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MANUAL of CIVIL AVIATION MEDICINE PRELIMINARY EDITION — 2008 International Civil Aviation Organization

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MANUAL of CIVIL AVIATION MEDICINE PRELIMINARY EDITION — 2008 International Civil Aviation Organization Doc 8984-AN/895 Part III MANUAL OF CIVIL AVIATION MEDICINE PRELIMINARY EDITION — 2008 International Civil Aviation Organization PART III. MEDICAL ASSESSMENT Approved by the Secretary General and published under his authority INTERNATIONAL CIVIL AVIATION ORGANIZATION ICAO Preliminary Unedited Version — October 2008 Part III Chapter 1. CARDIOVASCULAR SYSTEM Page Introduction................................................................................................. III-1-1 History and medical examination .............................................................. III-1-5 Coronary artery disease .............................................................................. III-1-14 Rate and rhythm disturbances .................................................................... III-1-20 Atrioventricular conduction disturbances .................................................. III-1-26 Intraventricular conduction disturbances ................................................... III-1-27 Ion channelopathies ................................................................................... III-1-29 Endocardial pacemaking ............................................................................ III-1-30 Heart murmurs and valvar heart disease .................................................... III-1-31 Pericarditis, myocarditis and endocarditis ................................................. III-1-34 Cardiomyopathy ......................................................................................... III-1-36 Congenital heart disease ............................................................................ III-1-40 Diseases of the great vessels ...................................................................... III-1-43 Peripheral vascular disease ........................................................................ III-1-44 Venous thrombosis ..................................................................................... III-1-44 Syncope ...................................................................................................... III-1-45 References: ................................................................................................. III-1-48 Appendix 1a — Basic electrocardiography.......................................... III-A1a-1 Appendix 1b — Illustrative resting electrocardiograms ...................... III-A1b-1 Appendix 2 — Illustrative exercise electrocardiograms ...................... III-A2-1 Appendix 3 — Illustrative angiogram and angioplasty ....................... III-A3-1 ICAO Preliminary Unedited Version — October 2008 Chapter 1. CARDIOVASCULAR SYSTEM INTRODUCTION The ICAO Class 1 medical Standards and Recommended Practices (SARPs) relating to the cardiovascular system are contained in Annex 1, Chapter 6: 6.3.2.5 The applicant shall not possess any abnormality of the heart, congenital or acquired, which is likely to interfere with the safe exercise of the applicant’s licence and rating privileges. 6.3.2.5.1 An applicant who has undergone coronary bypass grafting or angioplasty (with or without stenting) or other cardiac intervention or who has a history of myocardial infarction or who suffers from any other potentially incapacitating cardiac condition shall be assessed as unfit unless the applicant’s cardiac condition has been investigated and evaluated in accordance with best medical practice and is assessed not likely to interfere with the safe exercise of the applicant’s licence or rating privileges. 6.3.2.5.2 An applicant with an abnormal cardiac rhythm shall be assessed as unfit unless the cardiac arrhythmia has been investigated and evaluated in accordance with best medical practice and is assessed not likely to interfere with the safe exercise of the applicant’s licence or rating privileges. Note.— Guidance on cardiovascular evaluation is contained in the Manual of Civil Aviation Medicine (Doc 8984). 6.3.2.6 Electrocardiography shall form part of the heart examination for the first issue of a Medical Assessment. 6.3.2.6.1 Electrocardiography shall be included in re-examinations of applicants over the age of 50 no less frequently than annually. 6.3.2.6.2 Recommendation.— Electrocardiography should be included in re-examinations of applicants between the ages of 30 and 50 no less frequently than every two years. Note 1.— The purpose of routine electrocardiography is case finding. It does not provide sufficient evidence to justify disqualification without further thorough cardiovascular investigation. Note 2.— Guidance on resting and exercise electrocardiography is contained in the Manual of Civil Aviation Medicine (Doc 8984). 6.3.2.7 The systolic and diastolic blood pressures shall be within normal limits. 6.3.2.7.1 The use of drugs for control of high blood pressure shall be disqualifying except for those drugs, the use of which is compatible with the safe exercise of the applicant’s licence and rating privileges. Note.— Guidance on the subject is contained in the Manual of Civil Aviation Medicine (Doc 8984). 6.3.2.8 There shall be no significant functional nor structural abnormality of the circulatory system. Corresponding requirements for private pilots (Class 2) and air traffic controllers (Class 3) are given in 6.4 and 6.5 respectively. They differ from the requirements for commercial pilots (Class 1) only with regard to the frequency of electrocardiographic examinations. The full cardiological standard, which runs to less than 350 words, leaves much scope for interpretation in the context of reduced medical fitness. Medical certification outside the requirements in Chapter 6 is ICAO Preliminary Unedited Version — October 2008 III-1-1 reliant upon the so-called “flexibility standard”, paragraph 1.2.4.8 and is allowable subject to accredited medical conclusion (see also Part I Chapter 2), provided that this “is not likely to jeopardize flight safety”. The word “likely” is defined in Annex 1 to mean “a probability of occurrance that is unacceptable to the Medical Assessor.” This permits latitude to be taken by him or her. An explicit standard would give rise to loss of flexibility with risk of unfairness to individual aircrew. Discussion of acceptable incapacitation risk in pilots may be found in Part I Chapter 3 of this manual, and below. This chapter is not intended as a primer in clinical cardiology but as guidance for medical assessors, designated medical examiners (DMEs), cardiologists and others seeking to investigate and manage cardiological problems in accordance with ICAO SARPs. Levels of operation As detailed in Part I, Chapter 1 there are three levels of Medical Assessment: Class 1 - commercial pilots, Class 2 - private pilots (including glider and balloon pilots), and Class 3 - air traffic controllers (ATC). No international standard has been established for microlight pilots. In this chapter, reference will be made to a “full” or “unrestricted” Class 1 Medical Assessment, whilst “restricted” certification refers to a Class 1 Medical Assessment with an operational multi-crew limitation (OML) thereon. Note that not all Contracting States utilise the OML concept, and in such States an applicant may be assessed either as unfit or as fit for unrestricted certification whereas in those utilising an OML, the same individual would be allowed to fly with such a restriction applied to the licence, for example, following recovery from a myocardial infarction. The development of cardiological experience Thirty years ago, a number of reports on cardiovascular problems were sponsored by the aviation regulatory agencies in some Contracting States. These included the Federal Aviation Administration (FAA) in the United States, the Civil Aviation Authority (CAA) in the United Kingdom, and the Civil Aviation Authorities of Canada and Australia. Their purpose was to address the need for appropriate scientific data to assist in making aeromedical decisions more consistent and fair. The United Kingdom and European Workshops in Aviation Cardiology, four in number over a 16 year period between 1982 and 1998, focused on the epidemiology, natural history and outcome of most of the commonly encountered cardiological problems. From them a methodology was evolved which was coherent with the man-machine interface in regulatory terms. The pilot was identified as one component in an aviation system, the failure of any part of which would lead to an erosion of safety with the ultimate potential risk of catastrophic outcome. Accidents are most commonly the result of a series of adverse events, which may include cardiovascular incapacitation, none of which in isolation needs to lead to disaster because of safety redundancy in the system. Taking these aspects into account, the workshops formed the basis of the first and second drafts of the European Joint Aviation Authorities (JAA) Joint Aviation Requirements - Flight Crew Licensing (JAR - FCL) Part 3 (medical) in cardiology and contributed by providing a cardiological “road map” in regulatory terms. Since the 1990s, this material has been used as guidance by many regulators outside Europe. The guidance contained in this chapter is based on recommendations that have been found acceptable to the JAA. ICAO Preliminary Unedited Version — October 2008 III-1-2 Determination of the limits of cardiological certification There should be separation between the regulator and the specialist advisor (in cardiology). The cardiologist is required to identify the probability of a cardiovascular event in a given individual over a defined
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