Cardiovascular -Rhythm and Conduction Disturbances

Implementing Rules (IRs), Acceptable Means of Compliance (AMCs) and Guidance Material (GM) on rhythm & conduction disturbances

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 (rhythm and conduction) system.

Implementing Rules

Acceptable Means of Compliance

Guidance Material

MED.B.010 Cardiovascular System

(e) Rhythm/Conduction Disturbances

(1) Applicants for a class 1 medical certificate shall be referred to the licensing authority when they have any significant disturbance of cardiac conduction or rhythm, including any of the following:

Class 1
(e) Rhythm and Conduction Disturbances 
(1) Any significant rhythm or conduction disturbance should require evaluation by a cardiologist and appropriate follow-up in the case of a fit assessment.  Such evaluation should include:
   1.1 exercise ECG to the Bruce protocol or equivalent.  Bruce stage 4 should be achieved and no significant abnormality of rhythm or conduction, or evidence of myocardial ischaemia should be demonstrated.  Withdrawal of cardioactive medication prior to the test should normally be required.
   1.2 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;
   1.3  2D Doppler echocardiogram which should show no significant selective chamber enlargement or significant structural or functional abnormality, and a left ventricular ejection fraction of at least 50%.
 Further evaluation may include (equivalent tests may be substituted):
   1.4 24-hour ECG recording repeated as necessary;
   1.5 electrophysiological study;
   1.6 myocardial perfusion imaging; 
   1.7 cardiac magnetic resonance imaging (MRI);
   1.8 coronary angiogram.

ECG Abnormalities Matrix 

Arrhythmia Medication guidance


Short PR interval
Defined as a PR interval of less than 100ms.
Class 1 initial applicant, or new finding on ECG, requires cardiological review (to establish no history of tachyarrhythmia) and exercise test.

Long PR Interval
Defined as a PR interval of more than 240ms.
Class 1 initial applicant, or new finding on ECG, requires cardiological review, exercise test and 24 hour ECG.

Class 2
Any significant rhythm or conduction disturbance should require cardiological evaluation and an appropriate follow-up in the case of a fit assessment.  An OSL or OPL limitation should be considered as appropriate.




Implementing Rules

Acceptable Means of Compliance

Guidance Material

    
   (i) disturbance of supraventricular rhythm, including intermittent or established sinoatrial dysfunction, atrial fibrillation and/or flutter and asymptomatic sinus pauses;

Class 1
(2) Applicants with frequent or complex forms of supra ventricular or ventricular ectopic complexes require full cardiological evaluation.

(4) Supraventricular Arrhythmias

   4.1 Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, should be assessed as unfit.  A fit assessment may be considered by the licensing authority if cardiological evaluation is satisfactory.


UK CAA Ventricular Ectopy flow chart

   4.2 Atrial fibrillation/flutter 
      4.2.1 For initial applicants, a fit assessment should be limited to those with a single episode of arrhythmia which is considered by the licensing authority to be unlikely to recur. 
      4.2.2 For revalidation, applicants may be assessed as fit if cardiological evaluation is satisfactory. 
   4.3 Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if exercise electrocardiography, echocardiography and 24 hour ambulatory ECG are satisfactory.    
   4.4 Symptomatic sino-atrial disease should be disqualifying.

UK CAA Atrial Fibrillation flow chart

Class 2
(2) Supraventricular Arrhythmias 
   2.1 Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, may be assessed as fit if cardiological evaluation is satisfactory. 
   2.2 Applicants with atrial fibrillation/flutter may be assessed as fit if cardiological evaluation is satisfactory. 
   2.3 Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if cardiological evaluation is satisfactory.




Implementing Rules

Acceptable Means of Compliance

Guidance Material


   (ii) complete left bundle branch block;
Class 1
(7) Complete left bundle branch block A fit assessment may be considered by the licensing authority. 
   7.1 Initial applicants should demonstrate a 3-year period of stability.
   7.2 For revalidation, after a 3-year period with a multi-pilot limitation applied, a fit assessment without multi-pilot limitation may be considered.
   7.3 Investigation of the coronary arteries is necessary for applicants over age 40.

UK CAA Left Bundle Branch Block (LBBB) flow chart
Class 2
(5) Complete left bundle branch block
Applicants with complete left bundle branch block may be assessed as fit subject to satisfactory cardiological assessment.
   
   (iii) Mobitz type 2 atrioventricular block;
Class 1
(5) Mobitz type 2 atrio-ventricular block
Applicants with Mobitz type 2 AV block should require full cardiological evaluation and may be assessed as fit in the absence of distal conducting tissue disease.
Class 2 
(3) Heart Block
   3.1 Applicants with first degree and Mobitz type 1 A-V block may be assessed as fit. 
   3.2 Applicants with Mobitz type 2 AV block may be assessed as fit in the absence of distal conducting tissue disease.
   (iv) broad and/or narrow complex tachycardia;



Implementing Rules

Acceptable Means of Compliance

Guidance Material

  
 (v) ventricular pre-excitation;
Class 1   
(8) Ventricular pre-excitation
A fit assessment may be considered by the licensing authority.
   8.1 Asymptomatic initial applicants with pre-excitation may be assessed as fit by the licensing authority if an electrophysiological study, including adequate drug-induced autonomic stimulation reveals no inducible re-entry tachycardia and the existence of multiple pathways is excluded. 
   8.2 Asymptomatic applicants with pre-excitation may be assessed as fit by the licensing authority at revalidation with a multi-pilot limitation.

UK CAA Wolff-Parkinson White pre-excitation flow chart
Class 2
(6) Ventricular pre-excitation
Asymptomatic applicants with ventricular pre-excitation may be assessed as fit subject to satisfactory cardiological evaluation.



Implementing Rules

Acceptable Means of Compliance

Guidance Material


   (vi) asymptomatic QT prolongation;
Class 1
(10) QT Prolongation
Prolongation of the QT interval on the ECG associated with symptoms should be disqualifying.  Asymptomatic applicants require cardiological evaluation for a fit assessment and a multi-pilot limitation may be required.

   (vii) Brugada pattern on electrocardiography.UK CAA Brugada flow chart
(2) Applicants for a class 2 medical certificate with any of the conditions detailed in (1) shall undergo satisfactory cardiological evaluation before a fit assessment in consultation with the licensing authority can be considered.
(3) Applicants with any of the following:
   (i) incomplete bundle branch block;
   (ii) complete right bundle branch block;
Class 1
(6) Complete right bundle branch block
Applicants with complete right bundle branch block should require cardiological evaluation on first presentation and subsequently:
   6.1 for initial applicants under 40 years of age, a fit assessment may be considered by the licensing authority. Initial applicants over 40 years should demonstrate a period of stability of 12 months;
   6.2 for revalidation, a fit assessment may be considered if the applicant is under 40 years.  A multi-pilot limitation should be applied for 12 months for those over 40 years of age.

UK CAA Complete Right Bundle Branch Block (RBBB) flow chart
Class 2
(4) Complete right bundle branch block
Applicants with complete right bundle branch block may be assessed as fit subject to satisfactory cardiological evaluation.



Implementing Rules

Acceptable Means of Compliance

Guidance Material

   (iii) stable left axis deviation;Left anterior hemi block
requires investigation by means of at least an exercise ECG.  If left anterior hemi block (or left posterior hemi block) is noted in the presence of RBBB, the LBBB flow chart should be followed.
   (iv) asymptomatic sinus bradycardia;Sinus bradycardia
requires investigation if the rate is <40bpm (usually by means of a 24 hour ECG).
   (v) asymptomatic sinus tachycardia;Sinus tachycardia
requires investigation if the rate is consistently >110bpm.
   (vi) asymptomatic isolated uniform supra-ventricular or ventricular ectopic complexes;
   (vii) first degree atrioventricular block;
   (viii) Mobitz type 1 atrioventricular block; may be assessed as fit in the absence of any other abnormality and subject to satisfactory cardiological evaluation.



Implementing Rules

Acceptable Means of Compliance

Guidance Material


(4) Applicants with a history of: 
   (i) ablation therapy;
Class 1
(3) Ablation
Applicants who have undergone ablation therapy should be assessed as unfit.  A fit assessment may be considered by the licensing authority following successful catheter ablation and should require a multi-pilot limitation for at least one year, unless an electrophysiological study, undertaken at a minimum of two months after the ablation, demonstrates satisfactory results.  For those in whom the long term outcome cannot be assured by invasive or non-invasive testing, an additional period with a multi-pilot limitation and/or observation may be necessary.

UK CAA Catheter ablation for tachycardias (except WPW and AVNRT) flow chart

UK CAA Catheter ablation for WPW syndrome and AVNRT flow chart

Class 2
(1) Ablation
A fit assessment may be considered following successful catheter ablation subject to satisfactory cardiological review undertaken at a minimum of two months after the ablation.




Implementing Rules

Acceptable Means of Compliance

Guidance Material


   ii) pacemaker implantation; shall undergo satisfactory cardiovascular evaluation before a fit assessment can be considered.  Applicants for a class 1 medical certificate shall be referred to the licensing authority.  Applicants for a class 2 medical certificate shall be assessed in consultation with the licensing authority.
Class 1
(9) Pacemaker
   9.1 Applicants with a subendocardial pacemaker should be assessed as unfit.  A fit assessment may be considered at revalidation by the licensing authority no sooner than three months after insertion and should require:
      9.1.1 no other disqualifying condition;
      9.1.2 a bipolar lead system, programmed in bipolar mode without automatic mode change of the device;
      9.1.3 that the applicant is not pacemaker dependent;
      9.1.4 regular follow-up, including a pacemaker check; and
      9.1.5 a multi-pilot limitation.

UK CAA Implantation of a Cardiac Pacemaker flow chart
Class 2
(7) Pacemaker
   7.1 Applicants with a subendocardial pacemaker may be assessed as fit no sooner than three months after insertion provided:
      7.1.1 there is no other disqualifying condition;
      7.1.2 a bipolar lead system is used, programmed in bipolar mode without automatic mode change of the device;
      7.1.3 the applicant is not pacemaker dependent; and 
      7.1.4 the applicant has a regular follow-up including a pacemaker check.
(5) Applicants with any of the following conditions shall be assessed as unfit:
   (i) symptomatic sinoatrial disease;
   (ii) complete atrioventricular block;
   (iii) symptomatic QT prolongation;
   (iv) an automatic implantable defibrillating system;
   (v) a ventricular anti-tachycardia pacemaker.