Cardiac health for astronauts: Current selection standards and their limitations

Introduction: The screening tests for coronary artery disease (CAD) for applicants and the active astronaut corps are similar to those performed in the 1960s. Due to the limited treatment and return capabilities of most space vehicles, an in-flight cardiac event would result in mission failure. Improved CAD screening of astronauts is, therefore, paramount to long-duration mission success. Methods: Literature review was performed to compare active and retired astronaut populations to other asymptomatic low-risk cohorts. All populations were examined to determine the incidence and prevalence of CAD. Framingham risk scores were calculated in NASA's active and retired astronaut corps and compared with age- and gender-matched controls. Results: The current standards used for astronaut selection have been successful in creating a cohort that has less risk than their age- and gender-matched counterparts from the general population. However, the existing astronaut cardiovascular screening and selection tests do not adequately rule out CAD for long-duration missions, and, therefore, a "significant" risk of cardiac event remains, especially as we look toward Exploration Class missions. Conclusions: The current astronaut selection and retention standards may not adequately prevent cardiac events from occurring with the longer duration flights. Future research should be directed toward increasing the primary and secondary prevention of CAD in the astronaut cohort. In the meantime, the space program should evaluate the use of more aggressive terrestrial screening tools. It is important not to remove all older, experienced pilots from spaceflight crews unless overt or predictable pathology has been clearly identified.