Managing Travel Risks for Patients With Heart Disease

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Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements.

Dr. Ashish Sarraju:

Hi everyone. Thank you for joining us. My name is Dr. Ashish Sarraju. I'm a preventive cardiologist here at the Heart, Vascular & Thoracic Institute of Cleveland Clinic. I'm the Director of Research for Preventive Cardiology and the Director for the Center for Inherited Lipid Disorders. We're privileged today. We're joined by Dr. Abhayjit Singh, who's also a preventive cardiologist here at Cleveland Clinic. He is the Officer for Patient Experience here at the Heart, Vascular & Thoracic Institute. Thank you for joining us.

Dr. Abhayjit Singh:

Thank you for having me.

Dr. Ashish Sarraju:

So, let's talk about something that I suspect a lot of clinicians get a lot of questions about, but there may be a lot of variability in how we address this question, which is travel clearance for patients, especially people with heart conditions. When a patient comes to you, putting your clinician hat on, what are some of the frameworks you use or systems you use to approach answering that question: is this patient okay to travel?

Dr. Abhayjit Singh:

Absolutely. It's something that you and I get asked about every day in our clinic, and that a lot of our colleagues, both in cardiology and non-cardiology, get asked about every single day by their patients. Let's get into it. We do treat patients with heart conditions a little bit differently when it comes to travel. The approach that I use in general doesn't come down so much to the conditions that they're diagnosed with, but their clinical stability. Whether you have a patient with coronary artery disease, heart failure, atrial fibrillation, valvular disease, following surgery, or various hospitalizations for heart conditions, I really think about stability: stability of patient condition and stability of medications.

First and foremost, does the patient have ongoing severe angina, rapid uncontrolled atrial fibrillation, resting heart failure, or NYHA class III heart failure? If you have something that's making you nervous in the clinic, it should make you nervous when your patient is asking you whether they can travel.

Similarly, on that note, I think about the medications. If the medications are working for the patient and their vital signs are stable, and they have no residual symptoms of their cardiac condition, then similarly, I feel very good. If the medications are rapidly being changed, up- or down-titrated, or they're causing patients to have vital sign abnormalities, I think twice.

With that being said, I would raise a couple of caveats. Even when patients appear stable, there are some conditions that I think are worth knowing about and discussing with a patient further, even when everything otherwise seems stable. Some of those conditions include severe pulmonary hypertension, severe untreated valvular disease, severe unrevascularized coronary disease, or the presence of what we call a left ventricular assist device or LVAD. These are conditions which, even with clinical stability, patients can be at some increased risk when they are traveling, and you do want to be very careful about.

Dr. Ashish Sarraju:

Yeah, let's jump right into that a little bit. Let's talk a little bit about devices, right? People may have pacemakers, they may have ICDs, they may have LVADs. How do you approach travel clearance in patients with devices and what precautions should they take when they're traveling?

Dr. Abhayjit Singh:

Very good. I break it down again into two things. One is the travel itself, and one is being at the destination with those things. Jumping into your first question about ICDs and pacemakers, what I tell folks is that during car travel, especially under four to six hours, there are really no added concerns. Just make sure you have your usual medications. If you send remote device checks or anything like that, try to ascertain whether or not you're going to have reliable service wherever you're going.

For air travel, a little bit of a different consideration. I do recommend that people are able to go through airport security just as they would without it, but I recommend to make sure they have a copy of their card that tells you exactly what kind of device you have. Try to avoid extended periods of time where the TSA agents may be putting a wand directly on their device, just in case there are magnets found in it. But other than that, patients are generally safe to travel. I think the most important thing is just being informed and making sure that the people who are helping you get through security and onto the plane are also informed of the kind of device you have.

When it comes to left ventricular assist devices or LVADs, those are slightly more complicated patients, and those are ones where you really want to inform the gate agents and security agents upfront that this is something you're traveling with. Why? Because you often need to be carrying extra controllers, extra batteries, and there are just extra precautions that they take. I always tell my patients to seek the advice of either their LVAD physician or their LVAD team when it comes to specifics about how they're going to approach the travel.

Then moving on to the destination, again, a lot of the similar concepts will apply as they do with other types of patients who are traveling. Again, I tell my patients to make sure they have the copy of their medications and have extra medications wherever they're going. Then again, specific to the device or the other ICD pacemaker or LVAD patients, I always tell them to have extra controllers, extra batteries, and make sure they've had no recent alarms on their LVAD. For ICDs, I make sure that they've had no recent device shocks.

Dr. Ashish Sarraju:

That's very helpful advice. How do you, in somebody, let's say, who doesn't have an established history of DVTs or PEs, proactively tell people to take measures to prevent DVTs during periods of long travel?

Dr. Abhayjit Singh:

I do for any period of travel that's greater than about four hours, whether that be on the road or in the air. On the road, I generally tell people to stop at gas stations or rest stops, get out of the car, walk around, and then, when they're in the car, to be moving their calves. For people on air travel, similarly, I advise regular movement of the calves up and down, choosing an aisle seat if they can, and every one or two hours getting up and walking up and down. This applies a little bit less to patients who are already on blood thinners, DOACs or warfarin, for example. But in those patients, I try to make sure that they continue their medication uninterrupted throughout their travel and their stay at their destination. I generally do not prescribe prophylactic anticoagulants for folks who aren't otherwise high risk for DVTs.

Dr. Ashish Sarraju:

Great. When people say, "Should I take a baby aspirin or should I take something to prevent a blood clot on a plane," if they're not at high risk.

Dr. Abhayjit Singh:

Correct. There are certain conditions that are generally managed by vascular medicine physicians or hematologists where that will apply, but for the vast majority of our patients, I don't recommend that.

Dr. Ashish Sarraju:

Do you give patients any anticipatory guidance on things to carry with them, medications to carry with them, emergency precautions, symptoms? As a clinician, what would you advise somebody, let's say, who has a heart condition and who's traveling abroad for a few weeks?

Dr. Abhayjit Singh:

Yeah, great question. First and foremost, I say, "Pay attention to the same sorts of signs and symptoms that you would if you were here." So, what I tell people is, "If the symptoms you're experiencing, whether it be chest pain, shortness of breath, palpitations, irregular heartbeat, if those things are happening to you and they make you nervous here stateside, then they should similarly make you nervous abroad." The biggest difference I advise folks is that here they'll know who to contact. They'll know their physicians. They'll know how to get in touch with them. They'll know where the local emergency rooms are or urgent cares, and they might not have that information abroad. I always try to tell them to make sure that they both know what symptoms to recognize, which are generally not different here versus traveling, but also to know in general where they're going to seek care should the situation arise where they need to.

With regard to your question about medications, the two things I always advise are know what medications you're taking and have a printed out list of them, including the generic names. If you're in a situation, God forbid, where your medications get lost and you need to seek new medications, they may have different trade names than we do here. Know the medications, know the generic names, and try to always pack an extra week to two weeks, depending on how long you're traveling for, to bring with you to your destination.

Dr. Ashish Sarraju:

That's great. Great advice for clinicians. Is there anything else? Let's say you want to give clinicians a one-liner or two-liner sentence that they can remember to tell their patients every time they get asked about travel. Is there a standard template line that everyone can keep in mind?

Dr. Abhayjit Singh:

Yeah, I think from my standpoint, it's number one: what condition are you dealing with? Is there something severe that you will require extra attention to? For example, severe aortic stenosis, severe pulmonary hypertension, or severe coronary artery disease. For things like that, I think it's always appropriate to phone your local cardiologist or the patient's cardiologist and seek their opinion. For patients who don't have that and are just seeking your general advice, but they have a condition such as heart failure or bypass surgery, atrial fibrillation, then I go to the clinical stability. If my patient is feeling good here, I have no reason to believe they're not going to feel good when they travel. If they're not feeling good, if they recently got out of the hospital, if they have been suffering from undue symptoms at home, I take those things seriously, and I try to correct those before letting them travel.

Dr. Ashish Sarraju:

Fabulous. Well, thank you for joining us today, Dr. Singh. I certainly learned a lot from listening. Thank you, everybody, for joining us.

Dr. Abhayjit Singh:

Thanks for having us.

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