• Implementing Rules 

    Acceptable means of compliance 

    Guidance material 

    MED.B.010 Cardiovascular System Examination     
    (a) Examination

    (1) A standard 12-lead resting electrocardiogram (ECG) and report shall be completed when clinically indicated and at the following moments:

    (i) for a class 1 medical certificate, at the initial examination, then every 5 years until age 30, every 2 years until age 40, annually until age 50, and at all revalidation or renewal examinations thereafter;

    (ii) for a class 2 medical certificate, at the initial examination, at the first examination after age 40 and then at the first examination after age 50, and every 2 years thereafter.

     

     

    Investigation of ECG abnormalities table (PDF)


    CAA ECG reporting system (PDF)

    ECG Diagnostic Statements Advice on acceptable ECG diagnostic software and acceptable diagnostic statements (PDF)
     

     
    (2) An extended cardiovascular assessment shall be required when clinically indicated.   

    Extended cardiovascular assessment


    An extended cardiovascular assessment should include a clinical report of an examination by an accredited physician/cardiologist, an exercise ECG and any other test that is clinically indicated.

     
    (3) For a class 1 medical certificate, an extended cardiovascular assessment shall be completed at the first revalidation or renewal examination after age 65 and every 4 years thereafter.   

    Age 65 and over extended cardiovascular assessment.


    When a professional licence holder reaches the age of 65, they will be sent a standard letter from the UK CAA to advise them of the need for an extended cardiovascular assessment within the next six months.  This will include an exercise ECG or other test that will provide equivalent information.  If the pilot has had an acceptable review and exercise test (or equivalent) within the preceding two years, this will be deemed as acceptable to meet this requirement.  They will require follow-up four years from the last test or sooner if clinically indicated.

    (4) For a class 1 medical certificate, estimation of serum lipids, including cholesterol, shall be required at the initial examination, and at the first examination after having reached the age of 40     
      CLASS 1 - AMC1 MED.B.010  

     

    (a) Examination

    Exercise electrocardiography

    An exercise ECG when required as part of a cardiovascular assessment should be symptom limited and completed to a minimum of Bruce Stage IV or equivalent.

    CLASS 2 - AMC2 MED.B.010   

    (a) Examination

    Exercise electrocardiography

    An exercise ECG when required as part of a cardiovascular assessment should be symptom-limited and completed to a minimum of Bruce Stage IV or equivalent.

    .
     

    Exercise electrocardiography
    (instructions for the Bruce Protocol - PDF)

     
      CLASS 1 - AMC1 MED.B.010  

     

    (b) General 

    (1) Cardiovascular risk factor assessment

     

    (i) Serum lipid estimation is case finding and significant abnormalities should be reviewed, investigated and supervised by the AeMC or AME in consultation with the medical assessor of the licensing authority.

     

    (ii) Applicants with an accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should undergo a cardiovascular evaluation by the AeMC or AME, if necessary in consultation with the medical assessor of the licensing authority.
      
    (2) Cardiovascular assessment

     

    (i) Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist.

    (ii) The extended cardiovascular assessment should be undertaken at an AeMC or may be delegated to a cardiologist.

    CLASS 2 - AMC2 MED.B.010  

     

    (b) General 

     

    (1) Cardiovascular risk factor assessment
    Applicants with an accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should undergo a cardiovascular evaluation by the AeMC or AME.

    (2) Cardiovascular assessment
    Reporting of resting and exercise electrocardiograms should be by the AME or an accredited specialist.

     

    Cardiovascular risk assessment

    A cardiovascular risk assessment tool

































    Cardiovascular risk assessment

    A cardiovascular risk assessment tool
     

     

    Implementing Rules 

    Acceptable means of compliance 

    Guidance material 

    MED.B.010 Cardiovascular System     
    (b) Cardiovascular System - General

    (1) Applicants for a class 1 medical certificate with any of the following medical conditions shall be assessed as unfit:

    (i) aneurysm of the thoracic or supra-renal abdominal aorta, before surgery;

    (ii) significant functional or symptomatic abnormality of any of the heart valves; 

    (iii) heart or heart/lung transplantation;

    (iv) symptomatic hypertrophic cardiomyopathy.


     
      Medical reports - Cardiology  (PDF) 
    (2) Before further consideration is given to their application, applicants for a class 1 medical certificate with a documented medical history or diagnosis of any of the following medical conditions shall be referred to the medical assessor of the licensing authority:     

    (i) peripheral arterial disease before or after surgery;

    CLASS 1 - AMC1 MED.B.010  

    (c)   Peripheral arterial disease

    If there is no significant functional impairment, a fit assessment may be considered provided:

    (1) applicants without symptoms of coronary artery disease have reduced any vascular risk factors to an appropriate level;
    (2) applicants should be on appropriate secondary prevention treatment;
    (3) exercise electrocardiography is 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. 
    Medical Reports - Cardiology (PDF)

     
    (ii) aneurysm of the thoracic or supra-renal abdominal aorta after surgery;

    (iii) aneurysm of the infra-renal abdominal aorta before or after surgery;

     

    CLASS 1 - AMC1 MED.B.010 

    (d) Aortic aneurysm

    (1) Applicants with an aneurysm of the infra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit before surgery, with an OML subject to satisfactory evaluation by a cardiologist. Follow-up by ultra-sound scans or other imaging techniques, as necessary, should be determined by the medical assessor of the licensing authority.

    (2) Applicants may be assessed as fit with an OML after surgery for an aneurysm of the thoracic or abdominal aorta if the blood pressure and cardiovascular evaluation is satisfactory. Regular evaluations by a cardiologist should be carried out.

    Thoracic and Abdominal Aortic Aneurysms Guidance

    UK CAA Dilated Aortic Root (PDF) flow chart

     

    Medical Reports - Cardiology (PDF)

     

    (iv) functionally insignificant cardiac valvular abnormalities; 

    CLASS 1 - AMC1 MED.B.010  

    (e) Cardiac valvular abnormalities

    (1) Applicants with previously unrecognised cardiac murmurs should undergo evaluation by a cardiologist and assessment by the medical assessor of the licensing authority. If considered significant, further investigation should include at least 2D Doppler echocardiography or equivalent imaging.

    (2) Applicants with minor cardiac valvular abnormalities may be assessed as fit. Applicants with significant abnormality of any of the heart valves should be assessed as unfit.
     

    Medical Reports - Cardiology (PDF)
      CLASS 1 - AMC1 MED.B.010 (e)

     

    (3) Aortic valve disease

    (i) Applicants with a 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 medical assessor of the licensing authority. 

    (ii) Applicants with aortic stenosis may be assessed as fit provided the left ventricular function is intact and the mean pressure gradient is less than 20 mmHg. Applicants with an aortic valve orifice with indexation on the body surface of more than 0.6 cm2/m2 and a mean pressure gradient above 20 mmHg, but not greater than 50 mmHg, may be assessed as fit with an OML. Follow-up with 2D Doppler echocardiography, as necessary, should be determined by the medical assessor of the licensing authority in all cases. Alternative measurement techniques with equivalent ranges may be used. Regular evaluation by a cardiologist should be considered. Applicants with a history of systemic embolism or significant dilatation of the thoracic aorta should be assessed as unfit.

    (iii) Applicants with trivial aortic regurgitation may be assessed as fit. A greater degree of aortic regurgitation should require an OML. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined by the medical assessor of the licensing authority.

    UK CAA Aortic Stenosis (PDF) flow chart

    Medical Reports - Cardiology (PDF)

     

      CLASS 1 - AMC1 MED.B.010 (e)

     

    (3) Aortic valve disease

    (i) Applicants with a 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 medical assessor of the licensing authority. 

    (ii) Applicants with aortic stenosis may be assessed as fit provided the left ventricular function is intact and the mean pressure gradient is less than 20 mmHg. Applicants with an aortic valve orifice with indexation on the body surface of more than 0.6 cm2/m2 and a mean pressure gradient above 20 mmHg, but not greater than 50 mmHg, may be assessed as fit with an OML. Follow-up with 2D Doppler echocardiography, as necessary, should be determined by the medical assessor of the licensing authority in all cases. Alternative measurement techniques with equivalent ranges may be used. Regular evaluation by a cardiologist should be considered. Applicants with a history of systemic embolism or significant dilatation of the thoracic aorta should be assessed as unfit.

    (iii) Applicants with trivial aortic regurgitation may be assessed as fit. A greater degree of aortic regurgitation should require an OML. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined by the medical assessor of the licensing authority.

     
      CLASS 1 - AMC1 MED.B.010 (e)

     

    (4) 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 minor regurgitation may be assessed as fit. Periodic cardiological review should be determined by the medical assessor of the licensing authority.

    (iv) Applicants with moderate mitral regurgitation may be considered as fit with an OML 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 medical assessor of 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.

     
    (v) after cardiac valve surgery;  AMC1 MED.B.010  

     

    (f) Valvular surgery
    Applicants who have undergone cardiac valve replacement or repair should be assessed as unfit. A fit assessment may be considered in the following cases:
     

    (1) 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.

    (2) 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 an OML. Investigations which demonstrate normal valvular and ventricular configuration and function should have been completed as demonstrated by:

    (i) 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 is suspected;

    (ii) 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 medical assessor of the licensing authority. 

    (3) Where anticoagulation is needed after valvular surgery, a fit assessment with an OML may be considered if the haemorrhagic risk is acceptable and the anticoagulation is stable. Anticoagulation should be considered stable if, within the last 6 months, at least 5 international normalised ratio (INR) values are documented, of which at least 4 are within the INR target range. The INR target range should be determined by the type of surgery performed. 

     

    UK CAA  Aortic Valve Replacement (PDF) flow chart 

     

    Medical reports - Cardiology (PDF)

    Mitral Valve Repair

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

     

    (vi) abnormality of the pericardium, myocardium or endocardium;  CLASS 1 - AMC1 MED.B.010   

     

    (h) Other cardiac disorders

    (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 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 an OML may be required after fit assessment.

     

    (2) Applicants with a congenital abnormality of the heart should be assessed as unfit. Applicants following surgical correction or with minor abnormalities that are functionally unimportant may be assessed as fit following cardiological evaluation. No cardioactive medication is acceptable. Investigations may include 2D Doppler echocardiography, exercise ECG and 24-hour ambulatory ECG. The potential hazard of any medication should be considered as part of the assessment. Particular attention should be paid to the potential for the medication to mask the effects of the congenital abnormality before or after surgery. Regular cardiological evaluations should be carried out.

     

    UK CAA  Hypertrophic Cardiomyopathy (PDF) flow chart

     

    Medical reports - Cardiology (PDF)

    Acute Benign Aseptic Pericarditis 

    Recertification can be considered 3 months after recovery to Class 1 OML 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 pericardiectomy to Class 1 OML 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.

     

    (vii) congenital abnormality of the heart, before or after corrective surgery;     
    (viii) vasovagal syncope of uncertain cause;  CLASS 1 - AMC1 MED.B.010  

     

    (i) Syncope

    (1) In the case of a single episode of vasovagal syncope which can be explained and is compatible with flight safety, a fit assessment may be considered.

    (2) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered after a 6-month period without recurrence, provided cardiological evaluation is satisfactory. Such evaluation should include:

    (i) 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 or equivalent test should be carried out;

    (ii) a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium;

    (iii) a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia.

    (3) A tilt test, or equivalent, carried out to a standard protocol showing no evidence of vasomotor instability may be required.

    (4) Neurological review should be required.

    (5) An OML should be required until a period of 5 years has elapsed without recurrence. The medical assessor of the licensing authority may determine a shorter or longer period of OML according to the individual circumstances of the case.

    (6) Applicants who experienced loss of consciousness without significant warning should be assessed as unfit.

     

    UK CAA  Neurocardiogenic Syncope (PDF) flow chart

    Medical reports - Cardiology (PDF)

     

    (ix) arterial or venous thrombosis;

    (x) pulmonary embolism;

    (xi) cardiovascular condition requiring systemic anticoagulant therapy.

     
    CLASS 1 - AMC1 MED.B.010  

     

    (g) Thromboembolic disorders

    Applicants with arterial or venous thrombosis or pulmonary embolism should be assessed as unfit. A fit assessment with an OML may be considered after a period of stable anticoagulation as prophylaxis, after review by the medical assessor of 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 and the haemorrhagic risk is acceptable. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months. Applicants with pulmonary embolism should also be evaluated by a cardiologist. Following cessation of anticoagulant therapy, for any indication, applicants should undergo a re-assessment by the medical assessor of the licensing authority.

     

    Anticoagulant Therapy 

    Certification to Class 1 OML level is possible on anticoagulant therapy. 

     

    (3) Applicants for a class 2 medical certificate with an established diagnosis of one of the conditions specified in points (1) and (2) shall be evaluated by a cardiologist before they may be assessed as fit, in consultation with the medical assessor of the licensing authority.

     (4) Applicants with cardiac disorders other than those specified in points (1) and (2) may be assessed as fit subject to satisfactory cardiological evaluation.

     
       

     

    Implementing rules  Acceptable means of compliance  Guidance material 
    MED.B.010 Cardiovascular System      
    (b) Cardiovascular System - General

    (1) Applicants for a class 1 medical certificate with any of the following medical conditions shall be assessed as unfit:

    (i) aneurysm of the thoracic or supra-renal abdominal aorta, before surgery;

    (ii) significant functional or symptomatic abnormality of any of the heart valves; 

    (iii) heart or heart/lung transplantation;

    (iv) symptomatic hypertrophic cardiomyopathy.

     
      Medical reports - Cardiology  (PDF) 

    (2) Before further consideration is given to their application, applicants for a class 1 medical certificate with a documented medical history or diagnosis of any of the following medical conditions shall be referred to the medical assessor of the licensing authority:

       
    (i) peripheral arterial disease before or after surgery;  CLASS 2 - AMC2 MED.B.010   
    (c) 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.

     

    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 an 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. 

    Medical Reports - Cardiology (PDF)

     

    (ii) aneurysm of the thoracic or supra-renal abdominal aorta after surgery;

    (iii) aneurysm of the infra-renal abdominal aorta before or after surgery;
     
    CLASS 2 - AMC2 MED.B.010

     

    (d) Aortic aneurysm

    (1) Applicants with an aneurysm of the infra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.

    (2) Applicants with an aneurysm of the thoracic or supra-renal abdominal aorta of less than 5 cm in diameter may be assessed as fit with an ORL or OSL, subject to satisfactory cardiological evaluation. Regular follow-up should be carried out.

    (3) Applicants may be assessed as fit after surgery for an infra-renal abdominal aortic aneurysm, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.

    (4) Applicants may be assessed as fit with an ORL or OSL after surgery for a thoracic or supra-renal abdominal aortic aneurysm, subject to satisfactory cardiological evaluation. Regular cardiological evaluations should be carried out.


     

    Thoracic and Abdominal Aortic Aneurysms Guidance

    UK CAA Dilated Aortic Root (PDF) flow chart

     

    Medical Reports - Cardiology (PDF)

     

    (iv) functionally insignificant cardiac valvular abnormalities; 

    CLASS 2 - AMC2 MED.B.010   

    (e) Cardiac valvular abnormalities

    (1) Applicants with previously unrecognised cardiac murmurs should undergo further cardiological evaluation. 

    (2) Applicants with minor cardiac valvular abnormalities may be assessed as fit.

     

    Medical Reports - Cardiology (PDF) 
      CLASS 2 - AMC2 MED.B.010 (e)  

     

    (3) Aortic valve disease

    (i) Applicants with a 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 in consultation with the medical assessor of the licensing authority.

     

    (ii) Applicants with aortic stenosis may be assessed as fit provided the left ventricular function is intact and the mean pressure gradient is less than 20 mmHg. Applicants with an aortic valve orifice of more than 1 cm2 and a mean pressure gradient above 20 mmHg, but not greater than 50 mmHg, may be assessed as fit with an ORL or OSL. Follow-up with 2D Doppler echocardiography, as necessary, should be determined in consultation with the medical assessor of the licensing authority in all cases. Alternative measurement techniques with equivalent ranges may be used. Regular cardiological evaluation should be considered. Applicants with a history of systemic embolism or significant dilatation of the thoracic aorta should be assessed as unfit.

     

    (iii) Applicants with trivial aortic regurgitation may be assessed as fit. Applicants with a greater degree of aortic regurgitation may be assessed as fit with an OSL. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Follow-up, as necessary, should be determined in consultation with the medical assessor of the licensing authority.

     


    UK CAA Aortic Stenosis (PDF) flow chart

    Medical Reports - Cardiology (PDF)

     

      CLASS 2 - AMC2 MED.B.010 (e)

     

    (4) 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 be assessed as unfit.

    (iii) Applicants with minor regurgitation may be assessed as fit. Periodic cardiological review should be determined in consultation with the medical assessor of the licensing authority.

    (iv) Applicants with moderate mitral regurgitation may be considered as fit with an ORL or OSL if the 2D Doppler echocardiogram demonstrates satisfactory left ventricular dimensions and satisfactory myocardial function is confirmed by exercise electrocardiography. Periodic cardiological review should be determined in consultation with the medical assessor of 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. 

     

    UK CAA Mitral Valve Disease (PDF) flow chart

     

    Medical reports - Cardiology (PDF)

     

    (v) after cardiac valve surgery;  AMC2 MED.B.010  

     

    (f) Valvular surgery

    (1) Applicants who have undergone cardiac valve replacement or repair may be assessed as fit without limitations subject to satisfactory post-operative cardiological evaluation and if no anticoagulants are needed.

    (2) Where anticoagulation is needed after valvular surgery, a fit assessment with an ORL or OSL may be considered after cardiological evaluation if the haemorrhagic risk is acceptable. 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. The INR target range should be determined by the type of surgery performed. Applicants who measure their INR on a 'near patient' testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range, may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.

     

    UK CAA  Aortic Valve Replacement (PDF) flow chart 

     

    Medical reports - Cardiology (PDF)

     

    Mitral Valve Repair

    After mitral valve repair, recertification to 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.

     

    (vi) abnormality of the pericardium, myocardium or endocardium;  CLASS 2 - AMC2 MED.B.010  

     

    (h) Other cardiac disorders

    (1) Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium may be assessed as fit subject to satisfactory cardiological evaluation.

    (2) Applicants with a congenital abnormality of the heart, including those who have undergone surgical correction, may be assessed as fit subject to satisfactory cardiological evaluation. Cardiological follow-up may be necessary and should be determined in consultation with the medical assessor of the licensing authority.

     

    UK CAA  Hypertrophic Cardiomyopathy (PDF) flow chart

    Medical reports - Cardiology (PDF)

    Acute Benign Aseptic Pericarditis 

    Recertification can be considered 3 months after recovery to 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. Follow-up can usually be discontinued after 2 years. 

    Constrictive Pericarditis 

    Recertification can be considered after pericardiectomy to 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.

     

    (vii) congenital abnormality of the heart, before or after corrective surgery;     
    (viii) vasovagal syncope of uncertain cause;  CLASS 2 - AMC2 MED.B.010  

     

    (i) Syncope

    (1) In the case of a single episode of vasovagal syncope which can be explained and is compatible with flight safety, a fit assessment may be considered.

    (2) Applicants with a history of recurrent vasovagal syncope should be assessed as unfit. A fit assessment may be considered after a 6-month period without recurrence, providing cardiological evaluation is satisfactory. Neurological review may be indicated.


     

    UK CAA  Neurocardiogenic Syncope (PDF) flow chart

     

    Medical reports - Cardiology (PDF)

     

    (ix) arterial or venous thrombosis;

    (x) pulmonary embolism;

    (xi) cardiovascular condition requiring systemic anticoagulant therapy.

     
    CLASS 2 - AMC2 MED.B.010   

     

    (g) Thromboembolic disorders

    Applicants with arterial or venous thrombosis or pulmonary embolism should be assessed as unfit. A fit assessment with an ORL or OSL may be considered after a period of stable anticoagulation as prophylaxis in consultation with the medical assessor of 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 and the haemorrhagic risk is acceptable. Applicants who measure their INR on a 'near patient' testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months. Applicants with pulmonary embolism should also undergo a cardiological evaluation. Following cessation of anticoagulant therapy for any indication, applicants should undergo a re-assessment in consultation with the medical assessor of the licensing authority.

     

    Anticoagulant Therapy 

     

    Certification to unrestricted Class 2 level is possible on anticoagulant therapy. 
     

    (3) Applicants for a class 2 medical certificate with an established diagnosis of one of the conditions specified in points (1) and (2) shall be evaluated by a cardiologist before they may be assessed as fit, in consultation with the medical assessor of the licensing authority.

     (4) Applicants with cardiac disorders other than those specified in points (1) and (2) may be assessed as fit subject to satisfactory cardiological evaluation.

     
    CLASS 2 - AMC2 MED.B.010  

     

    (m) Heart or heart/lung transplantation
    (1) Applicants who have undergone heart or heart/lung transplantation may be assessed as fit, with appropriate limitation(s) such as an ORL, no sooner than 12 months after transplantation, provided that cardiological evaluation is satisfactory with:

    (i) no rejection in the first year following transplantation;

    (ii) no significant arrhythmias;

    (iii) a left ventricular ejection fraction ≥ 50%;

    (iv) a symptom limited exercise ECG; and

    (v) a coronary angiogram if indicated;

    (2) Regular cardiological evaluations should be carried out.

     

    Heart and Heart Lung Transplant Guidance 

     

    MED.B.010 Cardiovascular System    

    (c) Blood Pressure

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

    (2) Applicants whose blood pressure is not within normal limits shall be further assessed with regard to their cardiovascular condition and medication with a view to determining whether they are to be assessed as unfit in accordance with points (3) and (4).

    (3)       Applicants for a class 1 medical certificate with any of the following medical conditions shall be assessed as unfit:

    (i)        symptomatic hypotension;

    (ii)       blood pressure at examination consistently exceeding 160 mmHg systolic or 95 mmHg diastolic, with or without treatment.

    (4)       Applicants who have commenced the use of medication for the control of blood pressure shall be assessed as unfit until the absence of significant side effects has been established.

     

    CLASS 1 - AMC1 MED.B.010  

    (j) Blood pressure

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

    (2) Anti-hypertensive treatment should be agreed by the medical assessor of the licensing authority. Acceptable medication may include:

    (i) non-loop diuretic agents;

    (ii) ACE inhibitors;

    (iii) angiotensin II receptor blocking agents (sartans);

    (iv) channel calcium blocking agents;

    (v) certain (generally hydrophilic) beta-blocking agents.

    (3) Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that satisfactory control has been achieved and the treatment is compatible with the safe exercise of the privileges of the applicable licence(s).

     

    CLASS 2 - AMC2 MED.B.010  

     

    (j)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 satisfactory control has been achieved and that the treatment is compatible with the safe exercise of the privileges of the applicable licence(s).

     

    UK CAA Hypertension flow chart (PDF)

    Medical reports - Hypertension (PDF)

    Guidance on BP measurement

    (d) Coronary Artery Disease

    (1) Before further consideration is given to their application, applicants for a class 1 medical certificate with any of the following medical conditions shall be referred to the medical assessor of the licensing authority and undergo cardiological evaluation to exclude myocardial ischaemia:

    (i) suspected myocardial ischaemia;

    (ii) asymptomatic minor coronary artery disease requiring no anti-anginal treatment.

    (2) Before further consideration is given to their application, applicants for a class 2 medical certificate with any of the medical conditions set out in point (1) shall undergo satisfactory cardiological evaluation.

                       

    CLASS 1 - AMC1 MED.B.010

    (k) Coronary artery disease

    (1) Chest pain of uncertain cause should require full investigation. Applicants with angina pectoris should be assessed as unfit, whether or not it is alleviated by medication.

    (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 - AMC2 MED.B.010

    (k) Coronary artery disease

    (1) Chest pain of uncertain cause requires full investigation.

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

     

    UK CAA Investigation of suspected coronary artery disease flow chart (PDF)

    Medical Reports - Cardiology (PDF)

    (3) Applicants with any of the following medical conditions shall be assessed as unfit:

    (i)myocardial ischaemia;

    (ii) symptomatic coronary artery disease;

    (iii) symptoms of coronary artery disease controlled by medication.

     

    (4) Applicants for the initial issue of a class 1 medical certificate with a medical history or diagnosis of any of the following medical conditions shall be assessed as unfit:

    (i) myocardial ischaemia;

    (ii) myocardial infarction;

    (iii) revascularisation or stenting for coronary artery disease.

         

    CLASS 1 - AMC1 MED.B.010 (k)  

    (3) Applicants with evidence of exercise-induced myocardial ischaemia should be assessed as unfit.

    (4) After an ischaemic cardiac event or revascularisation procedure, applicants should have reduced cardiovascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on appropriate secondary prevention treatment.

    (i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event or revasculisation procedure and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be made available to the medical assessor of the licensing authority:

    (A) 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;

    (B) 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;

    (C) Applicants with an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should be assessed as unfit.

    (ii) At least 6 months from the ischaemic myocardial event or revascularisation procedure, the following investigations should be completed (equivalent tests may be substituted):

    (A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm or conduction disturbance;

    (B) 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;

    (C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, or equivalent test, 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, or equivalent test, should also be carried out;

    (D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance.

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

    (A) After coronary artery 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.

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

    (iv) Successful completion of the 6-month or subsequent review will allow a fit assessment with an OML.

    CLASS 2 - AMC2 MED.B.010 (k)   

    (3) Applicants with evidence of exercise-induced myocardial ischaemia should be assessed as unfit.

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

    (i) A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be available to the AME.

    (A) 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.

    (B) 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.

    (C)  Applicants with an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should be assessed as unfit.

    (ii) At least 6 months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed (equivalent tests may be substituted):

    (A) an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm disturbance;

    (B) an echocardiogram showing satisfactory left ventricular function with no important abnormality of wall motion and a satisfactory left ventricular ejection fraction of 50 % or more;

    (C) in cases of angioplasty/stenting, a myocardial perfusion scan or stress echocardiogram, or equivalent test, which should show no evidence of reversible myocardial ischaemia. If there is doubt about revascularisation in myocardial infarction or bypass grafting, a perfusion scan, or equivalent test, should also be carried out;

    (D) further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance.

    (iii) Periodic follow-up should include a cardiological evaluation.

    (A) After coronary artery bypass grafting, a myocardial perfusion scan (or 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 an OSL, OPL or ORL.

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

    (iv) Successful completion of the six-month or subsequent review will allow a fit assessment. Applicants may be assessed as fit with an ORL having successfully completed only an exercise ECG.

    (5) Applicants with angina pectoris should be assessed as unfit, whether or not it is alleviated by medication.

       
       

    UK CAA Post Event Flow Chart (PDF)

    Medical Reports - Cardiology (PDF)

     
    (5) Before further consideration is given to their application, applicants for a class 2 medical certificate who are asymptomatic following myocardial infarction or surgery for coronary artery disease shall undergo satisfactory cardiological evaluation, in consultation with the medical assessor of the licensing authority. Such applicants for the revalidation of a class 1 medical certificate shall be referred to the medical assessor of the licensing authority.      

     


     

     

     

    Implementing Rules  Acceptable means of compliance  Guidance Material 
    Cardiovascular rhythm and conduction
    disturbances - Class 1
       
    (e) Rhythm/Conduction Disturbances

    (1) Applicants with any of the following medical 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.
     
    CLASS 1 - AMC1 MED.B.010  

     

    (l) Rhythm and conduction disturbances

    (1) Applicants with significant rhythm or conduction disturbance should undergo evaluation by a cardiologist before a fit assessment with an OML, as necessary, may be considered. Appropriate follow-up should be carried out at regular intervals. Such evaluation should include:

    (i) 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;

    (ii) 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;

    (iii) 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):

    (iv) 24-hour ECG recording repeated as necessary;

    (v) electrophysiological study;

    (vi) myocardial perfusion imaging;

    (vii) cardiac magnetic resonance imaging (MRI);

    (viii) coronary angiogram.

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


     

    Investigation of ECG Abnormalities table(PDF)

     

    Arrhythmia Medication guidance 

    UK CAA Ventricular Ectopy (PDF) flow chart

    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 1 - AMC1 MED.B.010 (l)

    (3) Where anticoagulation is needed for a rhythm disturbance, a fit assessment with an OML may be considered if the haemorrhagic risk is acceptable and 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. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months.

     


    Anticoagulant Therapy 

    Certification to Class 1 OML level is possible on anticoagulant therapy. 

     

     
    (2) Before further consideration is given to their application, applicants for a class 1 medical certificate having any significant disturbance of cardiac conduction or rhythm, including any of the following, shall be referred to the medical assessor of the licensing authority:
     
       
    (i) disturbance of supraventricular rhythm, including intermittent or established sinoatrial dysfunction, atrial fibrillation and/or flutter and asymptomatic sinus pauses;  CLASS 1 - AMC1 MED.B.010  (l)

     

    (5) Supraventricular arrhythmias
    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 if cardiological evaluation is satisfactory.

    (i) Atrial fibrillation/flutter

    (A) For initial applicants, a fit assessment should be limited to those with a single episode of arrhythmia which is considered by the medical assessor of the licensing authority to be unlikely to recur.

    (B) For revalidation, applicants may be assessed as fit if cardiological evaluation is satisfactory and the stroke risk is sufficiently low. A fit assessment with an OML may be considered after a period of stable anticoagulation as prophylaxis, after review by the medical assessor of 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. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an OML may be considered after review by the medical assessor of the licensing authority after a stabilisation period of 3 months.

    (ii) 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.

    (iii) Applicants with symptomatic sino-atrial disease should be assessed as unfit.

     

    UK CAA Atrial Fibrillation (PDF) flow chart

    Anticoagulant Therapy 

     

    Certification to Class 1 OML level is possible in some cases on anticoagulant therapy. 
     

    (ii) complete left bundle branch block;

     

    CLASS 1 - AMC1 MED.B.010  (l)

    (8) Complete left bundle branch block

    (i) A fit assessment may be considered subject to satisfactory cardiological evaluation and a 3-year period with an OML, and without an OML after 3 years of surveillance and satisfactory cardiological evaluation.

     (ii) Investigation of the coronary arteries is necessary for applicants over age 40.

     

    UK CAA Left Bundle Branch Block (PDF) (LBBB) flow chart 
    (iii) Mobitz type 2 atrioventricular block; 

    CLASS 1 - AMC1 MED.B.010  (l)

    (6) 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.

     

     
    (iv) broad and/or narrow complex tachycardia;     
    (v) ventricular pre-excitation;  CLASS 1 - AMC1 MED.B.010  (l)

     

    (9) Ventricular pre-excitation

    (i) Asymptomatic initial applicants with pre-excitation may be assessed as fit if an electrophysiological study, including adequate drug-induced autonomic stimulation reveals no inducible re-entry tachycardia and the existence of multiple pathways is excluded.

    (ii) Asymptomatic applicants with pre-excitation may be assessed as fit at revalidation with limitation(s) as appropriate. Limitations may not be necessary if an electrophysiological study, including adequate drug-induced autonomic stimulation, reveals no inducible re-entry tachycardia and the existence of multiple accessory pathways is excluded.

     

    UK CAA Wolff-Parkinson White pre-excitation (PDF) flow chart 

    (vi) asymptomatic QT prolongation;
     
    CLASS 1 - AMC1 MED.B.010  (l)

     

    (11) QT prolongation
    Applicants with asymptomatic QT prolongation may be assessed as fit with an OML subject to satisfactory cardiological evaluation.

     

     
    (vii) Brugada pattern on electrocardiography. 

    CLASS 1 - AMC1 MED.B.010  (l)

    12) Brugada pattern on electrocardiography
    Brugada Pattern on electrocardiography
    Applicants with Brugada pattern Type 1 who are symptomatic or have evidence of
    tachyarrhythmia should be assessed as unfit. Applicants with asymptomatic Type 1, Type 2
    or Type 3 may be assessed as fit, with limitation(s) as appropriate, subject to satisfactory cardiological evaluation.

     

    UK CAA Brugada (PDF) flow chart 
    (3) Before further consideration is given to their application, applicants for a class 2 medical certificate with any of the medical conditions specified in point (2) shall undergo satisfactory cardiological evaluation, in consultation with the medical assessor of the licensing authority.     
    (4) Applicants with any of the following medical conditions may be assessed as fit subject to satisfactory cardiological evaluation and in the absence of any other abnormality:     
    (i) incomplete bundle branch block;     
    (ii) complete right bundle branch block; 

    CLASS 1 - AMC1 MED.B.010  (l)

    (7) Complete right bundle branch block

    (i) Applicants with complete right bundle branch block should undergo a cardiological evaluation on first presentation. A fit assessment may be considered if there is no underlying pathology.

    (ii) Applicants with bifascicular block may be assessed as fit with an OML after a satisfactory cardiological evaluation. The OML may be considered for removal if an electrophysiological study demonstrates no infra-Hissian block, or a 3-year period of satisfactory surveillance has been completed.

     

    UK CAA Complete Right Bundle Branch Block (PDF) (RBBB) flow chart 
    (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 (PDF) 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.     
    (5) Applicants with a medical history of any of the following medical conditions shall undergo satisfactory cardiovascular evaluation before they may be assessed as fit:      
    (i) ablation therapy;  CLASS 1 - AMC1 MED.B.010 (l) 

     

    (4) Ablation

    Applicants who have undergone ablation therapy should be assessed as unfit. A fit assessment may be considered following successful catheter ablation and should require an OML for at least one year, unless an electrophysiological study, undertaken at a minimum of 2 months after the ablation, demonstrates satisfactory results. For those whose long-term outcome cannot be assured by invasive or non-invasive testing, an additional period with an OML and/or observation may be necessary.

     

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

     

    UK CAA Catheter ablation for WPW syndrome and AVNRT (PDF) flow chart

     

    (ii) pacemaker implantation.  CLASS 1 - AMC1 MED.B.010  (l)

    (10) Pacemaker
    Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment with an OML may be considered at revalidation no sooner than 3 months after insertion provided:

    (i) there is no other disqualifying condition;

    (ii) a bipolar lead system, programmed in bipolar mode without automatic mode change has been used;

    (iii) the applicant is not pacemaker dependent; and

    (iv) the applicant has a follow-up at least every 12 months, including a pacemaker check.

     

    UK CAA Implantation of a Cardiac Pacemaker (PDF) flow chart 
    Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. Such applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.     

     

    Implementing Rules  Acceptable means of compliance  Guidance Material 
    Cardiovascular rhythm and conduction
    disturbances - Class 2
       
    (e) Rhythm/Conduction Disturbances

    (1) Applicants with any of the following medical 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.

     
    CLASS 2 - AMC2 MED.B.010   

     

    (l) Rhythm and conduction disturbances

    (1) Applicants with significant rhythm or conduction disturbance should undergo cardiological evaluation before a fit assessment may be considered with an ORL or OSL, as appropriate. Such evaluation should include:

    (i) 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;

    (ii) 24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;

    (iii) 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):
    (iv) 24-hour ECG recording repeated as necessary;
    (v) electrophysiological study;
    (vi) myocardial perfusion imaging;
    (vii) cardiac magnetic resonance imaging (MRI);
    (viii) coronary angiogram.

     

    Investigation of ECG Abnormalities table  (PDF)

     

    Arrhythmia Medication guidance 

    UK CAA Ventricular Ectopy (PDF) flow chart

    Short PR interval

    Defined as a PR interval of less than 100ms.  
    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. 
    New finding on ECG, requires cardiological review, exercise test and 24 hour ECG.

     

      CLASS 2 - AMC2 MED.B.010 (l)   

     

    (2) Where anticoagulation is needed for a rhythm disturbance, a fit assessment with an ORL or OSL may be considered, if the haemorrhagic risk is acceptable and 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. Applicants who measure their INR on a 'near patient' testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.

     

    Anticoagulant Therapy 

     

    Certification to unrestricted Class 2 level is possible on anticoagulant therapy. 

     

    (2) Before further consideration is given to their application, applicants for a class 1 medical certificate having any significant disturbance of cardiac conduction or rhythm, including any of the following, shall be referred to the medical assessor of the licensing authority:     
    (i) disturbance of supraventricular rhythm, including intermittent or established sinoatrial dysfunction, atrial fibrillation and/or flutter and asymptomatic sinus pauses;  CLASS 2 - AMC2 MED.B.010 (l)  

     

    (4) Supraventricular arrhythmias

    (i) Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, may be assessed as fit if cardiological evaluation is satisfactory.

    (ii) Applicants with atrial fibrillation/flutter may be assessed as fit if cardiological evaluation is satisfactory and the stroke risk is sufficiently low. Where anticoagulation is needed, a fit assessment with an ORL or OSL may be considered after a period of stable anticoagulation as prophylaxis, in consultation with the medical assessor of 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. Applicants who measure their INR on a 'near patient' testing system within 12 hours prior to flight and only exercise the privileges of their licence(s) if the INR is within the target range may be assessed as fit without the above-mentioned limitation. The INR results should be recorded and the results should be reviewed at each aero-medical assessment. Applicants taking anticoagulation medication not requiring INR monitoring, may be assessed as fit without the above-mentioned limitation in consultation with the medical assessor of the licensing authority after a stabilisation period of 3 months.

    (iii) Applicants with asymptomatic sinus pauses up to 2.5 seconds on resting electrocardiography may be assessed as fit if cardiological evaluation is satisfactory.

     

    UK CAA Atrial Fibrillation (PDF) flow chart

    Anticoagulant Therapy 
    Certification to unrestricted Class 2 level is possible in some cases on anticoagulant therapy. 

     
    (ii) complete left bundle branch block;  CLASS 2 - AMC2 MED.B.010   (l)

     

    (7) Complete left bundle branch block
    Applicants with complete left bundle branch block may be assessed as fit with appropriate limitations, such as an ORL, and subject to satisfactory cardiological evaluation.

     

    UK CAA Left Bundle Branch Block (PDF) (LBBB) flow chart 
    (iii) Mobitz type 2 atrioventricular block;  CLASS 2 - AMC2 MED.B.010   (l)

     

    (5) Heart block

    (i) Applicants with first degree and Mobitz type 1 AV block may be assessed as fit.

    (ii) 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;     
    (v) ventricular pre-excitation; 

    CLASS 2 - AMC2 MED.B.010   

    (8) Ventricular pre-excitation

    Asymptomatic applicants with ventricular pre-excitation may be assessed as fit with limitation(s) as appropriate, subject to satisfactory cardiological evaluation. Limitations may not be necessary if an electrophysiological study is conducted and the results are satisfactory.

     

    UK CAA Wolff-Parkinson White pre-excitation (PDF) flow chart 
    (vi) asymptomatic QT prolongation;  CLASS 2 - AMC2 MED.B.010   (l)

     

    (10) QT prolongation
    Applicants with asymptomatic QT prolongation may be assessed as fit with an ORL or OSL subject to satisfactory cardiological evaluation.

     

     
    (vii) Brugada pattern on electrocardiography. 

    CLASS 2 - AMC2 MED.B.010   (l)

    (11) Brugada pattern on electrocardiography

    Applicants with Brugada pattern Type 1 who are symptomatic or have evidence of tachyarrhythmia should be assessed as unfit. Applicants with asymptomatic Type 1, Type 2 or Type 3 may be assessed as fit, with limitation(s) as appropriate, subject to satisfactory
    cardiological evaluation.

     

    UK CAA Brugada (PDF) flow chart 
    (3) Before further consideration is given to their application, applicants for a class 2 medical certificate with any of the medical conditions specified in point (2) shall undergo satisfactory cardiological evaluation, in consultation with the medical assessor of the licensing authority.    
    (4) Applicants with any of the following medical conditions may be assessed as fit subject to satisfactory cardiological evaluation and in the absence of any other abnormality:     
    (i) incomplete bundle branch block;     
    (ii) complete right bundle branch block;  CLASS 2 - AMC2 MED.B.010   (l)

     

    (6) Complete right bundle branch block
    Applicants with complete right bundle branch block may be assessed as fit with appropriate limitations, such as an ORL, and subject to satisfactory cardiological evaluation.

     

    UK CAA Complete Right Bundle Branch Block (PDF) (RBBB) flow chart 
    (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 (PDF) 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.     
    (5) Applicants with a medical history of any of the following medical conditions shall undergo satisfactory cardiovascular evaluation before they may be assessed as fit:      

    (i)      ablation therapy;

     
    CLASS 2 - AMC2 MED.B.010   (l)


    3) Ablation

     

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

     

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

     

    UK CAA Catheter ablation for WPW syndrome and AVNRT (PDF) flow chart

     

    (ii) pacemaker implantation.  CLASS 2 - AMC2 MED.B.010   (l)

     

    (9) Pacemaker

     

    Applicants with a subendocardial pacemaker should be assessed as unfit. A fit assessment may be considered no sooner than 3 months after insertion, providing:
    (i) there is no other disqualifying condition;
    (ii) a bipolar lead system, programmed in bipolar mode without automatic mode change, has been used;
    (iii) the applicant is not pacemaker dependent; and
    (iv) the applicant has a follow-up at least every 12 months, including a pacemaker check.

     

    UK CAA Implantation of a Cardiac Pacemaker (PDF) flow chart 
    Such applicants for a class 1 medical certificate shall be referred to the medical assessor of the licensing authority. Such applicants for a class 2 medical certificate shall be assessed in consultation with the medical assessor of the licensing authority.