AMC2 MED.B.010 Cardiovascular system

(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.

(b) General

(1) Cardiovascular risk factor assessment

Cardiovascular risk factor assessment should take place at least once every 5 years for applicants 40 to 59 years old, and once every 2 years thereafter. A more frequent assessment of the cardiovascular risk factors may be considered when risk factors have been identified.

Applicants with an accumulation of two or more risk factors 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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(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).

(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.

(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 or OSL 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.

(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.

(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.

(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.

(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.

(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.

(6) Complete right bundle branch block

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.

(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.

(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.

(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.

(10) QT prolongation

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

(11) Brugada pattern on electrocardiography

Applicants with a Brugada pattern Type 1 should be assessed as unfit. Applicants with Type 2 or Type 3 may be assessed as fit, with limitation(s) as appropriate, subject to satisfactory cardiological evaluation.

(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.