium, sodium, transferrin saturation, thyroid-stimulating hormone, vitamin D and urea, estimated glomerular filtration rate, and lipid profile and liver function tests), full blood count (to identify potential anaemia), exercise test and/or transthoracic echocardiography

Set up remote monitoring of implanted devices

Administration of immunizations (routine vaccines include measles–mumps–rubella, tetanus–diphtheria–pertussis, coronavirus disease 2019 (COVID-19), pneumococcal disease and influenza as well as any destination-specific vaccine that might be needed for diseases such as hepatitis A or yellow fever) or malaria chemoprophylaxis (if required)

Strategies to prevent or treat traveller’s diarrhoea (food and water precautions, oral rehydration, treatment with loperamide and bismuth subsalicylate, and antibiotic self-treatment options for severe diarrhoea)

Focused education before travel

Medical kit and documents required during travel: personal health kit (medication, device information or medical records), evacuation and health insurance

Location of medical facilities at destination

Education on heart failure medication adjustment (to avoid dehydration and volume overload), cardiac device handling, telemonitoring and factors that contribute to volume depletion (excess alcohol, coffee or salt intake; traveller’s diarrhoea)

Patients with a cardiac implanted device should avoid strong electromagnetic fields

Travel-related illnesses: altitude illness, traveller’s thrombosis, bloodborne and sexually transmitted diseases, transportation-associated illnesses, respiratory infections, rabies and other animal-associated illness, and skin conditions and wounds

Personal protection for vector-borne disease (if at risk)

Risk assessment and medication adjustment

As mentioned in the previous section, pre-travel risk assessment should consider the type and duration of travel, the travel destination, and the medical history of the patient. Typical health emergencies that patients with HF might encounter during travel are listed in Table 2 . Patients should be advised that provision of incomplete medical information during a cardiac emergency might increase the risk of death. Any accompanying travellers need to know where to find important documents (Box 4 ) in case of an emergency. Given the difficulty in obtaining prescription drugs in a different country as well as the different brands of drugs having varying strengths in different countries, extra medication should be brought on the trip. Importantly, some over-the-counter drugs might be legal in the patient’s home country but illegal elsewhere (such as certain analgesics).

Box 4 Medication and documents required during travel

Sufficient medication for the whole journey (consider bringing extra drugs in case of unforeseen delays in returning home)

Medication to be kept in carry-on luggage for flights (in case of loss of luggage or emergency)

Photocopy of last prescription

Insurance card

Patient identification card

List of diagnosed health conditions and prescribed medicines

Last discharge letter from hospital

Device interrogation print-out

List of names and phone numbers of cardiologist and other relevant clinicians

Remote device monitoring

Remote monitoring is recommended by the ESC and other professional societies for patients with cardiac implantable devices such as pacemakers, implantable cardioverter–defibrillators (ICDs) and implantable cardiac monitors 51 , 52 , 53 . Most remote monitoring systems use a transmitter (base station) placed in the vicinity of the implanted device, with information sent via an internet connection to a remote monitoring service. Alternatively, alerts can be activated after events that trigger an immediate remote transmission (for example, after ICD shock, detection of ventricular tachyarrhythmias or signs of lead failure). Given that travelling is usually associated with increased physical activity levels, daily remote monitoring might be useful for the detection of events such as arrhythmias, HF decompensation or device malfunction (Box 5 ).

Box 5 Travel-related activities and related cardiac events reported via remote monitoring

Sports (such as swimming and diving)

Arrhythmias (atrial fibrillation, ventricular tachyarrhythmia or premature ventricular contractions)

Heart failure decompensation

Damage to the implanted cardiac lead (fracture or insulation failure)

Cardiac device compression with loss of function (during diving)

Stay in high altitude

Eating out (higher intake of sodium) and alcohol consumption

Reduced adherence to medication

Arrhythmias

Travel by aircraft

Electromagnetic interference with cardiac electronic device

Travel by train or ship

Special considerations

Patients who have undergone recent surgery.

Major cardiac surgery ranges from minimally invasive approaches to complete sternotomy. The Canadian Cardiac Society guidelines on air travel recommend that patients with a haemoglobin level <9 g/dl who have undergone coronary artery bypass graft surgery should be advised against air travel 54 ; recommendations for travel in patients with HF who have undergone coronary artery bypass graft surgery should perhaps be even more conservative. These patients should be advised not to travel by air until intrathoracic gas resorption is completed given that gas expands when air pressure is reduced with increasing altitude (the Boyle law) 4 . Gas resorption usually takes 3–10 days after surgery. Any air remaining in the pericardial space or in the thoracic cavity can expand by up to 60%, which might be dangerous and painful 4 . Indeed, the Aerospace Medical Association guidelines state that pneumothorax is an absolute contraindication to air travel and advocate an interval of 2–3 weeks before flying after thoracic surgery 5 . Furthermore, patients who have had a recent operation are in a state of increased oxygen consumption owing to the trauma of surgery, possible presence of sepsis and increased adrenergic outflow. A 2017 study compared complication rates between ground and air travel 5–25 days after pulmonary resection 55 . Air travel was as safe as ground travel if the chest tubes were removed after the absence of ongoing air leak and an output <300 ml over 24 hours combined with adequate pain medication and an active ambulation schedule.

Patients with LVADs

Left ventricular assist devices (LVADs) are increasingly implanted as a bridging strategy while patients wait for heart transplantation or as a permanent therapy for end-stage HF. Patients in either category can travel by air if medically stable and rehabilitation measures have been performed 56 . Box 6 lists precautions before and during travel for patients with an LVAD.

Box 6 Considerations before and during travel for patients with an LVAD

Considerations before departure

Approval should be sought from the responsible left ventricular assist devices (LVAD) centre, including an airline information letter (templates from LVAD manufacturer)

Closest LVAD centres within the travel destination should be located as possible emergency contacts

All LVAD-related equipment needs to be stored in carry-on luggage with handling advice and emergency contact information attached and batteries should be fully charged before departure

The size and weight of the equipment should be checked to ensure that it can be carried on board the plane and the airport and airline need to be informed about the LVAD before arrival to the airport

Considerations during travel

Flight attendants and other personnel need to be informed about the LVAD and the location of the emergency information card

Patients need to maintain fluid intake to avoid low flow alarms from the LVAD pump

For flights longer than 2 hours, support stockings should be considered

Considerations while en route

Departure from home.

Patients with HF or ischaemic heart disease need to take extra caution on the way to and from the departure point, such as an airport or train station, given the multitude of stressors: commotion, a delay or any last-minute changes to the train or flight, and lifting of heavy luggage, all of which can increase physical and mental exertion and risk of myocardial ischaemia 57 , 58 . As such, travel planning should include estimation of psychological stressors and physical loads as well as a plan for any emergencies (Table 2 ). Pre-planned assistance with luggage or transport by wheelchair at the point of departure might reduce pre-travel stress and physical exhaustion.

Dehydration and fluid intake

Patients with HF are susceptible to volume depletion during travel given that fluid intake, lifestyle and diuretics are tuned precisely to maintain a state of euvolaemia 59 (Fig. 2 ). A hypovolaemic state adversely affects cardiac and renal function, aggravates HF symptoms, and might interfere with the efficacy of HF medications. Fluid loss, caused by changes in temperature, diet (higher salt intake) or as a consequence of traveller’s diarrhoea, might occur during the flight.

A vast array of factors contributes to volume depletion in patients with heart failure (HF) and require medication adjustment and increased fluid intake. MRA, mineralocorticoid receptor antagonists; SGLT2i, sodium–glucose cotransporter 2 inhibitor.

On board a plane, the low cabin humidity and cooled air can increase resting ventilatory water losses by approximately 200 ml per hour 60 . In addition, chair rest immobilization for 4 hours can decrease plasma volume by approximately 6% as a result of blood pooling and greater loss of fluid within the interstitial space in the legs 60 . Urinary output is often normal or only slightly reduced 61 . Sodium-free, alcoholic or caffeine-containing drinks consumed during the flight can promote diuresis and might further increase fluid loss. Furthermore, arrival to a hot and dry climate can result in loss of fluid through sweating and breathing by up to 1.2 l per day independently of physical activity 62 .

Apart from air travel and a transition in climate, acute diarrhoea is the most common illness in individuals travelling from resource-rich to resource-limited regions of the world 63 , 64 . Traveller’s diarrhoea usually occurs 4–14 days after arrival and results from bacterial (>90% of cases), viral and parasitic infections 64 . Approximately 10–40% of travellers to high-risk regions in Asia, Africa, and South and Central America experience diarrhoea during their travels 64 . Patients should be educated on food and water safety to prevent ingestion of pathogens. Cardiac dysfunction and HF management and treatment strategies, such as fluid restriction, diuretic therapy and renin–angiotensin–aldosterone system (RAAS) inhibitors, also increase the risk of diarrhoea-related complications in patients with HF during (temporal) hypovolaemia 63 , 64 .

Signs and symptoms of volume depletion and dehydration-associated electrolyte or acid–base disorders include fatigue, exercise intolerance, weight loss, increase in heart rate, muscle cramps, weakness, postural dizziness, abdominal pain, low urine volume, low blood pressure, lethargy and confusion. On the basis of invidualized risk assessment, patients should be advised to increase fluid intake by 0.5–1 l per day and to avoid alcohol or excessive coffee consumption during long-haul flights and hot weather. In case of signs and symptoms of volume depletion, therapy with diuretics, mineralocorticoid receptor antagonists and sodium–glucose cotransporter 2 inhibitors should be stopped or reduced for a day or longer until symptoms have resolved and body weight has returned to normal 65 . In case of postural or symptomatic hypotension, therapy with RAAS inhibitors and angiotensin receptor blocker–neprilysin inhibitors should be reduced or discontinued until symptoms have resolved; patients who experience postural or symptomatic hypotension require medical evaluation.

In a hot environment, patients with HF are advised to restrain from strenuous activity to avoid increased fluid loss. In case of uncomplicated traveller’s diarrhoea, patients need to increase fluid intake with oral rehydration solutions and monitor body weight and urinary output to avoid dehydration. Given that patients with HF are at an increased risk of complications, an antimotility agent (loperamide) and an antibiotic (azithromycin or rifaximin) can be prescribed for self-treatment 63 , 64 .

Venous thromboembolism

The risk of deep venous thrombosis (DVT) is greatly increased in patients with incident HF according to data from the ARIC cohort 66 and a systematic review 67 . The term ‘economy class syndrome’ has been used to describe the venous complications caused by cramped seating conditions 68 . The risk of DVT or pulmonary embolism is increased during travel that is >4 hours in duration, most probably owing to the associated immobility that is a key component of the Virchow triad of hypercoagulability, stasis and endothelial injury. Travelling in general (>4 hours in the preceding 8 weeks) is associated with a twofold increase in the risk of venous thrombosis 69 . This risk seems to be similar regardless of the mode of transportation (airplane, bus or train) 67 . The overall absolute incidence of symptomatic venous thromboembolism (VTE) in healthy individuals within the first month after a flight lasting >4 hours is approximately 1 in 4,600 flights and increases by 18% for each additional 2 hours in flight duration 2 , 70 . Importantly, the risk of VTE in individuals with pro-thrombotic risk factors, such as chronic HF, is substantially higher than in the general population. A 2021 meta-analysis found that patients with chronic HF were at an increased risk of VTE (risk ratio 1.57, 95% CI 1.34–1.84) 71 . A window seat compared with an aisle seat has been associated with a twofold greater risk of VTE or a sixfold greater risk in individuals with a BMI of >30 kg/m 2 (ref. 72 ).

Strategies to prevent VTE include appropriate loose clothing, frequent walks, calf muscle exercises, use of elastic compression stockings and adequate hydration 73 . Leg exercises have been shown to improve popliteal venous flow during prolonged immobility in seated individuals 74 . Furthermore, a systematic review of 11 randomized trials that included 2,906 individuals revealed the benefits of compression stockings (15–30 mmHg) on reducing the incidence of asymptomatic DVT and, with less evidence, of leg oedema 75 .

The evidence for thromboprophylaxis to prevent VTE during travel is very limited. The LONFLIT-3 study 76 randomly assigned 300 individuals at high risk of flight-related VTE to receive aspirin, enoxaparine (a low-molecular-weight heparin) or no prophylaxis. In total, 4.8% of patients in the control group were diagnosed with asymptomatic DVT compared with 3.6% in the aspirin group and 0% in the enoxaparine group. The authors of this small study concluded that one dose of enoxaparine might be an important option for individuals at high risk of DVT during long-haul flights 76 . Of note, specific studies of thromboprophylaxis during long-haul travel in patients with HF are lacking.

Medical emergencies during air travel

Patients with HF can travel by air if their condition is stable (Box 1 ). Commercial airplanes are required to carry basic emergency medical equipment according to regulations of the Federal Aviation Administration (FAA) in the USA and the European Aviation Safety Agency (EASA) in Europe 77 . Commercial aircrafts travelling from Europe to the USA have to meet both FAA and EASA requirements and, thus, must carry on board an external automated defibrillator, a saline infusion system and a bag-valve mask resuscitator 77 .

Data on on-board medical emergencies are sparse owing to the lack of international registries 78 . According to the available data provided by the airline Lufthansa, which contains details on approximately 20,000 on-board medical events from 2000 to 2011, cardiac emergencies accounted for 43% of on-board incidents 77 . Reported medical issues included circulatory collapse, high blood pressure, chest symptoms and dehydration 47 . On-board treatment included blood pressure management in 76% of incidents, drug administration in 54%, oxygen delivery in 48%, blood glucose measurement in 9%, monitoring of oxygen saturation in 6% and use of an automated external defibrillator in 6% 77 .

Considerations at the destination

Dietary considerations.

Dietary intake of fluids, sodium, potassium and alcohol during travel should be guided by current ESC recommendations for the management of patients with HF 3 , 79 . According to the guidelines, fluid restriction of 1.5–2.0 l per day might be considered in patients with severe HF to relieve symptoms and congestion 80 . When travelling to hot and dry destinations, an additional intake of 0.5–1.0 l per day of non-alcoholic drinks is recommended. Patients at risk of volume overload or on moderate-to-high doses of diuretics should be advised to regularly check their body weight. In case of body weight changes, patients can adjust doses of diuretics and the amount of fluid intake for a few days until body weight has normalized. Controlling sodium intake is important for patients at risk of hyponatraemia and for the management of oedema, although evidence showing the effects of sodium intake on HF outcomes is scarce 3 . During travel, increased consumption of foods high in salt can adversely affect sodium and volume balance and thereby exacerbate HF symptoms by causing fluid retention. Patients with HF and cardiorenal syndrome and/or treated with RAAS inhibitors are at increased risk of hyperkalaemia 81 . In patients with advanced chronic kidney disease (estimated glomerular filtration rate <30 ml/min/1.73 m²), a daily sodium intake of <3 g is recommended 81 . These patients should also be aware that certain foods, such as fresh fruits, juices, vegetables and milk products, contain high amounts of potassium.

Drinking habits also change during vacation. Moderate-to-heavy alcohol consumption is associated with increased risk of supraventricular arrhythmias, especially atrial fibrillation, and high blood pressure 82 , 83 . Therefore, increased intake of alcoholic beverages might aggravate HF symptoms and promote volume overload. Alcohol intake should be limited to two units per day for men with HF, one unit for women with HF, or no intake if alcohol has caused or contributed to the individual’s HF, as recommended by the ESC 3 .

Drug-induced photosensitivity

Numerous classes of drugs commonly used for the treatment of patients with HF have been associated with photo-induced, cutaneous drug eruptions, which are adverse effects that occur as a result of the exposure to a drug (and its presence in the skin) and ultraviolet or visible radiation 84 . Box 7 provides an overview of drugs that have been linked with drug-induced photosensitivity. Amiodarone can cause drug-induced photosensitivity in >50% of treated patients 84 . The typical presentation of this adverse effect is a burning and tingling sensation in sun-exposed skin, with associated erythema. Amiodarone induces a distinctive blue–grey pigmentation on sun-exposed sites in 1–2% of patients, particularly after long-term sun exposure. Another prototypical drug class associated with photosensitivity is thiazide diuretics, which includes hydrochlorothiazide 85 . Thiazide diuretics can trigger a variety of photosensitive eruptions, including an exaggerated sunburn reaction, dermatitis and a lichenoid eruption.

Various factors, such as time of day, season, geographical location, altitude and weather conditions, can affect the amount of ultraviolet radiation exposure 86 . In general, patients with HF should be advised to seek shade when outside, in particular around midday, and to keep in mind that radiation can be stronger when reflected by water, sand or snow. Patients in areas with high sun exposure should wear clothing that protects as much of the body as possible as well as sunglasses and broad-brimmed hats. Broad-spectrum sunscreens with a sun protection factor of 30 or higher are recommended 86 .

Box 7 Medications linked to drug-induced photosensitivity 80

Angiotensin-converting enzyme inhibitors

Ramipril, enalapril and quinapril

Angiotensin receptor blockers

Candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan

Anti-arrhythmic drugs

Amiodarone and dronedarone

Anti-depressant drugs

Citalopram, clomipramine, escitalopram, fluoxetine, fluvoxamine, imipramine, paroxetine, sertraline, St. John’s wort and venlafaxine

Antimicrobial drugs

Anti-fungals, anti-malarials, anti-tuberculous drugs, anti-retrovirals, β-lactams, fluoroquinolones, nalidixic acid, sulphonamides and tetracyclines

Calcium channel blockers

Amlodipine, diltiazem and nifedipine

Bumetanide, furosemide, indapamide, thiazides and triamterene

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors

Atorvastatin, pravastatin and simvastatin

Non-steroidal anti-inflammatory drugs

Ampiroxicam, celecoxib, diclofenac, ibuprofen, indomethacin, ketoprofen, meclofenamide, nabumetone, naproxen, oxaprozin, piroxicam, sulindac and tiaprofenic acid

Psychotropic drugs

Anti-psychotic drugs (aripriprazole, chlorpromazine, clozanine, flupenthixol, haloperidol, olanzapine, risperidone and thioridazine) and anxiolytics (alprazolam and chlordiazepoxide)

Considerations for drivers

Driving regulations for individuals with HF take into account the severity of HF (NYHA class plus left ventricular ejection fraction) 54 . In the European Union, individuals with NYHA class I–III HF but not those with NYHA class IV HF are permitted to drive private vehicles. Patients with HF should ensure that they are permitted to drive in their travelling destination by accessing country-specific driving regulations online.

Considerations for patients with ICDs

Electromagnetic interference.

Many patients with HF are fitted with cardiac implantable electronic devices (CIEDs; namely ICDs), cardiac resynchronization therapy devices or pacemakers. These devices might be subject to electromagnetic interference (EMI) if exposed to a strong electromagnetic field (Table 3 ). Exposure of the device to EMI can result in device failure (loss of anti-bradycardia pacing with the risk of asystole), switch to asynchronous mode (pacing at a preset rate independent of intrinsic rhythm with the risk of inducing arrhythmias, including ventricular fibrillation), inappropriate tracking (atrial oversensing leading to rapid, irregular ventricular pacing) and in the inappropriate detection of ventricular tachyarrhythmias by ICDs, potentially with inappropriate shock therapy. High-voltage lines above trains, for example, have a strong electromagnetic field but the patient is shielded when inside the train. In trams or underground trains, electric motors can be located under the seat, whereas in cars and motorbikes, the only relevant source of EMI is the ignition system. Patients with a cardiac implantable device should be careful not lean over an unshielded, running motor.

Metal detectors at airport security checkpoints do not interfere with CIEDs 87 , 88 . However, patients with ICDs should be advised to have their device card ready to show to airport personnel before walking through the security checkpoint. To minimize the risk of interference, patients should move through metal detector gates at normal walking speed and should not linger. Hand-held scanners should not affect CIED functionality 89 but patients should ask personnel to move the wand over the device quickly and only once.

Magnets are not allowed in carry-on luggage and thus cannot be used to remedy inappropriate device activity on airplanes. EMI inside airplanes is rare but has been reported, for example, in association with electronic chair handles. Finally, cosmic radiation is approximately 100-fold higher during air travel, which increases the risk of radiation-induced EMI (for example, power-on reset).

Conclusions

The list of considerations for patients with HF embarking on national or international travel is extensive. Patients should be aware of an increased risk of cardiovascular events during their travels, which can be reduced with meticulous pre-travel risk assessment, physical examination, therapy adjustment and education. Pre-travel risk assessment should involve research into the local climate, air pollution levels, the distance and time for travelling, potential jet lag and altitude. En route, patients with HF should avoid volume depletion caused by extended chair rest, low cabin humidity and cooled air, excess alcohol or coffee intake, drugs with diuretic effects, hypoxia or traveller’s diarrhoea. Upon arrival at the destination, drug-induced photosensitivity and the health effects of local foods and beverages require consideration. Special recommendations are needed for patients after implantation of cardiac rhythm devices or LVADs as well as for patients who have undergone major cardiac surgery.

Ryan, E. T. & Kain, K. C. Health advice and immunizations for travelers. N. Engl. J. Med. 342 , 1716–1725 (2000).

Article CAS PubMed Google Scholar

Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical considerations before international travel. N. Engl. J. Med. 375 , 247–260 (2016).

Article PubMed Google Scholar

Jaarsma, T. et al. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur. J. Heart Fail. 23 , 157–174 (2021).

Smith, D. et al. Fitness to fly for passengers with cardiovascular disease. Heart 96 (Suppl. 2), ii1–ii16 (2010).

PubMed Google Scholar

Aerospace Medical Association. Medical considerations for airline travel: surgical conditions (ASMA, 2021).

Dharmarajan, K. et al. Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study. BMJ 350 , h411 (2015).

Article PubMed PubMed Central Google Scholar

Alba, C. et al. Complications after heart transplantation: hope for the best, but prepare for the worst. Int. J. Transpl. Res. Med. 2 , 022 (2016).

Article Google Scholar

Curriero, F. C. et al. Temperature and mortality in 11 cities of the eastern United States. Am. J. Epidemiol. 155 , 80–87 (2002).

De Blois, J. et al. The effects of climate change on cardiac health. Cardiology 131 , 209–217 (2015).

Kenny, G. P., Yardley, J., Brown, C., Sigal, R. J. & Jay, O. Heat stress in older individuals and patients with common chronic diseases. CMAJ 182 , 1053–1060 (2010).

Bouchama, A. & Knochel, J. P. Heat stroke. N. Engl. J. Med. 346 , 1978–1988 (2002).

Faunt, J. D. et al. The effete in the heat: heat-related hospital presentations during a ten day heat wave. Aust. N. Z. J. Med. 25 , 117–121 (1995).

Sommet, A., Durrieu, G., Lapeyre-Mestre, M., Montastruc, J. L. & Association of French PharmacoVigilance Centres. A comparative study of adverse drug reactions during two heat waves that occurred in France in 2003 and 2006. Pharmacoepidemiol. Drug Saf. 21 , 285–288 (2012).

McCormack, M. C. et al. Colder temperature is associated with increased COPD morbidity. Eur. Respir. J. 49 , 1601501 (2017).

AirNow. Air Quality Index (AQI) basics. AirNow https://airnow.gov/index.cfm?action=aqibasics.aqi (2019).

Miller, K. A. et al. Long-term exposure to air pollution and incidence of cardiovascular events in women. N. Engl. J. Med. 356 , 447–458 (2007).

Pope, C. A. Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. JAMA 287 , 1132–1141 (2002).

Article CAS PubMed PubMed Central Google Scholar

Escolar, V. et al. Impact of environmental factors on heart failure decompensations. ESC Heart Fail. 6 , 1226–1232 (2019).

Shah, A. S. et al. Global association of air pollution and heart failure: a systematic review and meta-analysis. Lancet 382 , 1039–1048 (2013).

Barregard, L. et al. Experimental exposure to wood-smoke particles in healthy humans: effects on markers of inflammation, coagulation, and lipid peroxidation. Inhal. Toxicol. 18 , 845–853 (2006).

Törnqvist, H. et al. Persistent endothelial dysfunction in humans after diesel exhaust inhalation. Am. J. Respir. Crit. Care Med. 176 , 395–400 (2007).

Wold, L. E. et al. Cardiovascular remodeling in response to long-term exposure to fine particulate matter air pollution. Circ. Heart Fail. 5 , 452–461 (2012).

Tofler, G. H. & Muller, J. E. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation 114 , 1863–1872 (2006).

Higgins, J. P., Tuttle, T. & Higgins, J. A. Altitude and the heart: is going high safe for your cardiac patient? Am. Heart J. 159 , 25–32 (2010).

US Office of the Federal Register. Code of Federal Regulations: Title 14 aeronautics and space, part 25.841 (US Government Printing Office, 1986).

Seccombe, L. M. & Peters, M. J. Physiology in medicine: acute altitude exposure in patients with pulmonary and cardiovascular disease. J. Appl. Physiol. 116 , 478–485 (2014).

Imray, C., Booth, A., Wright, A. & Bradwell, A. Acute altitude illnesses. BMJ 343 , d4943 (2011).

Bärtsch, P. & Gibbs, J. S. Effect of altitude on the heart and the lungs. Circulation 116 , 2191–2202 (2007).

Jones, J. G., Bakewell, S. E., Heneghan, C. P., Jones, S. E. & Snape, S. L. Profound hypoxemia in pulmonary patients in airline-equivalent hypoxia: roles of VA/Q and shunt. Aviat. Space Env. Med. 79 , 81–86 (2008).

Sawka, M. N., Convertino, V. A., Eichner, E. R., Schnieder, S. M. & Young, A. J. Blood volume: importance and adaptations to exercise training, environmental stresses, and trauma/sickness. Med. Sci. Sports Exerc. 32 , 332–348 (2000).

Cheung, S. S. et al. Ventilatory chemosensitivity, cerebral and muscle oxygenation, and total hemoglobin mass before and after a 72-day mt. Everest expedition. High Alt. Med. Biol. 15 , 331–340 (2014).

Hughson, R. L., Yamamoto, Y., McCullough, R. E., Sutton, J. R. & Reeves, J. T. Sympathetic and parasympathetic indicators of heart rate control at altitude studied by spectral analysis. J. Appl. Physiol. 77 , 2537–2542 (1994).

Vogel, J. A. & Harris, C. W. Cardiopulmonary responses of resting man during early exposure to high altitude. J. Appl. Physiol. 22 , 1124–1128 (1967).

Heistad, D. D., Abboud, F. M. & Dickinson, W. Richards Lecture: circulatory adjustments to hypoxia. Circulation 61 , 463–470 (1980).

Agostoni, P. et al. Effects of simulated altitude-induced hypoxia on exercise capacity in patients with chronic heart failure. Am. J. Med. 109 , 450–455 (2000).

Negrao, C. E. & Middlekauff, H. R. Adaptations in autonomic function during exercise training in heart failure. Heart Fail. Rev. 13 , 51–60 (2008).

Parati, G. et al. Clinical recommendations for high altitude exposure of individuals with pre-existing cardiovascular conditions: a joint statement by the European Society of Cardiology, the Council on Hypertension of the European Society of Cardiology, the European Society of Hypertension, the International Society of Mountain Medicine, the Italian Society of Hypertension and the Italian Society of Mountain Medicine. Eur. Heart J. 39 , 1546–1554 (2018).

Pratt, M. C. et al. Effect of angiotensin converting enzyme inhibitors on erythropoietin concentrations in healthy volunteers. Br. J. Clin. Pharmacol. 34 , 363–365 (1992).

Swenson, E. R. Carbonic anhydrase inhibitors and high altitude illnesses. Subcell. Biochem. 75 , 361–386 (2014).

Stewart, S., Keates, A. K., Redfern, A. & McMurray, J. J. V. Seasonal variations in cardiovascular disease. Nat. Rev. Cardiol. 14 , 654–664 (2017).

Stewart, S., McIntyre, K., Capewell, S. & McMurray, J. J. Heart failure in a cold climate. Seasonal variation in heart failure-related morbidity and mortality. J. Am. Coll. Cardiol. 39 , 760–766 (2002).

Hayward, J. M., Holmes, W. F. & Gooden, B. A. Cardiovascular responses in man to a stream of cold air. Cardiovasc. Res. 10 , 691–696 (1976).

Westheim, A. et al. Haemodynamic and neurohumoral effects of cold pressor test in severe heart failure. Clin. Physiol. 12 , 95–106 (1992).

Barnett, A. G., de Looper, M. & Fraser, J. F. The seasonality in heart failure deaths and total cardiovascular deaths. Aust. N. Z. J. Public Health 32 , 408–413 (2008).

Moholdt, T. Excess mortality at Christmas due to cardiovascular disease in the HUNT study prospective population-based cohort in Norway. BMC Public Health 21 , 549 (2021).

Schlagenhauf, P. et al. Sex and gender differences in travel-associated disease. Clin. Infect. Dis. 50 , 826–832 (2010).

McIntosh, I. B., Power, K. G. & Reed, J. M. Prevalence, intensity, and sex differences in travel related stressors. J. Travel Med. 3 , 96–102 (1996).

Taber, J. M., Leyva, B. & Persoskie, A. Why do people avoid medical care? A qualitative study using national data. J. Gen. Intern. Med. 30 , 290–297 (2015).

Aerospace Medical Association. Medical considerations for airline travel: anemia (ASMA, 2021).

Roig, E. et al. Disabling angina pectoris with normal coronary arteries in patients undergoing long-term hemodialysis. Am. J. Med. 71 , 431–434 (1981).

Brignole, M. et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur. Heart J. 34 , 2281–2329 (2013).

Dubner, S. et al. ISHNE/EHRA expert consensus on remote monitoring of cardiovascular implantable electronic devices (CIEDs). Ann. Noninvasive Electrocardiol. 17 , 36–56 (2012).

Slotwiner, D. et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm 12 , e69–e100 (2015).

Simpson, C. et al. Canadian cardiovascular society consensus conference. Assessment of the cardiac patient for fitness to drive and fly – executive summary. Can. J. Cardiol. 20 , 1313–1323 (2004).

Google Scholar

Cassivi, S. D. et al. Safety of air travel in the immediate postoperative period after anatomic pulmonary resection. J. Thorac. Cardiovasc. Surg. 153 , 1191–1196.e1 (2017).

MyLVAD Foundation. 10 Tips for traveling with an LVAD. MyLVAD https://www.mylvad.com/patients-caregivers/discuss-connect/forums/1048-10-tips-traveling-lvad (2011).

Kupper, N., Denollet, J., Widdershoven, J. & Kop, W. J. Cardiovascular reactivity to mental stress and mortality in patients with heart failure. JACC Heart Fail. 3 , 373–382 (2015).

Strike, P. C. & Steptoe, A. A systematic review of mental stress-induced myocardial ischaemia. Eur. Heart J. 24 , 690e703 (2003).

Mullens, W. et al. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur. J. Heart Fail. 21 , 137–155 (2019).

Greenleaf, J. E., Rehrer, N. J., Mohler, S. R., Quach, D. T. & Evans, D. G. Airline chair-rest deconditioning: induction of immobilisation thromboemboli? Sports Med. 34 , 705–725 (2004).

Greenleaf, J. E., Shvartz, E., Kravik, S. & Keil, I. C. Fluid shifts and endocrine responses during chair rest and water immersion in man. J. Appl. Physiol. 48 , 79–88 (1980).

Better, O. S. Impaired fluid and electrolyte balance in hot climates. Kidney Int. Suppl. 21 , S97–S101 (1987).

CAS PubMed Google Scholar

Riddle, M. S. et al. Guidelines for the prevention and treatment of travelers’ diarrhea: a graded expert panel report. J. Travel Med. 24 (Suppl. 2), S57–S74 (2017).

Steffen, R., Hill, D. R. & DuPont, H. L. JAMA patient page. Traveler’s diarrhea. JAMA 313 , 108 (2015).

Rosenstock, J. & Ferrannini, E. Euglycemic diabetic ketoacidosis: a predictable, detectable, and preventable safety concern with SGLT2 inhibitors. Diabetes Care 38 , 1638–1642 (2015).

Fanola, C. L. et al. Incident heart failure and long-term risk for venous thromboembolism. J. Am. Coll. Cardiol. 75 , 148–158 (2020).

Trujillo-Santos, A. J., Jiménez-Puente, A. & Perea-Milla, E. Association between long travel and venous thromboembolic disease: a systematic review and meta-analysis of case-control studies. Ann. Hematol. 87 , 79–86 (2008).

Czuprynska, J. & Arya, R. Annotation: travel and thrombosis. Br. J. Haematol. 188 , 838–843 (2020).

Cannegieter, S. C., Doggen, C. J., van Houwelingen, H. C. & Rosendaal, F. R. Travel-related venous thrombosis: results from a large population-based case control study (MEGA study). PLoS Med. 3 , e307 (2006).

Kahn, S. R. et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141 (Suppl. 2), e195S–e226S (2012).

Xu, T. et al. Heart failure is associated with increased risk of long-term venous thromboembolism. Korean Circ. J. 51 , 766–780 (2021).

Schreijer, A. J., Cannegieter, S. C., Doggen, C. J. & Rosendaal, F. R. The effect of flight-related behaviour on the risk of venous thrombosis after air travel. Br. J. Haematol. 144 , 425–429 (2009).

Dusse, L. M. S., Silva, M. V. F., Freitas, L. G., Marcolino, M. S. & Carvalho, M. D. G. Economy class syndrome: what is it and who are the individuals at risk? Rev. Bras. Hematol. Hemoter. 39 , 349–353 (2017).

Hitos, K., Cannon, M., Cannon, S., Garth, S. & Fletcher, J. P. Effect of leg exercises on popliteal venous blood flow during prolonged immobility of seated subjects: implications for prevention of travel-related deep vein thrombosis. J. Thromb. Haemost. 5 , 1890–1895 (2007).

Clarke, M. J., Broderick, C., Hopewell, S., Juszczak, E. & Eisinga, A. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database Syst. Rev. 9 , CD004002 (2016).

Cesarone, M. R. et al. Venous thrombosis from air travel: the LONFLIT3 study–prevention with aspirin vs low-molecular-weight heparin (LMWH) in high-risk subjects: a randomized trial. Angiology 53 , 1–6 (2002).

Graf, J., Stüben, U. & Pump, S. In-flight medical emergencies. Dtsch. Arztebl Int. 109 , 591–602 (2012).

PubMed PubMed Central Google Scholar

Goodwin, T. In-flight medical emergencies: an overview. BMJ 321 , 1338 (2000).

McDonagh, T. A. et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J. 42 , 3599–3726 (2021).

Seferovic, P. M. et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur. J. Heart Fail. 21 , 1169–1186 (2019).

Kalantar-Zadeh, K. & Fouque, D. Nutritional management of chronic kidney disease. N. Engl. J. Med. 377 , 1765–1776 (2017).

Hindricks, G. et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur. Heart J. 42 , 373–498 (2021); erratum 42, 507 (2021); erratum 42, 546–547 (2021).

Tasnim, S., Tang, C., Musini, V. M. & Wright, J. M. Effect of alcohol on blood pressure. Cochrane Database Syst. Rev. 7 , CD012787 (2020).

Drucker, A. M. & Rosen, C. F. Drug-induced photosensitivity: culprit drugs, management and prevention. Drug Saf. 34 , 821–837 (2011).

Blakely, K. M., Drucker, A. M. & Rosen, C. F. Drug-induced photosensitivity-an update: culprit drugs, prevention and management. Drug Saf. 42 , 827–847 (2019).

US Food and Drug Administration. The Sun and your medicine (FDA, 2015).

Kolb, C. et al. Do airport metal detectors interfere with implantable pacemakers or cardioverter-defibrillators? J. Am. Coll. Cardiol. 41 , 2054–2059 (2003).

Copperman, Y., Zarfati, D. & Laniado, S. The effect of metal detector gates on implanted permanent pacemakers. Pacing Clin. Electrophysiol. 11 , 1386–1387 (1988).

Jilek, C. et al. Safety of screening procedures with hand-held metal detectors among patients with implanted cardiac rhythm devices: a cross-sectional analysis. Ann. Intern. Med. 155 , 587–592 (2011).

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Acknowledgements

This Review is the result of a cooperation under the umbrella of the Study Group 10 (heart failure) of the German Cardiac Society. S.v.H. has received research funding from the German Center for Cardiovascular Research (DZHK). T.K. has received research funding from the German Heart Research Foundation and is supported by the German Research Foundation (Clinical Research Unit KFO311). R.W. has received research support from the German Center for Cardiovascular Research (DZHK).

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von Haehling, S., Birner, C., Dworatzek, E. et al. Travelling with heart failure: risk assessment and practical recommendations. Nat Rev Cardiol 19 , 302–313 (2022). https://doi.org/10.1038/s41569-021-00643-z

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DOI : https://doi.org/10.1038/s41569-021-00643-z

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Guidelines for Flying With Heart Disease

Air travel is generally safe for heart patients, with appropriate precautions

Pre-Flight Evaluation

Planning and Prevention

During your flight.

If you have heart disease, you can fly safely as a passenger on an airplane, but you need to be aware of your risks and take necessary precautions.

Heart conditions that can lead to health emergencies when flying include coronary artery disease (CAD) , cardiac arrhythmia (irregular heart rate), recent heart surgery, an implanted heart device, heart failure , and pulmonary arterial disease.

When planning air travel, anxiety about the prevention and treatment of a heart attack on a plane or worrying about questions such as "can flying cause heart attacks" may give you the jitters. You can shrink your concern about things like fear of having a heart attack after flying by planning ahead.

Air travel does not pose major risks to most people with heart disease. But there are some aspects of flying that can be problematic when you have certain heart conditions.

When you have heart disease, air flight can lead to problems due to the confined space, low oxygen concentration, dehydration, air pressure, high altitude, and the potential for increased stress. Keep in mind some of these issues compound each other's effects on your health.

Confined Space

The prolonged lack of physical movement and dehydration on an airplane may increase your risk of blood clots, including deep vein thrombosis (DVT) or pulmonary embolism (PE) . One of the biggest risks for people with heart disease who are flying is developing venous thrombosis.

These risks are higher if you have CAD or an implanted heart device, such as an artificial heart valve or a coronary stent. And if you have an arrhythmia, a blood clot in your heart can lead to a stroke.

One of the biggest risks for people with heart disease who are flying is developing an arterial blood clot or venous thrombosis.

Low Oxygen and Air Pressure

The partial pressure of oxygen is slightly lower at high altitudes than at ground level. And, while this discrepancy on an airplane is typically inconsequential, the reduced oxygen pressure in airplane cabins can lead to less-than-optimal oxygen concentration in your body if you have heart disease.

This exacerbates the effects of pre-existing heart diseases such as CAD and pulmonary hypertension .

The changes in gas pressure in an airplane cabin can translate to changes in gas volume in the body. For some people, airplane cabin pressure causes air expansion in the lungs. This can lead to serious lung or heart damage if you are recovering from recent heart surgery.

Dehydration

Dehydration due to cabin pressure at high altitude can affect your blood pressure, causing exacerbation of heart disease. This is especially problematic if you have heart failure, CAD, or an arrhythmia.

If you experience stress due to generalized anxiety about traveling or sudden turbulence on your flight, you could have an exacerbation of your hypertension or CAD.

Pre-Flight Health Evaluation

Before you fly, talk to your healthcare provider about whether you need any pre-flight tests or medication adjustments. If your heart disease is stable and well-controlled, it is considered safe for you to travel on an airplane.

But, if you're very concerned about your health due to recent symptoms, it might be better for you to confirm that it's safe with your healthcare provider first before you book a ticket that you may have to cancel.

Indications that your heart condition is unstable include:

Heart surgery within three months
Chest pain or a heart attack within three months
A stroke within six months
Uncontrolled hypertension
Very low blood pressure
An irregular heart rhythm that isn't controlled

If you've had a recent heart attack, a cardiologist may suggest a stress test prior to flying.

Your healthcare provider might also check your oxygen blood saturation. Heart disease with lower than 91% O2 saturation may be associated with an increased risk of flying.

Unstable heart disease is associated with a higher risk of adverse events due to flying, and you may need to avoid flying, at least temporarily, until your condition is well controlled.

People with pacemakers or implantable defibrillators can fly safely.

As you plan your flight, you need to make sure that you do so with your heart condition in mind so you can pre-emptively minimize problems.

While it's safe for you to fly with a pacemaker or defibrillator, security equipment might interfere with your device function. Ask your healthcare provider or check with the manufacturer to see if it's safe for you to go through security.

If you need to carry any liquid medications or supplemental oxygen through security, ask your healthcare provider or pharmacist for a document explaining that you need to carry it on the plane with you.

Carry a copy of your medication list, allergies, your healthcare providers' contact information, and family members' contact information in case you have a health emergency.

To avoid unnecessary anxiety, get to the airport in plenty of time to avoid stressful rushing.

As you plan your time in-flight, be sure to take the following steps:

Request an aisle seat if you tend to need to make frequent trips to the bathroom (a common effect of congestive heart failure ) and so you can get up and walk around periodically.
Make sure you pack all your prescriptions within reach so you won't miss any of your scheduled doses, even if there's a delay in your flight or connections.
Consider wearing compression socks, especially on a long trip, to help prevent blood clots in your legs.

If you have been cleared by your healthcare provider to fly, rest assured that you are at very low risk of developing a problem. You can relax and do whatever you like to do on flights—snack, read, rest, or enjoy entertainment or games.

Stay hydrated and avoid excessive alcohol and caffeine, which are both dehydrating. And, if possible, get up and walk for a few minutes every two hours on a long flight, or do leg exercises, such as pumping your calves up and down, to prevent DVT.

If you develop any concerning issues while flying, let your flight attendant know right away.

People with heart disease are at higher risk for developing severe complications from COVID-19, so it's especially important for those with heart disease to wear a mask and practice social distancing while traveling.

Warning Signs

Complications can manifest with a variety of symptoms. Many of these might not turn out to be dangerous, but getting prompt medical attention can prevent serious consequences.

Symptoms to watch for:

Lightheadedness
Dyspnea (shortness of breath)
Angina (chest pain)
Palpitations (rapid heart rate)
Tachypnea (rapid breathing)

To prepare for health emergencies, the U.S. Federal Aviation Administration mandates that supplemental oxygen and an automated external defibrillator (AED) is on board for passenger airplanes that carry 30 passengers or more. Flight crews receive training in the management of in-flight medical emergencies and there are protocols in place for flight diversions if necessary.

A Word From Verywell

For most people who have heart disease , it is possible to fly safely as long as precautions are taken. Only 8% percent of medical emergencies in the air are cardiac events, but cardiac events are the most common in-flight medical cause of death.

This means that you don't need to avoid air travel if you have stable heart disease, but you do need to take precautions and be aware of warning signs so you can get prompt attention if you start to develop any trouble.

Hammadah M, Kindya BR, Allard‐Ratick MP, et al. Navigating air travel and cardiovascular concerns: Is the sky the limit? Clinical Cardiology . 2017;40(9):660-666. doi:10.1002/clc.22741.

Greenleaf JE, Rehrer NJ, Mohler SR, Quach DT, Evans DG. Airline chair-rest deconditioning: induction of immobilisation thromboemboli? . Sports Med. 2004;34(11):705-25.doi:10.2165/00007256-200434110-00002

American Heart Association. Travel and heart disease .

Ruskin KJ, Hernandez KA, Barash PG. Management of in-flight medical emergencies . Anesthesiology. 2008;108(4):749-55.doi:10.1097/ALN.0b013e31816725bc

Naqvi N, Doughty VL, Starling L, et al. Hypoxic challenge testing (fitness to fly) in children with complex congenital heart disease . Heart. 2018;104(16):1333-1338.doi:10.1136/heartjnl-2017-312753

By Richard N. Fogoros, MD Richard N. Fogoros, MD, is a retired professor of medicine and board-certified in internal medicine, clinical cardiology, and clinical electrophysiology.

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Planning to travel with atrial fibrillation.

Take extra care when planning trips if you're living with AFib.

Atrial fibrillation — also called AFib — is a common heart rhythm disorder. If you have AFib , you may have some concerns about traveling with your condition. But taking a few steps to prepare may help you have an enjoyable and worry-free trip.

Before you travel, ask your health care provider any questions you have about traveling with AFib . Ask if there is anything you need to consider before and during your trip.

Travel tips with atrial fibrillation

Remember these helpful tips:

Bring your medicines. Bring all of the medications you'll need for your trip. Keep them in your carry-on luggage.
Carry a list of your medicines. Having a list of your medicines will make it easier to refill them if you run out of them or lose them.
Take your time. Get to the airport early to give yourself plenty of time before your plane is due to depart. Anxiety can sometimes trigger irregular heartbeats.
Bring your care provider's phone number. Write the number on a piece of paper. Also store the number in your phone when you travel.
Ask about a medical alert bracelet. Your provider may recommend that you wear a medical alert bracelet that has information about your condition on it.
Take steps to prevent blood clots. During your flight, stand and walk when you can to prevent blood clots in your legs. Your health care provider also may recommend that you wear compression stockings.
Find medical centers close to your travel destination. Before your trip begins, learn where the closest hospital or doctor's office is at your destination. Find out what services your health insurance will cover. This can help prepare you in case of an emergency.
Check the contact information for embassies. If you're traveling internationally, bring the address and contact information of the U.S. embassies or consulates in the countries where you'll be staying. They can help with medical care in the area and offer general advice.
Buy travel health insurance. Buy travel health insurance and medical evacuation insurance before your trip in case of an emergency while traveling overseas.
Watch for side effects of blood thinners. If you're taking warfarin (Jantoven), you'll need regular blood tests to monitor its effects. Check with your provider to see if you'll need blood tests while you're away. If you take other types of prescription blood thinners, continue to take the medicine as directed.
Ask about high altitudes. If you're going to visit a high-altitude location, such as the mountains, check with your provider first. High altitudes may worsen some irregular heart rhythms. Your care provider may suggest that you rest and lower your activity level for several days after arriving at a high altitude. Also, watch for any new or unusual symptoms of your condition or of altitude sickness.
Get recommended vaccines. Know which vaccines are required at your destination.

It's important to follow your atrial fibrillation treatment plan. If AFib isn't well controlled, it may lead to complications, including strokes and heart failure. With some planning, you can enjoy your travels and live an active life with atrial fibrillation.

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Travel and heart disease. American Heart Association. https://www.heart.org/en/health-topics/consumer-healthcare/what-is-cardiovascular-disease/travel-and-heart-disease. Accessed Aug. 25, 2022.
Tuttle T, et al. High altitude, air travel and heart disease. https://www.uptodate.com/contents/search. Accessed Aug. 25, 2022.
Walls RM, et al., eds. High-altitude medicine. In: Rosen's Emergency Medicine: Concepts and Clinical Practice. 10th ed. Elsevier; 2023. https://www.clinicalkey.com. Accessed Aug. 25, 2022.
Atrial fibrillation: Living with. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/atrial-fibrillation/living-with. Accessed Aug. 25, 2022.
Pack smart. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/page/pack-smart. Accessed Aug. 25, 2022.
Travelers with chronic illness. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/page/chronic-illnesses. Accessed Aug. 25, 2022.
Before you travel. Centers for Disease Control and Prevention. https://www.cdc.gov/travel/page/BeforeYouTravelInternationally. Accessed Aug. 25, 2022.
Wang M, et al. Long-term high-altitude exposure does not increase the incidence of atrial fibrillation associated with organic heart diseases. High Altitude Medicine & Biology. 2021; doi:10.1089/ham.2020.0228.

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Air travel considerations for the patients with heart failure

Affiliations.

1 Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran.
2 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran.
3 Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran.
PMID: 25068047
PMCID: PMC4102980
DOI: 10.5812/ircmj.17213

Context: Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them are limited.

Evidence acquisition: We evaluated the conditions that may be encountered in a HF patient and provide the recommendations to prevent the exacerbation of cardiac failure during air travel. For this review article, a comprehensive search was undertaken for the studies that evaluated the complications and considerations of HF patients during flight. Data bases searched were: MEDLINE, EMBASE, Science Direct, and Google Scholar.

Results: HF patients are more prone to experience respiratory distress, anxiety, stress, cardiac decompensation, and venous thromboembolism (VTE) during air travel. Although stable HF patients can tolerate air travel, but those with acute heart failure syndrome should not fly until complete improvement is achieved.

Conclusions: Thus, identifying the HF patients before the flight and providing them proper education about the events that may occur during flight is necessary.

Keywords: Aerospace Medicine; Heart Failure; Stress; Travel; Venous Thromboembolism.

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Experiences of air travel in patients with chronic heart failure

a Carnegie Research Institute, Leeds Metropolitan University, Beckett's Park, Headingley, Leeds, LS6 3QS, United Kingdom

James Hobkirk

b Department of Cardiology, Hull York Medical School, Daisy Building, University of Hull, Castle Hill Hospital, Cottingham, Kingston-upon-Hull HU16 5JQ, United Kingdom

Thibaud Damy

Samantha nabb.

c Department of Sport, Health & Exercise Sciences, University of Hull, Cottingham Road, Kingston-upon-Hull HU6 7RX, United Kingdom

Andrew L. Clark

John g.f. cleland.

To conduct a survey in a representative cohort of ambulatory patients with stable, well managed chronic heart failure (CHF) to discover their experiences of air travel.

An expert panel including a cardiologist, an exercise scientist, and a psychologist developed a series of survey questions designed to elicit CHF patients' experiences of air travel (Appendix 1). The survey questions, information sheets and consent forms were posted out in a self-addressed envelope to 1293 CHF patients.

464 patients (response rate 39%) completed the survey questionnaires. 54% of patients had travelled by air since their heart failure diagnosis. 20% of all patients reported difficulties acquiring travel insurance. 65% of patients who travelled by air experienced no health-related problems. 35% of patients who travelled by air experienced health problems, mainly at the final destination, going through security and on the aircraft. 27% of all patients would not travel by air in the future. 38% of patients would consider flying again if there were more leg room on the aeroplane, if their personal health improved (18%), if they could find cheaper travel insurance (19%), if there were less waiting at the airport (11%), or if there were less walking/fewer stairs to negotiate at the airport (7%).

For most patients in this sample of stable, well managed CHF, air travel was safe.

1. Introduction

Air travel, for business, family or vacation, is part of modern life in Western societies. Lower costs, greater convenience of travel, and greater longevity mean that older, retired people now frequently wish to travel by air and many of these travellers will have chronic ailments, including chronic heart failure (CHF). Cabin pressure in modern airliners is set to that equivalent to an altitude of approximately 8000 ft (2438 m) above sea level, which gives a partial pressure of oxygen similar to that of breathing approximately 15% oxygen at sea level. In healthy people, this leads to an increased respiratory rate, and a reduction in arterial oxygen partial pressure (PaO 2 ) and arterial oxygen saturation [1–3] . Operation EVEREST III suggested that altitude-induced hypoxaemia led to an increase in heart rate, a decline in stroke volume, an increase in the atrial component of left ventricular filling and a progressive rise in pulmonary vascular resistance, all of which are of potential concern in patients with CHF [4] .

The assessment of flight risk has received little attention and we could identify few studies that have formally assessed the risk of air travel in CHF. We showed that in 21 patients with CHF (NYHA class III/IV), lying supine and breathing 15% oxygen for 1 h caused a drop in arterial oxygen saturation to 86% but patients remained asymptomatic throughout [5] . In a study of 38 patients with CHF, exercise testing at sea level and simulated altitudes up to 3000 m using a fraction of inspired oxygen (FiO 2 ) of 14% [6] did not result in any angina, arrhythmias or ECG evidence of ischaemia. At peak exercise at a simulated altitude of 3000 m, the most symptomatic patients had the largest decrease in both arterial oxygen saturation (SaO 2 , to 88%) and exercise capacity (to 66% of that attained at simulated sea level). The study concluded that patients with stable CHF who do not have effort-induced arrhythmia or myocardial ischaemia can safely ascend to altitudes of 3000 m. The effect of increased altitude on exercise capacity becomes greater the more severe the exercise limitations at sea level [6] .

We hypothesised that many CHF patients might not fly due to health concerns. We found no information regarding patients' experiences of air travel, whether they wanted to travel by air, what factors encourage or discourage them from air travel, and what problems they may have encountered during flight and at their destination. We conducted a survey in a cohort of patients with well-treated, stable CHF to find out about their experiences of air travel.

The Hull and East Riding Ethics Committee approved the study, and all patients provided informed consent prior to the survey. Patients were recruited from a community heart failure clinic serving the population of Hull and East Yorkshire. We contacted patients with a previous diagnosis of heart failure defined as the presence of appropriate symptoms, or a history of symptoms controlled by ongoing therapy, due to cardiac dysfunction in the absence of any more likely cause [7] . All patients had left ventricular systolic impairment on 2D echocardiography carried out by one of three trained operators.

An expert panel including a cardiologist (JGFC), an exercise scientist (LI), and a psychologist (SN) developed a series of survey questions designed to elicit CHF patients' experiences of air travel ( Appendix 1 ). The survey questions, information sheets and consent forms were sent together with a return self-addressed envelope to 1293 patients.

2.1. Statistical analysis

PASW (SPSS version 17.0) was used to analyse the data. Continuous variables are presented as mean ± SD, and categorical data are presented as percentages. An arbitrary level of 5% statistical significance was used throughout (two-tailed). We conducted an age-adjusted logistic regression analysis to determine which element of the journey was more likely to predict symptoms of breathlessness in our patients.

464 CHF patients (response rate = 39%) returned completed survey questionnaires. Table 1 shows baseline clinical characteristics of patients. 54% (252/464) of patients had travelled by air since their heart failure diagnosis. Of those who had flown, 21% had taken one flight, 25% 2 flights, 21% 3 flights, and 33% at least 4 flights ( Fig. 1 ). 60% of patients who had flown had visited countries within Europe, 12% had flown to Australia, and other longer-haul destinations included North America (10%); Africa (6%); and Asia (6%) ( Fig. 2 ). For patients who had not travelled by air, reasons for not travelling included medical concerns (33%), travel insurance problems (7%), and a proportion (27%) had no desire to travel abroad citing reasons such as “too old”, “too much hassle”, and “don't like flying” ( Fig. 3 ).

An external file that holds a picture, illustration, etc.
Object name is gr1.jpg

Number of air travel journeys since first diagnosis.

An external file that holds a picture, illustration, etc.
Object name is gr2.jpg

Furthest air travel destinations reported by CHF patients.

An external file that holds a picture, illustration, etc.
Object name is gr3.jpg

Reasons for not engaging in air travel.

Table 1

Baseline clinical characteristics in patients with chronic heart failure (mean ± SD or %).

Baseline data available in 174 of 464 patients (38% of total).

20% of all patients (93/464) reported difficulties acquiring travel insurance due to extra premiums being required. In some cases, insurance companies refused to insure patients due to the nature of their condition. 15% of patients who did fly did not tell their insurer about their cardiac condition, and 11% of patients travelled without any insurance.

3.1. Health problems whilst travelling

65% (163/252) of patients who flew experienced no health-related problems. 35% (89/252) of patients who flew experienced health-related problems. Fig. 4 shows the location of the problems experienced by the patients. 18% (46/252) experienced a problem at one location; 6% (16/252) experienced problems at two locations; 5% (13/252) experienced problems at three locations; 5% (12/252) experienced problems at more than three locations.

An external file that holds a picture, illustration, etc.
Object name is gr4.jpg

Venn diagram showing the location of health-related problems experienced by 89 patients with CHF during air travel.

Of the 89 patients who flew and experienced health problems, 9% (8/89) of patients reported problems going through security at the airport due to pacemaker/ICD problem and breathlessness. During the flight, 9% (8/89) of patients experienced breathlessness, dizziness, swollen ankles, headache, and chest pain. 3 of 8 patients used in-flight oxygen due to breathlessness. At the final destination, 25% (22/89) of patients complained of health-related cardiovascular problems including fatigue, breathlessness, laboured walking, swollen ankles, palpitations, angina, or their defibrillator firing (2 of 22 patients). Following an age-adjusted logistic regression analysis, the final destination was a better predictor of self-reported symptoms of breathlessness than other travel points (i.e. to security, to the flight gate, during air travel, during disembarkation) in our patients ( P = 0.047; Hazard Ratio = 0.16; 95% confidence interval = 0.30–0.97).

3.2. Views on future air travel

27% (125/464) of all patients that we surveyed would not fly in the future. 32% (148/464) stated that it was too difficult, 25% (116/464) of patients were worried about their health, 23% (107/464) had no wish to travel by air, and 11% (51/464) had no insurance cover. 38% (176/464) of all patients stated that they would consider flying again if there were more leg room/more comfort on the aeroplane during the flight, if their personal health improved (18%; 84/464), if they could find cheaper travel insurance (19%; 88/464), if there were less waiting at the airport (11%; 51/464), and if there was less walking/fewer stairs to negotiate at the airport (7%; 32/464) ( Fig. 5 ).

An external file that holds a picture, illustration, etc.
Object name is gr5.jpg

Factors that would increase likelihood of future air travel in CHF patients.

46% (212/464) of all patients surveyed had not travelled by air since their diagnosis. 37% (79/212) would consider flying in the future if there were more leg room/comfort on the plane (38%; 30/79), if travel insurance were cheaper (22%; 17/79), if their health improved (18%; 14/79), and if there were less waiting time at the airport (10%; 8/79). 54% (252/464) of all patients surveyed had travelled since their diagnosis. 36% (91/252) would fly again if there were more leg room/comfort on the plane (37%; 34/91), if their health improved (20%; 18/91); if travel insurance were cheaper (19%; 17/91), and if there were less waiting time at the airport (13%; 12/91).

4. Discussion

Our study is the first to gauge heart failure patients' experiences of air travel. We have found that the majority of CHF patients who have flown since a diagnosis was made did not report any health-related problems. This finding is in agreement with the few published experimental studies which suggested that simulated flights did not produce complications in heart failure patients [5,6] , and the recently published expert consensus statement [8] . Indeed, we found that there were more health-related problems at the final destination (25% of flying patients) than there were during flight itself (9% of flying patients).

We have found that problems of air travel are not confined to hypoxia. Although we have not specifically asked about the following, considerable exertion is required to walk to and from the plane at the airport, especially if suitcases have to be carried. Take-off and landing in particular may cause stress and anxiety. Implanted devices may cause concerns at security points. Drug therapy may cause a variety of problems including diuretics (toilet access), anti-coagulants (change in diet), ACE inhibitors and aldosterone antagonists (fluid balance due to sweating and diarrhoea). Travel advice needs to recognise these issues in CHF patients.

Recently, Smith and colleagues [8] produced an expert consensus statement on fitness to fly for passengers with cardiovascular disease: they concluded that in CHF, short-term (up to 1 h) exposure to a hypoxic environment produces no significant adverse effects (including patients with NYHA class III/IV symptoms) at rest. Longer-term hypoxic exposure (up to 7 h) can be tolerated in patients with mild-to-moderate stable CHF [8] . The authors also reported that the aircraft could be considered a “relatively alien, restrictive and hostile environment” (p. ii1). The patients that we surveyed would appear to agree. 37% of patients reported that they would only consider flying again if aircraft were more comfortable i.e. having more leg room.

In our study, 32% of patients reported that they would never fly again because it was too “difficult”. Up to 40% of the population have reported a fear of flying [9] which may have been heightened by an increased perception of terrorist activity since 2001 [10] . These factors amongst others may have been concerns for our patients. 11% of patients stated that they were more likely to fly again if there were less waiting time at the airport terminal. Patients are often advised to arrive at the airport in plenty of time to avoid rushing and to give the airline notice of special requirements such as wheelchair access or supplementary oxygen [8] . Longer waiting times can cause frustration and anger for some patients at the airport [11] . Strike and colleagues [12] reported that anger is one of the precursors that can provoke myocardial ischaemia in stressful situations. Further, 6% of patients stated that the long walks around the airport caused breathlessness and 7% would not fly again due to the amount of walking required. The amount of walking around the airport terminal, perhaps with heavy luggage, and in conjunction with staircase-use, may cause deterioration in the patients' condition [8] . Whilst many airports offer excellent transport services for “disabled” passengers — many patients may not be aware of these services or how they can book them prior to arrival at the airport.

We recommend that more experimental work is required to find out if flying is really safe in patients with CHF. Current findings would appear to suggest that short- to longer-term hypoxic exposure is safe in most stable heart failure patients.

4.1. Limitations

Demographic data including age, sex, BMI, LVEF, drug therapy, and aetiology of CHF was collected in 174 of 464 patients (38% of total) due to a printing error with an initial batch of questionnaires.

A limitation of the postal survey is selection bias, often only patients with strong positive or negative experiences will respond.

Within the survey we did not ascertain what family doctors had actually told patients regarding their suitability for air travel. Lainscak and colleagues [13] reported that recall of, and adherence to medical advice was disappointing in a large pan-European cross-sectional survey of 3261 CHF patients. Therefore, it is possible that some of our patients may have misinterpreted medical advice from their family doctor regarding their suitability to undertake air travel.

5. Conclusions

Ours is the first study to document CHF patients' experiences of air travel. Health-related problems were only experienced in a minority of patients, therefore, we can conclude that air travel is safe in stable, well managed CHF patients. Future air travel experiences could be improved if flying were more comfortable, travel insurance were cheaper, and there were less waiting time and less walking at airports.

Conflict of interest

Financial disclosures.

This study was supported by the British Heart Foundation.

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [14] .

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Some people with heart failure find that they may become more reluctant to travel or go on holiday due to their condition. Travelling and being in unfamiliar surroundings with a change in routine may cause anxiety for you or your carer. However, if you’re well prepared and organised there is no reason why you shouldn’t be able to continue to travel safely if you wish.

Taking medicines on holiday
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ESC Guidelines for Heart Failure

What patients need to know.

This guide for patients from the European Society of Cardiology aims to provide an overview of the latest evidence-based recommendations for the diagnosis and treatment of heart failure.

In particular, it should help patients to understand the:

main types of heart failure
medicines used to treat heart failure
devices that may be appropriate
importance of rehabilitation
management by a multidisciplinary team
importance of self-care in managing your own condition

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Air travel considerations for the patients with heart failure.

Author information, affiliations.

Alemzadeh-Ansari MJ 2
Kazemisaleh D 3
Moshkani-Farahani M 3

ORCIDs linked to this article

Alemzadeh-Ansari MJ | 0000-0003-4698-3244
Moshkani-Farahani M | 0000-0003-4902-273X

Iranian Red Crescent Medical Journal , 05 Jun 2014 , 16(6): e17213 https://doi.org/10.5812/ircmj.17213 PMID: 25068047 PMCID: PMC4102980

Abstract

Evidence acquisition, conclusions, free full text , air travel considerations for the patients with heart failure, morteza izadi.

1 Health Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran

Mohammad Javad Alemzadeh-Ansari

2 Department of Cardiology, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, IR Iran

Davood Kazemisaleh

3 Department of Cardiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran

Maryam Moshkani-Farahani

Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them are limited.

Evidence Acquisition:

We evaluated the conditions that may be encountered in a HF patient and provide the recommendations to prevent the exacerbation of cardiac failure during air travel. For this review article, a comprehensive search was undertaken for the studies that evaluated the complications and considerations of HF patients during flight. Data bases searched were: MEDLINE, EMBASE, Science Direct, and Google Scholar.

HF patients are more prone to experience respiratory distress, anxiety, stress, cardiac decompensation, and venous thromboembolism (VTE) during air travel. Although stable HF patients can tolerate air travel, but those with acute heart failure syndrome should not fly until complete improvement is achieved.

Conclusions:

Thus, identifying the HF patients before the flight and providing them proper education about the events that may occur during flight is necessary.

Approximately two billion passengers undertake international and domestic air travels every year. Today, traveling by airplane has become increasingly common and accessible ( 1 , 2 ). There are some cardiovascular conditions that air travel could be worsen the patient condition such as decompensate heart failure (HF). Although given the right aircraft, on-board equipment and appropriately qualified and experienced escort personnel, aircraft can act as flying intensive care units and carry extremely ill travelers ( 3 ). However our ability to care for patients with cardiovascular diseases improves, an increasing number of people with cardiovascular diseases will be traveling long distances. In the other hand, despite availability of new therapies, the prevalence of HF and hospital admission rates have increased and the World Health Organization has recognized HF as an epidemic condition in this century ( 4 , 5 ). The 2012 statistics from the American heart association list HF as one of the leading cause of hospitalization and death in United States and Europe ( 6 ). Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 ( 7 ). Statistics showed that prevalence of HF in US adults (age more than 18 years) in 2010 was about 6.6 million (2.8%) and estimated that this increase in future and reach about 9.6 million people in 2030 (25% increase in prevalence) ( 6 ). Despite increasing the prevalence of patients with HF in the world and attention to this point that these patients are more prone to experience problems contributed air travel and requires more attention during flight, but there is little research to guide recommendations for HF patients wishing to travel by plane. Thus, in this study, we tried to evaluate the considerations for prevention of worsening of cardiac failure during flight based on the available evidences.

2. Evidence Acquisition

A comprehensive search was undertaken using MEDLINE database for the studies and guidelines that evaluated complications and considerations of HF patients during flight. Our search included the MESH headings heart failure, cardiac failure, congestive heart failure, and heart decompensation. We also searched under the MESH headings travel, aerospace, medicine, and transportation, and the text words flight and flying. We sought additional articles by performing the same search strategy in the databases of EMBASE, Science Direct, and Google Scholar. We then combined all searches and removed the duplicate articles. The total number of potential articles in primary search was 144 studies. We excluded irrelevant articles by reading their title and abstract. Finally, 39 studies were used for this review article. Two of our 4 authors reviewed studies independently and discrepancies were resolved by discussion.

3.1. Effect of Cabin Pressure on Heart Failure Patients

Cabin pressure can affect the health of travelers in many ways, including hyobaric hypoxia affecting those with pre-existing HF, chronic obstructive pulmonary disease, or haematological disorders. Commercial flights usually cruise at altitudes of 7010-12498 meter above sea level; however the passenger cabin is pressurized to an altitude of 1524-2438 m ( 8 - 10 ). Most healthy individuals tolerate this cabin pressure ( 11 ). Cabin pressurization to 2438 m lead to reduction in the atmospheric pressure of the cabin. Thus at the maximum cabin altitude of 2438 m, the arterial oxygen partial pressure (PaO2) decrease from 95 mmHg to 60 mmHg ( 12 ). In healthy travelers, these pressures lead to a 3-4% decrease in systemic oxy-hemoglobin saturation ( 9 , 13 ). However, many travelers with pre-existing diseases such as HF, chronic obstructive pulmonary disease, or hematological disorders have a reduced baseline PaO2, so reduced cabin pressure leads to further reduction of oxygen saturation. This condition was worsen with increasing flight times ( 11 , 12 ). For example, a recent study showed that travelers with HF significantly experience more respiratory distress during flight than other travel (HR: 0.16; 95% CI: 0.30 - 0.97) ( 14 ).

Some methods are available to assess the need for oxygen during flight. Hypoxic-challenge test is a good method to assess whether travelers with pre-exciting disorders require oxygen during flight. The maximum cabin altitude of 2438 m can be simulated at sea level with a gas mixture containing 15% oxygen in nitrogen. Individuals breathe the hypoxic gas mixture for 20 min during the test oxygen saturation is monitored. Furthermore, arterial blood gases are measured before and at the end of the test. If PaO2 drops below 50 mmHg, or, if the oxygen saturation drops below 85%, the traveler would need oxygen during flight ( 11 ). A recent study showed that patients with stable chronic HF in NYHA functional class II or III on stable treatment could tolerate inspiring 15% oxygen for one hour and no worsening of symptoms were occurred despite reductions in arterial oxygen saturation and increases in mean arterial pressure and systolic pulmonary artery pressure ( 15 ). The guidelines from the British Thoracic Society suggest hypoxic-challenge testing in HF patients who are hypoxemic at sea level, especially those with coexistent lung or pulmonary vascular disease ( 16 ). The guidelines of Aerospace Medical Association suggest hypoxic-challenge testing as the gold standard for suspicious travelers. These guidelines recommend using oxygen during flight for stable HF travelers with a sea-level PaO2 of 70 mmHg or lower, or with an expected PaO2 of 55 mmHg or lower during flight ( 17 ). Cabin pressure also could be affected gas in body cavities. Base on Boyle’s law, the volume that a gas occupies is inversely proportional to the surrounding pressure. Thus, with altitude increase, the low cabin pressures cause to expansion of gas trapped in body cavities up to 30% ( 10 , 11 ). Against healthy travelers that this expansion can result in minor abdominal cramping or baron-trauma to the ears, the travelers who have undergone recent surgical procedures are at increased risk of problems related to gas expansion such as bowel perforation or wound dehiscence ( 18 , 19 ). In addition, stretching gastric or intestinal mucosa may result in hemorrhage from ulcer ( 17 ). Abdominal bloating is a common complain of patient with right sided-HF ( 20 ), and more intestinal gas expansion at altitude could cause additional discomfort in patient with HF. For this reason, it is prudent to avoid gas-producing foods in the days before a scheduled flight or during flight.

3.2. Stress of Air Travel

Stress and anxiety is more common in patients with HF ( 21 ). About 40% of patients with HF may suffer from major anxiety, and overall anxiety levels are 60% higher than levels seen in healthy elders. The patients with HF, compared with other patients with cardiac disease and patients with cancer or lung disease have similarly high or worse anxiety levels ( 21 , 22 ). Moreover, anxiety may affect the outcomes of patients with HF. Riedinger et al. documented that anxiety was associated with a higher incidence of adverse cardiac events and cardiac death in the subsequent 6-10 years, among patients with recent acute myocardial infarction and decreased LVEF ( 23 ). In another study, De Jong et al. showed that HF patients with high anxiety had a shorter (HR: 2.2; 95%CI: 1.1-4.3) period of event-free survival than patients with lower anxiety ( 24 ). In the other hand, anxiety during flight is a common phenomenon, even in healthy travelers. About 40% of travelers experience the anxiety during take-off and landing ( 25 ). The patients with HF are more susceptible to increased sympathetic activity with altitude exposure, resulting in hemodynamic changes including vasoconstriction and tachycardia as well as release of inflammatory mediators ( 26 ). Increases in sympathetic activity cause to increase in the systemic vascular resistance, blood pressure, and heart rate ( 27 ). Also, some studies have shown that patients evacuated by helicopter and fixed-wing aircrafts experienced increased anxiety and heightened levels of catecholamine during flight ( 28 ). These changes in patients with HF may cause to cardiac decomposition, especially in those with pre-exciting anxiety disorder. Moreover, preflight activities can cause patients with compromised heart activity to overexert their body; which this may happen because of patients trying to meet time constraints and carrying heavy baggage through check-in or the long walking distance to and from their gate areas ( 29 ). Some considerations for control of anxiety during flight was recommended such as providing information about theory of flight and flight safety, and training relaxation techniques including simple breathing techniques, guided visualization, and progressive muscle relaxation ( 30 ).

3.3. Dehydration During Prolonged Flight

The relative humidity in the cabin gradually falls on high altitude and prolonged flights ( 31 ). Low humidity within the cabin of plane coupled with decreased fluid intake causes dehydration contribute to the deleterious effect of air travel on cardiac patients by effectively decline preload and subsequently cardiac output. The noticeable effect of low humidity on travelers such as drying of the skin and mucous membranes are present after 3-4 hours of flight ( 32 ). A study showed that low humidity in prolonged air travel can cause to increase in mean plasma osmolarity, mean urine osmolarity and urine specific gravidity, indicating dehydration ( 33 ); whereas some studies did not confirmed dehydration secondary to low humidity ( 34 , 35 ). Moreover, alcohol or coffee drinking (which promotes diuresis), together with the lower humidity of the cabin, may lead to some degree of dehydration ( 31 , 36 ). Although, most healthy individuals tolerate this dehydration during prolonged flight, but in HF patients especially those receiving diuretics, imbalance of fluid-electrolyte may occurred. Thus, they should be particularly careful about their salt intake and avoid excess consumption of alcohol or coffee.

3.4. Patients With Acute Heart Failure Syndrome Who Planning Air Travel

In general, acute heart failure syndromes (AHFS) can be defined as the new onset or recurrence of gradually or rapidly developing symptoms and signs of HF requiring urgent or emergent therapy and resulting in hospitalization. A variety of other overlapping terms have been used in the literature, including Acute HF, acute decompensated HF, and acute decompensation of chronic HF. AHFS is likely to increase in the future, and the high readmission rate of patients with Acute HF is an important issue in the world ( 37 ), despite improved rates of in-hospital mortality. The readmission rate of patient with HF is a high; 50% at 6 months ( 38 ). An important cause of AHFS is an acute coronary syndrome. However, improvements in the management of patients with acute coronary syndrome were associated with significant reductions in the rates of new-onset HF and mortality ( 39 ). The VALIANT study assessed the incidence of and prognostic factors for HF hospitalization among survivors of high-risk acute myocardial infarction. In this study, 1489 patients who died or experienced a non-fatal cardiovascular event (including HF) within the first 45 days and 2174 patients with prior history of HF were excluded. This large study showed that of remain 11040 stable post-myocardial infarction patients, 1139 (10.3%) developed new-onset HF during the median 25-month follow-up; and the most important predictors of HF were older age, antecedent diabetes, prior MI before index MI, and reduced renal function ( 40 ). The British Cardiovascular Society divided the travelers who have suffered an acute coronary syndrome based on LVEF into three groups: very low risk, medium risk, and high risk. Very low risk group include the patients with EF more than 45%. Also they had age below than 65 years with the first event, successful reperfusion, no other complications, and no planned investigations or interventions. Medium risk group included patients with EF more than 40% with no symptoms of HF, no evidence of inducible ischemia or arrhythmia, and no further investigations nor interventions planned. High risk group referred to patients with EF less than 40% with signs and symptoms of AHFS. Also these patients wait to further investigation with a view to re-vascularisation or device therapy. This report recommended safely flights as early as 3 days after the event for very low risk group, flights from 10 days onwards for medium group. But, those at high risk or awaiting further investigation/treatment, flying should be deferred until a more stable situation is achieved ( 3 ). Except acute coronary syndrome, episodes of AHFS may be provoked by anemia or infection on the background of chronic HF. When the patients with AHFS are identified and treated, most cases should be stabilized within 6 weeks and should be safe to fly ( 3 ). Regardless of etiology of AHFS, other references emphasis that the decompensated HF is one of the contraindication of air travel ( 16 , 17 , 41 , 42 ). The British Thoracic Society also confirmed above data and recommended that if air travel cannot be avoided for the patients with decompensated HF, they should have oxygen during flight ( 16 ). However in this condition, right aircraft, on-board equipment and appropriately qualified and experienced escort personnel should be provided ( 3 ).

3.5. Patients With Stable Chronic Heart Failure Who Planning Air Travel

Travelers with stable chronic HF without recent changes in symptoms or medication are likely to be able to tolerate the mild hypoxia of the aircraft cabin environment even if they have very low LVEF ( 14 , 15 , 43 ). Ingle et al. in a study conducted a survey in a representative cohort of ambulatory patients with stable, well managed chronic HF to discover their experiences of air travel. Results showed that 65% of patients with HF who travelled by air experienced no health-related problems, although 35% of them experience health problems such as breathlessness, dizziness, swollen ankles, headache, and chest pain, mainly at the final destination ( 14 ). The British Thoracic Society recommended that patients with stable HF who are hypoxemic at sea level with coexistent lung or pulmonary vascular disease should be considered for Hypoxic-challenge test. Also they suggested that if patients with stable HF in NYHA functional class I-III (without significant pulmonary hypertension) can fly without oxygen ( 16 ). However the Aerospace Medical Association advised in-flight medical oxygen for stable patients with NYHA functional class III-IV HF or baseline PaO2 less than 70 mmHg ( 17 ). The British Cardiovascular Society regarded the time of flight and suggested that, for patients with stable HF including NYHA functional class III and IV, short-term (up to 1 hour) hypoxia at rest produces no significant worsening effects; and periods of up to 7 hours are tolerated by those with mild to moderate stable HF (NYHA functional class II) ( 3 ).

3.6. Association of Venous Thromboembolism and Heart Failure During Air Travel

Chronic HF has long been proposed as a risk factor for venous thromboembolism (VTE) ( 44 ). This association relates to abnormal and slow flow patterns in dilated, poorly contracting cardiac chambers, which causes to venous stasis resulting mural thrombi. This may predispose to the development of VTE as well as peripheral arterial emboli. Thus, patients with worsening left ventricular systolic function are more prone to risk of thromboembolic events. Howell et al. indicated HF is an independent risk factor for VTE, and the risk increases markedly as the EF decreases. They found that a LVEF between 20% and 44% was associated with an increased risk of VTE, with an odds ratio of 2.8 (95% CI 1.4–5.7%); and LVEF less than 20% was associated with an odds ratio of 38.3 (95%CI 9.6–152.5%) for VTE ( 45 ). Dries et al. showed that the overall annual incidence of thromboembolic events were more in women with HF (2.4% in women vs. 1.8% in men). Also on multivariate analysis, they observed that a decline in LVEF independently associated with thromboembolic risk in women (relative risk per 10% decrease in LVEF 1.53, 95% CI 1.06-2.20), but no relation was observed in men ( 46 ). In the other hand, a direct relation between VTE and long-distance air travels has been documented in previous studies. Kuipers et al. in a systematic review showed that the long-distance travel increased the risk of VTE approximately 2 to 4-fold ( 47 ). Chandra et al. in a meta-analysis found that travel is associated with a 3-fold higher risk for VTE, with a dose-response relationship of 18% higher risk for each 2-hour increase in travel duration ( 48 ). The WRIGHT project in phase 1 reported that long-distance air travel (more than 4 hours) approximately doubled the risk of VTE. The absolute risk of VTE per more than 4 hour flying, in healthy individuals, is 1 in 6000, rising to about 1 to 1000 travelers for frequent flights (were taken in the four–week exposure period) and longer journeys ( 49 ). According to above data, it can be concluded that patients with HF who are planning for air travel are at higher risk of VTE. Based on current guidelines, there are general recommendations for preventing VTE during flight including perform regular leg exercises (e.g. ankle movements, isometric exercises, and walking), avoid excessive alcohol consumption, and avoid the use of tranquillizers and sleeping pills whilst sitting position ( 50 - 53 ). The Aerospace Medical Association considered the patient with uncontrolled HF as a moderate risk. Another study divided travelers with HF base on their LVEF. The patients with LVEF between 20% and 44% was considered as a moderate risk group for VTE and those with LVEF less than 20% was categorized as a high risk group. This study was recommended compression stockings, mobilization, hydration, and aisle seating for moderate risk group; and additional one injection of low-molecular-weight heparin prior to flight in those not currently treated with warfarin for high risk group ( 41 ).

3.7. Other Considerations for Heart Failure Patients Who Planning Air Travel

It was recommended that all patients with HF should first consult their doctors before traveling, and if they are to attempt a prolonged air travel, must be able to walk 100 yards and climb 12 steps ( 54 ). The HF patients may also be more prone to the symptoms of altitude sickness such as shortness of breath and profound fatigue ( 55 ). Patients with HF must carry a list of their medications using the generic name and dosages for each drug. It would be better that they bring extra medications and store them in carry-on luggage for the flight. A baseline electrocardiogram and the name and address of the patient’s treating physician should be carried. Furthermore, it will be very helpful to the evaluating physician that the patient carry a brief letter from the patient’s physician describing the traveler’s medical problems. Patients with cardiac pacemaker or implantable cardioverter defibrillator could be safely fly and will not be affected by airline metal detectors ( 56 ); although in rare cases, these devises may set off airport metal detectors ( 41 ). These patients should carry a copy of wallet card identifying type of pacemaker or implantable cardioverter defibrillator and those with pacemaker should carry a copy of their electrocardiogram with and without pacing ( 41 , 55 , 57 ).

3.8. Study Limitations

This review article has some limitations. First, we just searched English articles published in the selected databases and did not search for articles in other languages. Second, we used limited internet databanks and just used references which were available in full text.

4. Conclusions

The patients with HF are more prone to experience problems contributed air travel and needs more attention during flight. Altitude and cabin pressure causes to hyobaric hypoxia resulting reduced arterial oxygen partial pressure and more respiratory distress in HF patients. The hypoxic-challenge testing was suggested for HF patients who are hypoxamic at sea level, especially those with coexistent lung or pulmonary vascular disease. Also, in-flight oxygen for stable HF travelers with a sea-level PaO2 of 70 mmHg or lower, or with an expected PaO2 of 55 mmHg or lower during flight was recommended. The HF patients are more susceptible to experience anxiety during flight resulting in hemodynamic changes including vasoconstriction, tachycardia, and subsequently decompensated HF. Thus, training relaxation techniques are more necessary to these travelers. Attention to salt intake and avoid excess consumption of alcohol or coffee in HF patients in order to prevention of dehydration is essential. Although stable HF patients, even in NYHA functional class III or IV, can tolerate air travel, but those in the stage of AHFS should not fly until complete improvement is achieved. Patients with HF are prone to experience VTE following prolonged air travel, especially those with lower LVEF. Also, patients with HF should first consult their doctors before traveling, and carry a list of their medications, extra medications and store them in carry-on luggage, a baseline electrocardiogram, and the name and address of the own physician. Thus, identifying these patients before flight and proper education to them about the events that may occur during flight is necessary. Also physicians at the airport and crew in plane should be aware about the problems that may occur for these patients, to take the necessary action at the right time. This review article evaluated the complications of HF patients and also reviewed the considerations to prevent the exacerbation of cardiac failure during flight. However, to achieve better results, further investigations, especially randomized clinical trials studies are needed.

Acknowledgments

The authors sincerely thank Dr. Akbar Shafiee at Tehran Heart Center, Tehran University of Medical Sciences for his assistance in the revision of this work. The authors would like to extend their thanks to Mr. Javad Hoseinpour at Baqiyatallah University of Medical Sciences for his help in editing this manuscript.

Implication for health policy/practice/research/medical education: Prevalence of patients with heart failure (HF) is increasing in the world, and also the number of people with HF will be traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. Observational studies about problems of HF patients during flight and appropriated considerations for them are limited; thus, herein we tried to evaluate the problems that may be encountered in a HF patient and provide the recommendations for prevention of worsening of cardiac failure during air travel.

Authors' Contributions: Study concept and Design, Morteza Izadi, Mohammad Javad Alemzadeh-Ansari; Acquisition of data, Mohammad Javad Alemzadeh-Ansari, Morteza Izadi; Analysis and interpretation of data, Mohammad Javad Alemzadeh-Ansari, Morteza Izadi, Davood Kazemisaleh, Maryam Moshkani-Farahani; Drafting of the manuscript: Mohammad Javad Alemzadeh-Ansari; Critical revision of the manuscript for important intellectual content, Morteza Izadi; Statistical analysis, Mohammad Javad Alemzadeh-Ansari; Administrative, technical, and material support, Morteza Izadi, Davood Kazemisaleh; Study supervision, Morteza Izadi, Davood Kazemisaleh, Maryam Moshkani-Farahani.

Funding/Support: This study was supported by Health Research Center of Baqiyatallah University of Medical Sciences.

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How to fly with a wheelchair

Can you check a wheelchair on an airplane, how to pack a wheelchair for flight, accessible policies for those traveling with a wheelchair, broken down by airline, if you’re bringing a wheelchair on a plane.

Traveling on a plane can be a stressful endeavor, whether you’re bringing a checked bag, a whole family or extra equipment to get around. But for those who make use of a wheelchair, air travel is becoming more accessible than ever before.

Because of updated U.S. Department of Transportation policies, as well as innovations from certain airlines, flying with a wheelchair is becoming easier.

Let’s take a look at how the process works, what bringing a wheelchair on a plane entails and what changes are helping to make air travel for wheelchair users a better experience.

Air travel is meant to be accessible to everyone. Whether a traveler uses a wheelchair full time or requires one only to navigate through the airport, accessibility services are available to them.

Requesting a wheelchair at the airport

Airlines are required to provide prompt aid to passengers needing additional assistance. This includes those who need a wheelchair to get around, and you are allowed to request one for use in the airport. If this is the case for you, you’ll want to advise the airline as early as possible.

Once you arrive at the airport, you’ll need to let the airline know that you require a wheelchair.

Bringing your own wheelchair

There are a couple of extra conditions to be aware of if you’re traveling with your own wheelchair. You can fly with a power wheelchair, but the DOT’s guidance page notes that you’ll need to arrive an hour before standard check-in time.

You can stay in your own wheelchair until you get to the gate. At this point, if your chair will not fit in the cabin, it will be taken and checked.

If necessary, the airline will then provide an aisle chair to help you get to your seat. Once landed, your wheelchair will be waiting for you at the gate.

» Learn more: What everyone can learn from a traveler with a disability

Yes, you can check a wheelchair on a plane. This is the case for both manual wheelchairs and powered wheelchairs. Checking your medical equipment is free of charge.

However, note that some aircraft may have limitations when it comes to accepting powered wheelchairs due to their size. For example, United Airlines has recognized this and created new policies to address it (more on that below).

There are no special requirements necessary if you’re bringing your wheelchair on your flight. Eligible manual wheelchairs can be stowed in the cabin of the aircraft, whether that’s in the storage bin above you, under the seat in front of you or in the designated wheelchair storage area onboard the plane.

If your wheelchair doesn’t fit or uses a battery, it’ll be taken and checked into the cargo area for free.

In this case, we recommend labeling your wheelchair with your name and contact information and attaching any relevant handling or disassembly instructions.

Traveling with a wheelchair can be more complicated than you’d expect, which is why the government and certain airlines are adopting new strategies to help ensure dignity and respect for everyone.

U.S. DOT accessibility policies

The DOT has published its Bill of Rights for passengers with disbilities , which includes the right to be treated with dignity and respect, the right to accessible facilities and the right to travel with an assistive device, among other rights.

Generally speaking, it's free to check your wheelchair or mobility device in addition to your checked bags. This includes wheelchairs (manual or electric) as well as scooters, walkers, canes and crutches.

Note that devices must meet airline battery and safety requirements.

The DOT has also enacted a rule that will require single-aisle aircraft to provide an accessible lavatory.

» Learn more: New federal rules require more accessible airplane lavatories

American Airlines wheelchair assistance

American Airlines asks passengers to submit assistance requests in advance because after you’ve done so, a coordinator will contact you directly to ensure everything is ready for your trip.

The airline will also work with you to book the right seat if you need extra space or have specific mobility needs.

How to get a wheelchair at the airport for American Airlines

To request wheelchair assistance, select the “Add special assistance” option during booking or in “Manage Trips” from the airline’s home page after logging in to your account. You can also request assistance by calling 800-237-7976.

Delta wheelchair assistance

Delta Air Lines has debuted a prototype airline seat that allows powered wheelchair users to remain in their own seat during the flight. This is still some way off from being implemented in aircraft, but it’s nice to see that the airline is making strides to become more accessible.

How to get a wheelchair at the airport on Delta

You can request wheelchair service in your Delta SkyMiles account after booking your flight, under “My Trips.” You can also call the airline at 404-209-3434.

Southwest Airlines wheelchair assistance

You do not need to notify Southwest before arriving at the airport to receive disability-related assistance. The airline offers an online Accessible Travel Assistance hub to streamline planning, and while it prefers your wheelchair is stowed on board as a carry-on, it is possible to gate check your device for cargo.

How to request wheelchair at airport for Southwest

Simply ask any Southwest employee and they will guide you through the necessary steps. There are steps to do this in advance if you prefer, including calling 800-I-FLY-SWA (800-435-9792).

United Airlines wheelchair assistance

For its part, United Airlines has announced a change to its search system that’ll greatly simplify the process for those who use powered wheelchairs.

While the new system isn’t live yet, the updated search feature will include the ability to input the dimensions of your wheelchair. Doing so allows you to weed out aircraft with cargo doors that won’t accommodate the size of your wheelchair.

Even better, if your preferred flight cannot accommodate your wheelchair, you can book a different flight on the same day — and if it’s more expensive, United will refund you the difference.

How do I request a wheelchair on United Airlines?

You can request a wheelchair for your flight or airport experience in the traveler information section at booking or in your MileagePlus account under “My Trips” after you’ve purchased your ticket.

» Learn more: What I’ve learned as a disabled traveler

Airports and airlines are becoming better suited to passengers with disabilities who are traveling, including those who use a wheelchair. Whether you need one to navigate the airport or are bringing one from home, new regulations and policies have been established to ensure that your travel experience is as seamless as possible.

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IMAGES

Air Travel for Heart Failure Patients and Caregivers
Traveling Safely With Heart Failure
Heart Failure: Causes and Risk Factors
Heart Failure: Definition, Types, Causes, Symptoms & Treatments
Heart Failure: Introduction and Types
Heart Failure Infographic makes understanding heart failure clearer

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Heart failure? How to manage unexpected challenges
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Air Travel for Heart Failure Patients and Caregivers
Air travel. Air travel isn't usually a problem for people with heart failure even though oxygen levels are slightly lower - even in pressurised commercial aircraft cabins. However, some people may sometimes need supplemental oxygen during the flight. Generally, if your heart failure is well-controlled and stable, you shouldn't have any ...
Travelling with heart failure: risk assessment and practical ...
Chronic stable heart failure. NYHA class I-II: travel advisable, if patient is stable. NYHA class III: travel advisable, if patient is stable; consider use of on-board medical oxygen during air ...
Guidelines for Flying With Heart Disease
Air travel is generally safe for heart patients, with appropriate precautions. If you have heart disease, you can fly safely as a passenger on an airplane, but you need to be aware of your risks and take necessary precautions. Heart conditions that can lead to health emergencies when flying include coronary artery disease (CAD), cardiac ...
Air Travel Considerations for the Patients With Heart Failure
Patients With Stable Chronic Heart Failure Who Planning Air Travel. Travelers with stable chronic HF without recent changes in symptoms or medication are likely to be able to tolerate the mild hypoxia of the aircraft cabin environment even if they have very low LVEF (14, 15, 43). Ingle et al. in a study conducted a survey in a representative ...
Travel and Heart Disease
Sitting immobile on long plane flights or car, train or bus rides can slightly increase a normal person's risk of blood clots in the legs, but associated medical issues usually contribute to it. If someone has peripheral artery disease (PAD) or a history of heart failure, the clot risk increases. Recent surgery, older age and catheters in a ...
PDF Fitness to fly for passengers with cardiovascular disease
complicated or symptomatic, see heart failure You have had heart bypass surgery and time must be allowed for any air in the chest to be absorbed Fly after 10 days if no complications. If symptomatic, follow guidance for speciﬁc symptoms Acute heart failure You have been in hospital or treated at home because of 'water in the lungs'
PDF My Marvellous Guide to Travelling with Heart Failure
• Unsatisfactory control of heart failure • Unconolled tr arrhythmia • Unpredictable angina • Haemoglobin levels below 7.5g/dl • Currently have a transmittable infectious disease • Experience psychotic illness • Have recently been hospitalised due to heart failure Air Travel Medically Fit to Fly
Is heart failure an obstacle to air travel?
Rapid increasing trend in air travel brings necessity of urgent approach to health situations such as heart failure (HF). The prevalence of HF was projected to be more than 8 million patients ≥18 years of age in 2030; Main factors that contribute to physiological changes to cardiovascular system during a flight are changes in cabin pressure, humidity, stress, prolonged mobility.
Approach to patients with heart disease who wish to travel by air or to
The duration of travel, ascent profile, degree of exertion, and any prior cardiovascular history can each impact the health of a patient with cardiovascular disease who is considering traveling to high altitude. High altitude provides a unique physiologic challenge to the cardiovascular system. The cardiovascular response in both healthy ...
Navigating air travel and cardiovascular concerns: Is the sky the limit
Passengers with stable heart failure without recent changes in symptoms and medication are usually able to tolerate air travel and the associated mild hypoxia. 10, 11, 26 Decreased exercise capacity has been reported in heart failure passengers at high altitudes. 27 Oxygen supplementation is generally recommended in passengers with New York ...
My Marvellous Guide to travelling with heart failure
Travelling with Heart Failure. If your condition is unstable, or your blood pressure is very high, travel of any kind is best avoided. Heart conditions like any other condition can cause you problems on holiday, so choosing your destination wisely and planning your itinerary with care should help to minimise any potential risks.
Commercial Air Travel for Passengers With ...
Passengers with heart failure with reduced ejection fraction (HFREF), defined as a left ventricular ejection fraction <40%, 82, 83 presents an at-risk group for IMEs during commercial flights. 21, 84, 85 Hypoxia has deleterious effects on HFREF, but large populations trials of heart failure patients under hypobaric conditions presently do not ...
Holidays and travel with a heart condition
Most people with a heart condition will be okay travelling alone. Follow the helpful tips above and share the details of your holiday with your GP and family before departure. Be prepared and make sure you are bringing enough medication for the duration of your holiday and find out where the nearest hospital is at your destination.
Commercial Air Travel for Passengers With Cardiovascular Disease
Introduction. The exponential growth of commercial flights, both in terms of accessibility and cost, has resulted in a sharp rise of air travellers over the last 2 decades. 1, 2 Notwithstanding the ongoing COVID-19 pandemic that will set back the aviation industry for the next 1 to 2 years, air travel is expected to rebound fully by 2023-2024. Passengers with a wide range of cardiovascular ...
Planning to travel with atrial fibrillation?
Travel tips with atrial fibrillation. Remember these helpful tips: Bring your medicines. Bring all of the medications you'll need for your trip. Keep them in your carry-on luggage. Carry a list of your medicines. Having a list of your medicines will make it easier to refill them if you run out of them or lose them. Take your time.
Travel to high altitudes could be dangerous for people with heart
People with heart failure may need to adjust their medications at higher altitudes because of changes in blood pressure and the increased workload on the heart. Likewise, people with difficult-to-control blood pressure, or those visiting high-altitude areas for long periods of time, may need to carefully monitor blood pressure levels for any ...
Air travel considerations for the patients with heart failure
Context: Prevalence of patients with heart failure (HF) is increasing in worldwide, and also the number of people with HF traveling long distances is increasing. These patients are more prone to experience problems contributed air travel and needs more attention during flight. However, observational studies about problems of HF patients during flight and appropriated considerations for them ...
Experiences of air travel in patients with chronic heart failure
Air travel, for business, family or vacation, is part of modern life in Western societies. Lower costs, greater convenience of travel, and greater longevity mean that older, retired people now frequently wish to travel by air and many of these travellers will have chronic ailments, including chronic heart failure (CHF).
Experiences of air travel in patients with chronic heart failure
3. Results. 464 CHF patients (response rate = 39%) returned completed survey questionnaires. Table 1 shows baseline clinical characteristics of patients. 54% (252/464) of patients had travelled by air since their heart failure diagnosis. Of those who had flown, 21% had taken one flight, 25% 2 flights, 21% 3 flights, and 33% at least 4 flights ...
Travel and Heart Failure Patients
Travel. Some people with heart failure find that they may become more reluctant to travel or go on holiday due to their condition. Travelling and being in unfamiliar surroundings with a change in routine may cause anxiety for you or your carer. However, if you're well prepared and organised there is no reason why you shouldn't be able to ...
Air travel considerations for the patients with heart failure.
Individuals breathe the hypoxic gas mixture for 20 min during the test oxygen saturation is monitored. Furthermore, arterial blood gases are measured before and at the end of the test. If PaO2 drops below 50 mmHg, or, if the oxygen saturation drops below 85%, the traveler would need oxygen during flight ( 11 ).
Navigating air travel and cardiovascular concerns: Is the sky the limit
Passengers with stable heart failure without recent changes in symptoms and medication are usually able to tolerate air travel and the associated mild hypoxia. 10, 11, 26 Decreased exercise capacity has been reported in heart failure passengers at high altitudes. 27 Oxygen supplementation is generally recommended in passengers with New York ...
Flying with a Wheelchair: What to Know
How to get a wheelchair at the airport for American Airlines. To request wheelchair assistance, select the "Add special assistance" option during booking or in "Manage Trips" from the ...