Disclaimer: The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense or US Government.

Around 1% of the population is born with congenital heart disease (CHD), and the number of Americans with palliated CHD who survive into adulthood continues to grow.¹ Likewise, around 1% of the US population serves in the military when considering those on active duty, National Guard and Reserve status.² Among the nearly 100,000 new military recruits every year, there is a subset with CHD who apply to serve. It is helpful for pediatric and adult congenital cardiologists to understand the basic qualification standards and administrative process required for their patients who may be interested in military service.

When considering who can join the military, two important criteria come into play: the ability to perform required physical duties and the ability to receive the standard of medical care. Military service members are athletes, and guidelines pertaining to elite athletes should also apply to them. At a minimum, they must pass a biannual physical fitness test in addition to maintaining fitness for duty to perform training in a wide variety of settings. Their duties will often take them to remote and austere destinations where there may not be a cardiologist in the region to support them. Unlike our student athletes, we cannot depend on contingency plans like an external defibrillator on the sidelines or a cardiothoracic surgeon nearby in the event of an emergency.

With this in mind, the Department of Defense has specified comprehensive standards of medical fitness for entering the military,³ and the Air Force,⁴ Army,⁵ and Navy have set their own regulations particular to their branch.⁶ The Marine Corps falls under the Navy Bureau of Medicine, so Marine recruits follow Navy medical standards. These regulations state that congenital anomalies of the heart and great vessels, along with valvular disorders, are conditions disqualifying an applicant from military service — except in those conditions indicated in Table 1.

While these regulations may seem excessively restrictive, there is a mechanism in place to request a waiver if a potential recruit is initially denied entrance on medical grounds. The waiver request is then sent to the service branch for a case-by-case review by a medical board. (Of note, any waiver that is granted at this stage applies to initial accession only; it may not carry over to special duty qualifications the recruit may want to pursue, such as flight or dive status.)

As part of the waiver request, the primary cardiologist may be asked to provide documentation regarding the patient's medical condition, therapies and prognosis. When writing a letter supporting a waiver request, cardiologists should provide an honest summary of the patient's clinical status, while generally steering clear of making an emotional appeal or character assessment. Consider answering these questions:

• Does the patient require any activity restrictions?
• What frequency of follow-up does the patient require?
• Does the patient require follow-up with an adult CHD specialist?
• Is the patient's condition progressive?
• Will the patient likely require any interventions in the near- or long-term (20 years)?

While it may be discouraging for those who are denied a waiver to enter the military on medical grounds, patients should be encouraged to consider other avenues for public service that often have less restrictive medical requirements, including the US Public Health Service, the Peace Corps and AmeriCorps. These play valuable roles in society and provide a meaningful alternative for those who want to serve their country.

References

1. Bhatt AB, Foster E, Kuehl K, Alpert J, Brabeck S, Crumb S, et al. Congenital heart disease in the older adult: a scientific statement from the American Heart Association. Circulation. 2015;131:1884–931.
2. Defense Manpower Data Center report. Accessed 14 May 2018. https://www.dmdc.osd.mil/appj/dwp/dwp_reports.jsp.
3. DoD Instruction 6130.03 – Medical Standards for Appointment, Enlistment, or Induction in the Military Services. Accessed 14 May 2018. https://community.apan.org/wg/saf-llm/m/documents/184254.
4. AFI 48-123 – U.S Air Force Medical Examinations and Standards. Accessed 14 May 2019. http://aangfs.com/wp-content/uploads/2012/10/AFI-48-123-Medical-Examination-Standards.pdf.
5. AR 40-501- U.S. Army Standards of Medical Fitness. Accessed 14 May 2018. https://www.calculator.net/pdf/r40_501.pdf.
6. NAVMED P-117 – U.S. Navy Manual of the Medical Department. Accessed 14 May 2018. https://www.med.navy.mil/directives/Pages/NAVMEDP-MANMED.aspx.

Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Implantable Devices, SCD/Ventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Quality Improvement

Keywords: Heart Defects, Congenital, Military Personnel, Follow-Up Studies, Heart Diseases, Defibrillators

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