High altitude, air travel, and heart disease
- Troy Tuttle, MS
Troy Tuttle, MS
- Exercise Physiologist
- Cardiovascular Division
- Asif Ali, MD
Asif Ali, MD
- University of Texas Health Science Center
- Cardiovascular Medicine
- David Filsoof, MD
David Filsoof, MD
- Cedars Sinai Heart Institute
- John Higgins, MD, MBA, MPHIL, FACC, FAHA, FACP, FACSM, FASNC
John Higgins, MD, MBA, MPHIL, FACC, FAHA, FACP, FACSM, FASNC
- Associate Professor of Medicine
- The University of Texas Health Science Center at Houston (UTHealth)
- Section Editors
- Heidi M Connolly, MD, FASE
Heidi M Connolly, MD, FASE
- Section Editor — Congenital Heart Disease
- Professor of Medicine
- Mayo Medical School
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
The number of individuals exposed to high altitude through air travel and recreational activities has been greatly increasing in the past few decades. Changes in physiological functions during high altitude exposure vary with an individual’s physical fitness, rate of ascent, severity and/or duration of exposure, cultural habits, geographical locations, and genetic variation . While high altitude is well tolerated by most individuals, patients with cardiovascular disease are at risk of complications caused by tissue hypoxia and reduced oxygen delivery, sympathetic stimulation, increased myocardial demand, paradoxical vasoconstriction, and alterations in hemodynamics that occur with exposure to high altitude [2-4]. The consulting physician should know the duration of travel, ascent profile, degree of exertion, and any prior cardiovascular history before traveling to high altitude.
High altitude provides a unique physiologic challenge to the cardiovascular system. The cardiovascular response to high altitude in both healthy individuals and in patients with cardiovascular disease will be reviewed here. A general overview of high altitude disease will also be included to provide a comprehensive understanding. (See "High altitude illness: Physiology, risk factors, and general prevention".)
Most importantly, this topic will discuss the impact of high altitude on the heart. Altitude exposure can also lead to a variety of well-described clinical syndromes including some not directly involving the cardiovascular system, such as acute mountain sickness, high altitude pulmonary edema, high altitude cerebral edema, and high altitude retinal hemorrhage. These maladies are discussed in detail within this report. (See "High altitude pulmonary edema" and "Acute mountain sickness and high altitude cerebral edema" and "High altitude illness: Physiology, risk factors, and general prevention", section on 'Other altitude-related illnesses'.)
BAROMETRIC PRESSURE AND PIO2
When moving from sea level to high altitude, there are reductions in atmospheric pressure, oxygen pressure, humidity, and temperature . It is noteworthy to point out that significant changes occur beyond the critical height of 2500 meters (8200 feet) above sea level . Factors such as degree of change in elevation, degree of hypoxia, rate of ascent, level of acclimatization, exercise intensity, previous history of severe high-altitude illness, genetics, and age significantly affect the physiological change that the human body will experience during ascents . One study involving Chinese men aged 18 to 35 years noted that increased age (those 26 to 35 years old) was an independent risk factor for acute mountain sickness upon rapid ascent to high altitude (from 500 to 3700 m), and that the prevalence of acute mountain sickness also increased with increasing age . Hypoxia induces peripheral vasodilation and a pulmonary vasoconstriction, leading to changes in systemic blood pressure and an increase in pulmonary blood pressure that can also contribute to a high altitude pulmonary edema.
Although altitude is the most obvious determinant of barometric pressure and its resulting physiologic stress, other factors can contribute to a reduction in barometric pressure and can increase the physiologic consequences of altitude:
- Vats P, Ray K, Majumadar D, et al. Changes in cardiovascular functions, lipid profile, and body composition at high altitude in two different ethnic groups. High Alt Med Biol 2013; 14:45.
- Plant T, Aref-Adib G. Travelling to new heights: practical high altitude medicine. Br J Hosp Med (Lond) 2008; 69:348.
- Higgins JP, Tuttle T, Higgins JA. Altitude and the heart: is going high safe for your cardiac patient? Am Heart J 2010; 159:25.
- Wilkins MR, Ghofrani HA, Weissmann N, et al. Pathophysiology and treatment of high-altitude pulmonary vascular disease. Circulation 2015; 131:582.
- Morgan, BJ, Alexander, JK, Nicoli, SA, et al. The patient with coronary heart disease at altitude: observations during acute exposure to 3100 meters. J Wilderness Med 1990; 1:147.
- Richalet JP, Larmignat P, Poitrine E, et al. Physiological risk factors for severe high-altitude illness: a prospective cohort study. Am J Respir Crit Care Med 2012; 185:192.
- Tang XG, Zhang JH, Qin J, et al. Age as a risk factor for acute mountain sickness upon rapid ascent to 3,700 m among young adult Chinese men. Clin Interv Aging 2014; 9:1287.
- Huez S, Faoro V, Guénard H, et al. Echocardiographic and tissue Doppler imaging of cardiac adaptation to high altitude in native highlanders versus acclimatized lowlanders. Am J Cardiol 2009; 103:1605.
- Nishihara F, Shimada H, Saito S. Rate pressure product and oxygen saturation in tourists at approximately 3000 m above sea level. Int Arch Occup Environ Health 1998; 71:520.
- Jones JG, Bakewell SE, Heneghan CP, et al. Profound hypoxemia in pulmonary patients in airline-equivalent hypoxia: roles of VA/Q and shunt. Aviat Space Environ Med 2008; 79:81.
- Wagner PD, Sutton JR, Reeves JT, et al. Operation Everest II: pulmonary gas exchange during a simulated ascent of Mt. Everest. J Appl Physiol (1985) 1987; 63:2348.
- Maggiorini M, Mélot C, Pierre S, et al. High-altitude pulmonary edema is initially caused by an increase in capillary pressure. Circulation 2001; 103:2078.
- Cremona G, Asnaghi R, Baderna P, et al. Pulmonary extravascular fluid accumulation in recreational climbers: a prospective study. Lancet 2002; 359:303.
- Samaja M. Blood gas transport at high altitude. Respiration 1997; 64:422.
- Sawka MN, Convertino VA, Eichner ER, et al. Blood volume: importance and adaptations to exercise training, environmental stresses, and trauma/sickness. Med Sci Sports Exerc 2000; 32:332.
- Hultgren, HN. The systemic circulation. In: High Altitude Medicine, Hultgren Publications, Stanford 1997.
- Mazzeo RS, Reeves JT. Adrenergic contribution during acclimatization to high altitude: perspectives from Pikes Peak. Exerc Sport Sci Rev 2003; 31:13.
- Wille M, Mairer K, Gatterer H, et al. Changes in cardiac autonomic activity during a passive 8 hour acute exposure to 5 500 m normobaric hypoxia are not related to the development of acute mountain sickness. Int J Sports Med 2012; 33:186.
- Alexander JK. Coronary heart disease at altitude. Tex Heart Inst J 1994; 21:261.
- Nault P, Halman S, Paradis J. Ankle-brachial index on Kilimanjaro: lessons from high altitude. Wilderness Environ Med 2009; 20:72.
- Mytton OT, Simpson A, Thompson AA, et al. Manual assessment of the initial fall in blood pressure after orthostatic challenge at high altitude. Wilderness Environ Med 2008; 19:225.
- Karliner JS, Sarnquist FF, Graber DJ, et al. The electrocardiogram at extreme altitude: experience on Mt. Everest. Am Heart J 1985; 109:505.
- Saurenmann P, Koller EA. The ECG changes due to altitude and to catecholamines. Eur J Appl Physiol Occup Physiol 1984; 53:35.
- Coustet B, Lhuissier FJ, Vincent R, Richalet JP. Electrocardiographic changes during exercise in acute hypoxia and susceptibility to severe high-altitude illnesses. Circulation 2015; 131:786.
- Levine BD. Going High with Heart Disease: The Effect of High Altitude Exposure in Older Individuals and Patients with Coronary Artery Disease. High Alt Med Biol 2015; 16:89.
- Silva-Urra JA, Urizar C, Basualto-Alarcón C, et al. Effects of oxygen supplementation on acute mountain sickness symptoms and functional capacity during a 2-kilometer walk test on Chajnantor plateau (5050 meters, Northern Chile). Wilderness Environ Med 2011; 22:250.
- Erdmann J, Sun KT, Masar P, Niederhauser H. Effects of exposure to altitude on men with coronary artery disease and impaired left ventricular function. Am J Cardiol 1998; 81:266.
- Morgan, BJ, Alexandere, JK, Nicoli, SA, et al. The patient with coronary heart disease at altitude: observations during acute exposure to 3100 meters. J Wilderness Med 1990; 1:147.
- Levine BD, Zuckerman JH, deFilippi CR. Effect of high-altitude exposure in the elderly: the Tenth Mountain Division study. Circulation 1997; 96:1224.
- Schmid JP, Noveanu M, Gaillet R, et al. Safety and exercise tolerance of acute high altitude exposure (3454 m) among patients with coronary artery disease. Heart 2006; 92:921.
- Wyss CA, Koepfli P, Fretz G, et al. Influence of altitude exposure on coronary flow reserve. Circulation 2003; 108:1202.
- Al Riyami NB, Banerjee Y, Al-Waili K, et al. The Effect of Residing Altitude on Levels of High-Density Lipoprotein Cholesterol: A Pilot Study From the Omani Arab Population. Angiology 2015; 66:568.
- Grover RF, Tucker CE, McGroarty SR, Travis RR. The coronary stress of skiing at high altitude. Arch Intern Med 1990; 150:1205.
- Gordon DJ, Ekelund LG, Karon JM, et al. Predictive value of the exercise tolerance test for mortality in North American men: the Lipid Research Clinics Mortality Follow-up Study. Circulation 1986; 74:252.
- Whayne TF Jr. Altitude and cold weather: are they vascular risks? Curr Opin Cardiol 2014; 29:396.
- Negrao CE, Middlekauff HR. Adaptations in autonomic function during exercise training in heart failure. Heart Fail Rev 2008; 13:51.
- Chen YC, Lin FC, Shiao GM, Chang SC. Effect of rapid ascent to high altitude on autonomic cardiovascular modulation. Am J Med Sci 2008; 336:248.
- Pedrinelli R, Dell'Omo G, Talini E, et al. Systemic hypertension and the right-sided cardiovascular system: a review of the available evidence. J Cardiovasc Med (Hagerstown) 2009; 10:115.
- Palatini P, Businaro R, Berton G, et al. Effects of low altitude exposure on 24-hour blood pressure and adrenergic activity. Am J Cardiol 1989; 64:1379.
- Wright A, Brearey S, Imray C. High hopes at high altitudes: pharmacotherapy for acute mountain sickness and high-altitude cerebral and pulmonary oedema. Expert Opin Pharmacother 2008; 9:119.
- Kraus WE. Taking heart failure to new heights: its pathophysiology at simulated altitude. Am J Med 2000; 109:504.
- Agostoni P, Cattadori G, Guazzi M, et al. Effects of simulated altitude-induced hypoxia on exercise capacity in patients with chronic heart failure. Am J Med 2000; 109:450.
- Wozniak CJ, Baird BC, Stehlik J, et al. Improved survival in heart transplant patients living at high altitude. J Thorac Cardiovasc Surg 2012; 143:735.
- Woods D, Hooper T, Hodkinson P, et al. Effects of altitude exposure on brain natriuretic peptide in humans. Eur J Appl Physiol 2011; 111:2687.
- Smith D, Toff W, Joy M, et al. Fitness to fly for passengers with cardiovascular disease. Heart 2010; 96 Suppl 2:ii1.
- Rimoldi SF, Sartori C, Seiler C, et al. High-altitude exposure in patients with cardiovascular disease: risk assessment and practical recommendations. Prog Cardiovasc Dis 2010; 52:512.
- Pagé M, Sauvé C, Serri K, et al. Echocardiographic assessment of cardiac performance in response to high altitude and development of subclinical pulmonary edema in healthy climbers. Can J Cardiol 2013; 29:1277.
- Herbet N. Effects of altitude upon cardiovascular diseases. J Wilderness Med 1992; 3:301.
- Pichler Hefti J, Risch L, Hefti U, et al. Changes of coagulation parameters during high altitude expedition. Swiss Med Wkly 2010; 140:111.
- Sin DD, Man SF. Interleukin-6: a red herring or a real catch in COPD? Chest 2008; 133:4.
- Lomazzi F, Gurtner HP. [Staying at high altitudes and plane travel for heart patients]. Schweiz Med Wochenschr 1981; 111:618.
- Matthys H. Fit for high altitude: are hypoxic challenge tests useful? Multidiscip Respir Med 2011; 6:38.
- Gibelli G, Fantoni C, Anzà C, et al. Arrhythmic risk evaluation during exercise at high altitude in healthy subjects: role of microvolt T-wave alternans. Pacing Clin Electrophysiol 2008; 31:1277.
- Faulhaber M, Flatz M, Burtscher M. Frequency of cardiovascular diseases among ski mountaineers in the Austrian Alps. Int J Sports Med 2007; 28:78.
- Malconian M, Rock P, Hultgren H, et al. The electrocardiogram at rest and exercise during a simulated ascent of Mt. Everest (Operation Everest II). Am J Cardiol 1990; 65:1475.
- Kujaník S, Snincák M, Vokál' J, et al. Periodicity of arrhythmias in healthy elderly men at the moderate altitude. Physiol Res 2000; 49:285.
- Kujaník S, Snincák M, Galajdová K, Racková K. Cardiovascular changes during sudden ascent in a cable cabin to the moderate altitude. Physiol Res 2000; 49:729.
- Westerholm CJ. Threshold studies in transvenous cardiac pacemaker treatment. Direct measurement with special reference to short and long term stimulation and influence of certain metabolic, respiratory and pharmacological factors. Scand J Thorac Cardiovasc Surg Suppl 1971; 8:1.
- Weilenmann D, Duru F, Schönbeck M, et al. Influence of acute exposure to high altitude and hypoxemia on ventricular stimulation thresholds in pacemaker patients. Pacing Clin Electrophysiol 2000; 23:512.
- Sartori C, Allemann Y, Scherrer U. Pathogenesis of pulmonary edema: learning from high-altitude pulmonary edema. Respir Physiol Neurobiol 2007; 159:338.
- Allemann Y, Hutter D, Lipp E, et al. Patent foramen ovale and high-altitude pulmonary edema. JAMA 2006; 296:2954.
- Das BB, Wolfe RR, Chan KC, et al. High-altitude pulmonary edema in children with underlying cardiopulmonary disorders and pulmonary hypertension living at altitude. Arch Pediatr Adolesc Med 2004; 158:1170.
- Szkutnik M, Menacho-Delgadillo R, Palmero-Zilveti E, Bialkowski J. Transcatheter closure of patent ductus arteriosus among native high-altitude habitants. Pediatr Cardiol 2008; 29:624.
- Miao CY, Li WX, Geng D, et al. Effect of high altitude on prevalence of congenital heart disease. Chin Med J (Engl) 1988; 101:415.
- Vargas E, Spielvogel H. Chronic mountain sickness, optimal hemoglobin, and heart disease. High Alt Med Biol 2006; 7:138.
- Miao CY, Zuberbuhler JS, Zuberbuhler JR. Prevalence of congenital cardiac anomalies at high altitude. J Am Coll Cardiol 1988; 12:224.
- Chen QH, Liu FY, Wang XQ, et al. [A cross-sectional study of congenital heart disease among children aged from 4 to 18 years at different altitudes in Qinghai province, China]. Zhonghua Liu Xing Bing Xue Za Zhi 2009; 30:1248.
- DALEN JE, BRUCE RA, COBB LA. Interaction of chronic hypoxia of moderate altitude on pulmonary hypertension complicating defect of the atrial septum. N Engl J Med 1962; 266:272.
- Vogel JH, McNamara DG, Blount SG Jr. Role of hypoxia in determining pulmonary vascular resistance in infants with ventricular septal defects. Am J Cardiol 1967; 20:346.
- Brenner R, Pratali L, Rimoldi SF, et al. Exaggerated pulmonary hypertension and right ventricular dysfunction in high-altitude dwellers with patent foramen ovale. Chest 2015; 147:1072.
- Harinck E, Hutter PA, Hoorntje TM, et al. Air travel and adults with cyanotic congenital heart disease. Circulation 1996; 93:272.
- Thompson, DL. Fitness Focus Copy-and-Share: Exercise at Altitude. ACSM's Health & Fitness Journal 2009; 13:4.
- Possick SE, Barry M. Evaluation and management of the cardiovascular patient embarking on air travel. Ann Intern Med 2004; 141:148.
- Code of Federal Regulation 14 CFR 121. Appendix A:555-7. Office of the Federal Register; 2002.
- Gong H Jr. Air travel and oxygen therapy in cardiopulmonary patients. Chest 1992; 101:1104.
- Cottrell JJ. Altitude exposures during aircraft flight. Flying higher. Chest 1988; 93:81.
- Rayman RB. Passenger safety, health, and comfort: a review. Aviat Space Environ Med 1997; 68:432.
- Garrett, JS. Experience with 1132 in-flight medical emergencies: what have we learned? Presented at South Californian Institute, 15 January 1999.
- Goodwin T. In-flight medical emergencies: an overview. BMJ 2000; 321:1338.
- Gong H Jr. Exposure to moderate altitude and cardiorespiratory diseases. Cardiologia 1995; 40:477.
- Beighton PH, Richards PR. Cardiovascular disease in air travellers. Br Heart J 1968; 30:367.
- Thomas MD, Hinds R, Walker C, et al. Safety of aeromedical repatriation after myocardial infarction: a retrospective study. Heart 2006; 92:1864.
- Aerospace Medical Association Medical Guidelines Task Force. Medical Guidelines for Airline Travel, 2nd ed. Aviat Space Environ Med 2003; 74:A1.
- O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127:e362.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004; 110:e82.
- Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: developed in collaboration With the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction, Writing on Behalf of the 2004 Writing Committee. Circulation 2008; 117:296.
- Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009; 54:2205.
- Lampert R, Joska T, Burg MM, et al. Emotional and physical precipitants of ventricular arrhythmia. Circulation 2002; 106:1800.
- Fries R, König J, Schäfers HJ, Böhm M. Triggering effect of physical and mental stress on spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators. Clin Cardiol 2002; 25:474.
- Kolb C, Schmieder S, Lehmann G, et al. Do airport metal detectors interfere with implantable pacemakers or cardioverter-defibrillators? J Am Coll Cardiol 2003; 41:2054.
- Shlim DR, Houston R. Helicopter rescues and deaths among trekkers in Nepal. JAMA 1989; 261:1017.
- Burtscher M, Philadelphy M, Likar R. Sudden cardiac death during mountain hiking and downhill skiing. N Engl J Med 1993; 329:1738.
- Burtscher M, Pachinger O, Mittleman MA, Ulmer H. Prior myocardial infarction is the major risk factor associated with sudden cardiac death during downhill skiing. Int J Sports Med 2000; 21:613.
- http://www.princeton.edu/~oa/safety/altitude.html (Accessed on September 08, 2015).
- Hultgren, HN. Coronary heart disease and trekking. J Wilderness Med 1990; 1:154.
- BAROMETRIC PRESSURE AND PIO2
- NORMAL CARDIOVASCULAR RESPONSE TO HIGH ALTITUDE
- Short-term altitude exposure
- Long-term altitude exposure
- ALTITUDE STRESS IN HEART DISEASE
- Coronary heart disease
- - Patients without diagnosed CHD
- - Summary
- Heart failure
- - Our approach
- Valvular heart disease
- - Summary
- - Summary
- Pacemaker function
- Congenital heart disease
- - Summary
- AIR TRAVEL
- Potential risk
- Incidence of problems
- - Supplemental oxygen
- - Stable coronary artery disease
- - Myocardial infarction
- - Percutaneous coronary intervention
- - Coronary artery bypass graft surgery
- - Implanted devices
- - Deep vein thrombosis and pulmonary embolism
- TREKKING AND MOUNTAINEERING