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predicted maximum heart rate of 190 bpm on the Bruce treadmill protocol after 12 minutes
exercise and was limited by exhaustion.
The panel demonstrates the chest leads V1 – V6 at baseline, maximum ST-segment shift in recovery and
at peak exercise and, finally, at the end of recovery. The recording is completely normal. Note the Ta
phenomenon in which the PR-segment falls progressively with effort but is matched by displacement of
the J-point – the junction between the S-wave and the ST-segment. This is a normal variant. Such a good
walking time predicts a low (<1% / annum) risk of significant cardiovascular event/year.
ICAO Preliminary Unedited Version — October 2008 III-App. 2-2
26. 53-year-old obese and hypertensive ATPL-holder who developed “indigestion-like” symptoms
whilst on a stop-over. He reported sick following his return to base. Cardiological review was
carried out with exercise electrocardiography. The upper three leads, V4,5,6, represent his
electrocardiographic response to exercise, which was limited by central chest pain to 6.05
minutes of the Bruce treadmill protocol. Progressive J-point depression is seen, the ST-segments
becoming flat at the end of effort.
The lower panel reflects his normal response to exercise following the insertion of three coronary artery
bypass grafts. Six months following the index intervention, he was assessed fit following clinical and
exercise electrocardiographic review: attention had been paid to his vascular risk factors. His exercise
electrocardiogram was normal at 11 minutes of the Bruce protocol. He was limited to fly as/with co-pilot
only and will not be able to fly in future as pilot in sole command.
ICAO Preliminary Unedited Version — October 2008 III-App. 2-3
27. The same pilot as in 26, above, demonstrating the same leads during recovery from exercise. It is
noteworthy that the ST-changes in the upper panel are more impressive during recovery than
during exercise, underscoring the need for recording the full ten minutes of the recovery period.
The lower panel shows the normal response following coronary surgery.
ICAO Preliminary Unedited Version — October 2008 III-App.3-1
APPENDIX 3.— ILLUSTRATIVE ANGIOGRAM AND ANGIOPLASTY
Panel A. Left anterior oblique image of the right main coronary artery in a 54-year-old professional pilot
who demonstrated an 80 per cent proximal stenosis. He had presented with angina pectoris.
His exercise electrocardiogram was abnormal at seven minutes of the Bruce protocol and he
was limited by chest pain.
A
ICAO Preliminary Unedited Version — October 2008 III-App.3-2
Panel B. The same individual during angioplasty. The index lesion has been successfully dilated. The
guide wire is in the posterior descending branch. The left ventricular branch is blocked. Six
months later and free of symptoms, he was made fit for multi-crew duties, having
successfully undergone exercise electrocardiography, echocardiography (to determine the left
ventricular ejection fraction) and pharmacological stress thallium myocardial perfusion
imaging (MPI). Stress echocardiography would have been an alternative.
— END —
ICAO Preliminary Unedited Version — October 2008
PART III
Chapter 2. RESPIRATORY SYSTEM
Page
Introduction.................................................................................. III-2-1
Guidelines for assessment............................................................ III-2-1
Pulmonary tuberculosis ...........................................................III-2-2
Chronic obstructive pulmonary disease (COPD) .................... III-2-3
Pneumothorax..........................................................................III-2-4
Bronchial asthma.....................................................................III-2-4
Post-operative effects of thoracic surgery ............................... III-2-5
Pulmonary sarcoidosis.............................................................III-2-5
ICAO Preliminary Unedited Version — October 2008 III-2-1
Chapter 2. RESPIRATORY SYSTEM
INTRODUCTION
In the introductory chapters of this manual the basic principles for the assessment of an applicant’s
medical fitness for aviation duties are outlined.
The general provisions of Annex 1, 6.2.2, state that an applicant shall be required to be free from any
abnormality, disability, etc. “such as would entail a degree of functional incapacity which is likely to
interfere with the safe operation of an aircraft or with the safe performance of duties.”
Medical fitness requirements referring specifically to the respiratory system are detailed in Annex 1,
6.3.2.9 to 6.3.2.12.1 for a Class l Medical Assessment (and in the corresponding paragraphs of Chapter 6
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