Cardiovascular System

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

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


Blood Pressure/Hypertension

 
(c) Blood Pressure

(1) The blood pressure shall be recorded at each examination.

(2) The applicant’s blood pressure shall be within normal limits.

(3) Applicants for a Class 1 medical certificate: 
   (i) with symptomatic hypotension; or 
   (ii) whose blood pressure at examination consistently exceeds 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment; shall be assessed as unfit.
 
(4) The initiation of medication for the control of blood pressure shall require a period of temporary suspension of the medical certificate to establish the absence of significant side effects.

Class 1
(c) Blood Pressure


(1) The diagnosis of hypertension should require cardiovascular review to include potential vascular risk factors.

(2) Anti-hypertensive treatment should be agreed by the licensing authority. Medication acceptable to the licensing authority may include: 

   2.1 non-loop diuretic agents; 
   2.2 ACE Inhibitors; 
   2.3 angiotensin II AT1 blocking agents (sartans); 
   2.4 slow channel calcium blocking agents; 
   2.5 certain (generally hydrophilic) beta-blocking agents.

(3) Following initiation of medication for the control of blood pressure, applicants should be reassessed to verify that the treatment is compatible with the safe exercise of the privileges of the licence held.

Class 2
(c) Blood Pressure

(1) When the blood pressure at examination consistently exceeds 160 mmHg systolic and/or 95 mmHg diastolic, with or without treatment, the applicant should be assessed as unfit.

(2) The diagnosis of hypertension requires review of other potential vascular risk factors.

(3) Applicants with symptomatic hypotension should be assessed as unfit.

(4) Anti-hypertensive treatment should be compatible with flight safety.

(5) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that the treatment is compatible with the safe exercise of the privileges of the licence held.


UK CAA Hypertension flow chart

Medical reports - Hypertension

Guidance on BP measurement    

 




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Coronary Artery Disease

(d) Coronary Artery Disease

(1) Applicants for a class 1 medical certificate with:
   (i) suspected myocardial ischaemia;
   (ii) asymptomatic minor coronary artery disease requiring no anti-anginal treatment; shall be referred to the licensing authority and undergo cardiological evaluation to exclude myocardial ischaemia before a fit assessment can be considered.

(2) Applicants for a class 2 medical certificate with any of the conditions detailed in (1) shall undergo cardiological evaluation before a fit assessment can be considered.

(3) Applicants with any of the following conditions shall be assessed as unfit:
   (i) myocardial ischaemia;
   (ii) symptomatic coronary artery disease;
   (iii) symptoms of coronary artery disease controlled by medication.


Class 1 and 2
(1) Chest pain of uncertain cause should require full investigation.

Class 1

(2) In suspected asymptomatic coronary artery disease, exercise electrocardiography should be required. Further tests may be required, which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.


Class 2

(2) In suspected asymptomatic coronary artery disease cardiological evaluation should show no evidence of myocardial ischaemia or significant coronary artery stenosis.

 

 

 




UK CAA Investigation of suspected coronary artery disease flow chart

Medical Reports - Cardiology

 

 

 

 

 

 

 

 

 

 

 

  

 




Implementing Rules

Acceptable Means of Compliance

Guidance Material

Myocardial Ischaemia/Myocardial Infarction/Revascularisation for Coronary Artery Disease 

(4) Applicants for the initial issue of a class 1 medical certificate with a history or
diagnosis of any of the following conditions shall be assessed as unfit:
   (i) myocardial ischaemia;
   (ii) myocardial infarction;
   (iii) revascularisation for coronary artery disease. 

Class 1
(3) Evidence of exercise induced myocardial ischaemia should be disqualifying.

(4) After an ischaemic cardiac event, including revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on acceptable secondary prevention treatment. 

   4.1 A coronary angiogram obtained around the time of, or during, the ischaemic cardiac event and a complete, detailed clinical report of the ischaemic event, the angiogram and any operative procedures should be available to the licensing authority: 
      4.1.1 there should be no stenosis more than 50% in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction.. More than two stenoses between 30% and 50% within the vascular tree should not be acceptable; 
      4.1.2 the whole coronary vascular tree should be assessed as satisfactory by a cardiologist, and particular attention should be paid to multiple stenoses and/or multiple revascularisations; 
      4.1.3 an untreated stenosis greater than 30% in the left main or proximal left anterior descending coronary artery should not be acceptable. 

   4.2 At least 6 months from the ischaemic cardiac event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted): 
      4.2.1 an exercise ECG showing no evidence of myocardial ischaemia or rhythm or conduction disturbance; 
      4.2.2 an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion (such as dyskinesia or akinesia) and a left ventricular ejection fraction of 50% or more; 
      4.2.3 in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, which should show no evidence of reversible myocardial ischaemia. If there is any doubt about myocardial perfusion, in other cases (infarction or bypass grafting) a perfusion scan should also be required; 
      4.2.4 further investigations, such as a 24 hour ECG, may be necessary to assess the risk of any significant rhythm disturbance. 

   4.3 Follow-up should be yearly (or more frequently, if necessary) to ensure that there is no deterioration of cardiovascular status. It should include a review by a cardiologist, exercise ECG and cardiovascular risk assessment. Additional investigations may be required by the licensing authority. 

   4.4 After coronary artery vein bypass grafting, a myocardial perfusion scan or equivalent test should be performed if there is any indication, and in all cases within 5 years from the procedure. 

   4.5 In all cases, coronary angiography shall be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia. 

   4.6 Successful completion of the six month or subsequent review will allow a fit assessment with a multi-pilot limitation.


UK CAA Post Event flow chart

Medical Reports - Cardiology




Implementing Rules

Acceptable Means of Compliance

Guidance Material


(5) Applicants for a class 2 medical certificate who are asymptomatic following
myocardial infarction or surgery for coronary artery disease shall undergo
satisfactory cardiological evaluation before a fit assessment can be considered in
consultation with the licensing authority. Applicants for the revalidation of a class 1
medical certificate shall be referred to the licensing authority.

Class 2
(3) After an ischaemic cardiac event, or revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control angina pectoris, is not acceptable. All applicants should be on acceptable secondary prevention treatment. 

   3.1 A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event, the angiogram and any operative procedures should be available. 
      3.1.1  There should be no stenosis more than 50% in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending to an infarct. More than two stenoses between 30% and 50% within the vascular tree should not be acceptable. 
      3.1.2 The whole coronary vascular tree should be assessed as satisfactory and particular attention should be paid to multiple stenoses and/or multiple revascularisations. 
      3.1.3 An untreated stenosis greater than 30% in the left main or proximal left anterior descending coronary artery should not be acceptable. 

   3.2 At least 6 months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted): 
      3.2.1 an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm disturbance; 
      3.2.2 an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion and a satisfactory left ventricular ejection fraction, not less than 50%; 
      3.2.3 in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram which should show no evidence of reversible myocardial ischaemia. If there is doubt about revascularisation in myocardial infarction or bypass grafting, a perfusion scan should also be required; 
      3.2.4 further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance. 

   3.3 Periodic follow-up should include cardiological review. 

   3.4 After coronary artery bypass grafting, a myocardial perfusion scan (or satisfactory equivalent test) should be performed if there is any indication, and in all cases within five years from the procedure for a fit assessment without a safety pilot limitation. 

   3.5 In all cases, coronary angiography should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia. 

   3.6 Successful completion of the six month or subsequent review will allow a fit assessment. Applicants may fly with a safety pilot limitation having successfully completed only an exercise ECG.

(4) Angina pectoris is disqualifying, whether or not it is abolished by medication.


UK CAA Post Event Flow Chart

Medical Reports - Cardiology