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Cardiovascular System - Heart Attacks / Angina

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I would like to do my Dive Master course. I understand that I would need to have a HSE medical. Would my previous heart attack in 2000 prevent me doing this course. I have no chest pain, was taken off cardiology consultant list after the first year following my heart attack. My BP is usually around 120/80 pulse resting is 70. No oedema around my ankles or wet cough.

Thanks for any information about the Diver master course / HSE medical.

A - You are caught between a rock and a hard place here, so I hope the following makes sense.

A commercial diver, having had a heart attack, would normally be barred from diving. However, a non-commercial diver if they are controlled and fit, are fine to dive in your situation [as long as they pass the medical]. So is a DM a commercial diver. According to the HSE they are as they all need to have the full HSE medical. Though they did not a year ago. But if you were getting the same level of qualification with BSAC you would not need an HSE and so would be OK.

Confused? Yes, so am I!

For some reason BSAC divers, even the top instructors do not need to do an HSE but can self-cert themselves. Apparently it's because they are a club, and not a commercial organisation like PADI who do the DM course.

I think your best bet is to contact the HSE and ask for exemption and explain that you want to do the DM solely for yourself and would not be gainfully employed as a diver. If they get arsey about it try BSAC as it seems you would pass the basic medical for them with your condition.

Q - I wonder if you could give me some advice. I have a colleague wanting to take up open water but has angina. He is on beta blockers (METAPROLOL)and carries a GTN spray. He also has a stent.Is he still able to dive.
Thanks for your help as usual.

A - Someone who has had angina, corrected with a stent [a small plastic tube inserted into the coronary artery to keep it open] is often fine to dive. However your colleague's problem is that he has to have a GTN spray. This is an admission that he still gets the occasional attack of chest pain. He would then spray this under his tongue to help dilate the coronary arteries along with the other blood vessels. It would be hard to do this if he had an attack underwater. The other problem is the beta blockers. These are usually a bar to diving as they affect the heart's response to exercise and also can worsen breathing underwater.
So, a double whammy here.

His only way out is if the GTN spray is cosmetic and he never needs it, or he does a full on exercise ECG to prove all is well. So off to a cardiologist with diving experience. There's a good one in Shrewsbury called Dr Wilmshurst. Find him via the web.

Q - I've just had a qualified SAA-Dive supervisor asking to dive with us. He's had a bypass, but says he never had a heart attack/angina. His last medical is from January 1999. The operation took place before that date. I know it's not much info, but in your opinion, is he fit to dive?

A - He probably will be if what he says is true. It's surprising that he had a bypass though having never had any cardiac symptoms. Something has to lead a man into the cardiologist to have either a coronary angiogram or a thallium scan that would show the necessary poor blood supply from the cardiac arteries to the heart muscles that then ends up as a bypass. So the fact he says he has never had any angina or even the teeniest heart attack makes we wonder.

However if he is symptom free, and by that I mean he is not just sitting at home watching telly beer in one hand, fag in the other saying there's no chest pain with me doc. He has to prove that on exercise he gets no reduced blood supply to the heart, and this would need an exercise ECG or even better a thallium scan.

He may well have had one of these after the operation and if fine then let him dive with you as long as there hasn't been any symptom return.

Also note that some patients after this sort of op take beta blockers to decrease the workload on the heart, so if he is then he should not risk diving. Its also in his best interests that he does get certified as fit to dive with a proper diving doctor on a regular basis then he wouldn't have any problems from insurance companies if anything were to happen.

Q - I had a heart attack on the 23rd August, apparently mild as it was quickly attended to. It has been reported as a clot in the right artery or in medical terms - acute inferior myocardial infarction. I was discharged from hospital after a 9 minute treadmill test.

I am due to see a cardiologist later this month.

I received strepokinase on admission and am now on Ramipril (5 mg), Simvastatin (20mg), Atenolol (50mg) and Aspirin (75mg).I have suffered no further pain since admission and am currently doing regular one-hour walks. On Saturday, I am meeting a hospital-trained fitness trainer to get a programme for further work.

I am hoping to travel to Hawaii by the end of October and would like to do some diving. I have Padi Open Water 1 and probably about 100 dives behind me. I would not intend diving beyond 20 m at this stage. I am 61 years old.

Is this sensible? Can I/should I have any specific checks or tests to be sure and where can I get this done?

Thank you

A - Sorry to hear about your heart attack, but I guess the silver lining is that our medical advances mean that you can return to normal life a lot quicker than you could a few years ago.

As regards your return to the deep, there are a few criteria you have to satisfy first. There must be no remaining decreased blood supply to your cardiac muscle, this will come across as chest pain on exercise, but as your treadmill seemed to be alright then I assume that's OK. The reason for this is that we have to make sure you don't get another one underwater. You are now not allowed to buddy with a novice diver either, but must team up with someone of DM standard at least. Before going back in you need to be passed by a diving doc who will probably impose a depth restriction on you, normally 20-25 metres. One of the reasons for this is that the deeper you go, the more resistance in your peripheral blood vessels due to the pressure, and the harder your heart has to work. You will need an annual medical, and you must never risk a dive where conditions could turn for the worse, resulting in an unexpected increased level of activity.

Sorry to lay it on like that, but that's the rules. You sound like you should be fine. See you on a one way gentle drift in tropical waters!

(other dive medical questions)


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