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Appendix 2 — Illustrative exercise electrocardiograms ...................... III-A2-1
Appendix 3 — Illustrative angiogram and angioplasty ....................... III-A3-1
ICAO Preliminary Unedited Version — October 2008 III-1-1
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-1-2
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
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