Cardiovascular System - General

Implementing Rules (IRs), Acceptable Means of Compliance (AMCs) and Guidance Material (GM) on the cardiovascular system in general

The following are the requirements for the medical certification of aircrew, including guidance material issued by the UK CAA Medical Department in relation to the cardiovascular system.

Implementing Rules

Acceptable Means of Compliance

Guidance Material

MED.B.010 Cardiovascular System

(b) Cardiovascular System – General
   (1) Applicants shall not suffer from any cardiovascular disorder which is likely to interfere with the safe exercise of the privileges of the applicable licence(s).

   (2) Applicants for a class 1 medical certificate with any of the following conditions shall be assessed as unfit:
      (i) aneurysm of the thoracic or supra-renal abdominal aorta, before or after surgery;
      (ii) significant functional abnormality of any of the heart valves;
      (iii) heart or heart/lung transplantation.

Medical reports - Cardiology
 

 

   
(3) Applicants for a class 1 medical certificate with an established history or diagnosis of any of the following conditions shall be referred to the licensing authority:
      (i) peripheral arterial disease before or after surgery;

Class 1
   (3) Peripheral Arterial Disease
If there is no significant functional impairment, a fit assessment may be considered by the licensing authority, provided:
   3.1 applicants without symptoms of coronary artery disease have reduced any vascular risk factors to an appropriate level;
   3.2 all applicants should be on acceptable secondary prevention treatment;
   3.3 exercise electrocardiography should be satisfactory.  Further tests may be required which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.

Class 2
   (3) Peripheral Arterial Disease
A fit assessment may be considered for an applicant with peripheral arterial disease, or after surgery for peripheral arterial disease, provided there is no significant functional impairment, any vascular risk factors have been reduced to an appropriate level, the applicant is receiving acceptable secondary prevention treatment, and there is no evidence of myocardial ischaemia.
If there is no significant functional impairment, a fit assessment may be considered by the licensing authority, provided:    
   3.1 applicants without symptoms of coronary artery disease have reduced any vascular risk factors to an appropriate level;    
   3.2 all applicants should be on acceptable secondary prevention treatment;
   3.3 exercise electrocardiography should be satisfactory.  Further tests may be required which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.


Peripheral Arterial Disease
If exercise electrocardiography cannot be performed (e.g. due to claudication), then a myocardial perfusion scan or stress echocardiogram may be an acceptable alternative investigation.


Carotid Artery Dissection
Cases should be investigated with Angiography (usually MRI).  Specialist review by consultant neurologist is required.  Any supratentorial stroke is disqualifying due to seizure risk.

Six months following full functional recovery a Class 1 OML/unrestricted Class 2 assessment may be possible.  A further angiogram (usually MRA) is required after 6 months to check whether the dissection has remained stable.




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (ii) aneurysm of the abdominal aorta, before or after surgery;

Class 1
   (4) Aortic Aneurysm
   4.1 Applicants with an aneurysm of the infra-renal abdominal aorta may be assessed as fit with a multi-pilot limitation by the licensing authority.  Follow-up by ultra-sound scans or other imaging techniques, as necessary, should be determined by the licensing authority.
   4.2 Applicants may be assessed as fit by the licensing authority after surgery for an infra-renal aortic aneurysm with a multi-pilot limitation at revalidation if the blood pressure and cardiovascular assessment are satisfactory.  Regular cardiological review should be required.

Class 2
   (4) Aortic Aneurysm
   4.1 Applicants with an aneurysm of the thoracic or abdominal aorta may be assessed as fit, subject to satisfactory cardiological evaluation and regular follow-up.
   4.2 Applicants may be assessed as fit after surgery for a thoracic or abdominal aortic aneurysm subject to satisfactory cardiological evaluation to exclude the presence of coronary artery disease.

Infrarenal Abdominal Aortic Aneurysm                  

Class 1:< 5cmOML
5cm or moreunfit
Class 2:< 5cmunrestricted
5–5.5cmOSL
> 5.5cmunfit

UK CAA Dilated Aortic Root flow chart

Medical Reports - Cardiology




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (iii) functionally insignificant cardiac valvular abnormalities;

Class 1
(5) Cardiac Valvular Abnormalities
   5.1 Applicants with previously unrecognised cardiac murmurs should require evaluation by a cardiologist and assessment by the licensing authority.  If considered significant, further investigation should include at least 2D Doppler echocardiography or equivalent imaging. 
   5.2 Applicants with minor cardiac valvular abnormalities may be assessed as fit by the licensing authority.  Applicants with significant abnormality of any of the heart valves should be assessed as unfit.   

 5.2.1 Aortic Valve Disease
      (i) Applicants with bicuspid aortic valve may be assessed as fit if no other cardiac or aortic abnormality is demonstrated.  Follow-up with echocardiography, as necessary, should be determined by the licensing authority.
      (ii) Applicants with aortic stenosis require licensing authority review.  Left ventricular function should be intact.  A history of systemic embolism or significant dilatation of the thoracic aorta is disqualifying.  Those with a mean pressure gradient of up to 20 mmHg may be assessed as fit.  Those with mean pressure gradient above 20 mmHg but no greater than 40 mmHg may be assessed as fit with a multi-pilot limitation.  A mean pressure gradient up to 50 mmHg may be acceptable.  Follow-up with 2D Doppler echocardiography, as necessary, should be determined by the licensing authority.  Alternative measurement techniques with equivalent ranges may be used.
      (iii) Applicants with trivial aortic regurgitation may be assessed as fit.  A greater degree of aortic regurgitation should require a multi-pilot limitation.  There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography.  Follow-up, as necessary, should be determined by the licensing authority.

UK CAA Aortic Stenosis flow chart

Medical Reports -  Cardiology

5.2.2  Mitral Valve Disease
      (i) Asymptomatic applicants with an isolated mid-systolic click due to mitral leaflet prolapse may be assessed as fit.
      (ii) Applicants with rheumatic mitral stenosis should normally be assessed as unfit.
      (iii) Applicants with uncomplicated minor regurgitation may be assessed as fit.  Periodic cardiolological review should be determined by the licensing authority.
      (iv)  Applicants with uncomplicated moderate mitral regurgitation may be considered as fit with a multi-pilot limitation if the 2D Doppler echocardiogram demonstrates satisfactory left ventricular dimensions and satisfactory myocardial function is confirmed by exercise electrocardiography.  Periodic cardiological review should be required, as determined by the licensing authority.
      (v)  Applicants with evidence of volume overloading of the left ventricle demonstrated by increased left ventricular end-diastolic diameter or evidence of systolic impairment should be assessed as unfit.

Class 2
  
 (5) Cardiac Valvular Abnormalities
   5.1 Applicants with previously unrecognised cardiac murmurs require further cardiological evaluation. 
   5.2 Applicants with minor cardiac valvular abnormalities may be assessed as fit.

UK CAA Mitral Valve Disease flow chart

Medical reports - Cardiology




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (iv) after cardiac valve surgery;

Class 1
   (6) Valvular surgery
Applicants with cardiac valve replacement/repair should be assessed as unfit.  A fit assessment may be considered by the licensing authority.
   6.1 Aortic valvotomy should be disqualifying.
   6.2 Mitral leaflet repair for prolapse is compatible with a fit assessment, provided post-operative investigations reveal satisfactory left ventricular function without systolic or diastolic dilation and no more than minor mitral regurgitation.
   6.3 Asymptomatic applicants with a tissue valve or with a mechanical valve who, at least 6 months following surgery, are taking no cardioactive medication may be considered for a fit assessment with a multi-pilot limitation by the licensing authority.  Investigations which demonstrate normal valvular and ventricular configuration and function should have been completed as demonstrated by:
   6.3.1 a satisfactory symptom limited exercise ECG.  Myocardial perfusion imaging/stress echocardiography should be required if the exercise ECG is abnormal or any coronary artery disease has been demonstrated;
   6.3.2 a 2D Doppler echocardiogram showing no significant selective chamber enlargement, a tissue valve with minimal structural alteration and a normal Doppler blood flow, and no structural or functional abnormality of the other heart valves.  Left ventricular fractional shortening should be normal.  Follow-up with exercise ECG and 2D echocardiography, as necessary, should be determined by the licensing authority. 
   6.4 Where anticoagulation is needed after valvular surgery, a fit assessment with a multi-pilot limitation may be considered after review by the licensing authority.  The review should show that the anticoagulation is stable.  Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range.

Class 2
   (6) Valvular surgery
   6.1 Applicants who have undergone cardiac valve replacement or repair may be assessed as fit if post-operative cardiac function and investigations are satisfactory and no anticoagulants are needed.
   6.2 Where anticoagulation is needed after valvular surgery, a fit assessment with an OSL or OPL limitation may be considered after cardiological review.  The review should show that the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range.


UK CAA Aortic Valve Replacement flow chart 

Medical reports - Cardiology 

 


Mitral Valve Repair
After mitral valve repair, recertification to Class 1 OML/Unrestricted Class 2 level is possible 6 months post operatively, subject to a satisfactory cardiology review, to include an echocardiogram.  Follow-up should include annual echocardiograms.




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (v) abnormality of the pericardium, myocardium or endocardium;

Class 1
   8.1 Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium should be assessed as unfit.  A fit assessment may be considered by the licensing authority following complete resolution and satisfactory cardiological evaluation which may include 2D Doppler echocardiography, exercise ECG and/or myocardial perfusion imaging/stress echocardiography and 24-hour ambulatory ECG.  Coronary angiography may be indicated.  Frequent review and a multi-pilot limitation may be required after fit assessment.


Class 2
   8.1 Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium may be assessed as unfit pending satisfactory cardiological evaluation.


UK CAA Hypertrophic Cardiomyopathy flow chart

Medical reports - Cardiology 

Acute Benign Aseptic Pericarditis
Recertification can be considered 3 months after recovery to Class 1 OML/unrestricted Class 2 level, subject to a satisfactory cardiology review to include a 24hr ECG, echocardiogram and exercise ECG.  Follow-up should initially be 6 monthly cardiology reviews to include a 12 lead resting ECG and echocardiogram. Unrestricted Class 1 can be considered after 2 years.  Follow-up can usually be discontinued after 2 years. 

Constrictive Pericarditis
Recertification can be considered after pericardectomy to Class 1 OML/unrestricted Class 2 level subject to a satisfactory cardiological review, to include exercise ECG, echocardiogram and 24hr ECG.  The applicant should be in sinus rhythm. Annual cardiological follow up is required.




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (vii) recurrent vasovagal syncope;
Class 1
   (9) Syncope
   9.1 Applicants with a history of recurrent vasovagal syncope should be assessed as unfit.  A fit assessment may be considered by the licensing authority after a 6 month period without recurrence provided cardiological evaluation is satisfactory.  Such evaluation should include:
   9.1.1 a satisfactory symptom limited 12 lead exercise ECG to Bruce Stage IV or equivalent.  If the exercise ECG is abnormal, myocardial perfusion imaging/stress echocardiography should be required; a satisfactory symptom limited 12 lead exercise ECG to Bruce Stage IV or equivalent. If the exercise ECG is abnormal, myocardial perfusion imaging/stress echocardiography should be required; 
   9.1.2 a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium;
   9.1.3 a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia.
   9.2 A tilt test carried out to a standard protocol showing no evidence of vasomotor instability may be required. 
   9.3 Neurological review should be required.
   9.4 A multi-pilot limitation should be required until a period of 5 years has elapsed without recurrence.  The licensing authority may determine a shorter or longer period of multi-pilot limitation according to the individual circumstances of the case. 
   9.5 Applicants who experienced loss of consciousness without significant warning should be assessed as unfit.


UK CAA Neuro-Cardiogenic Syncope flow chart

Medical reports - Cardiology

Class 2
   (9) Syncope
Applicants with a history of recurrent vasovagal syncope may be assessed as fit after a 6 month period without recurrence, provided that cardiological evaluation is satisfactory.  Neurological review may be indicated. 


UK CAA Neuro-Cardiogenic Syncope flow chart

 

Medical reports - Cardiology




Implementing Rules

Acceptable Means of Compliance

Guidance Material


      (viii) arterial or venous thrombosis;

      (ix) pulmonary embolism;

      (x) cardiovascular condition requiring systemic anticoagulant therapy.

Class 1
   (7) Thromboembolic Disorders
Arterial or venous thrombosis or pulmonary embolism are disqualifying whilst anticoagulation is being used as treatment.  After 6 months of stable anticoagulation as prophylaxis, a fit assessment with multi-pilot limitation may be considered after review by the licensing authority.  Anticoagulation should be considered stable if, within the last 6 months, at least 5 INR values are documented, of which at least 4 are within the INR target range.  Pulmonary embolus should require full evaluation.  Following cessation of anti-coagulant therapy, for any indication, applicants should require review by the licensing authority.

Anticoagulant Therapy
Certification to Class 1 OML/unrestricted Class 2 level is possible on anticoagulant therapy

Thrombophilia testing guidance 

   (4) Applicants for a class 2 medical certificate with an established diagnosis of one of the conditions specified in (2) and (3) above shall be assessed by a cardiologist before a fit assessment can be considered in consultation with the licensing authority.