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Indian sub-continent. Apart from causing (sudden) death, acute cardiovascular events such as stroke,
aortic rupture and myocardial infarction may cause complete incapacitation, whilst the pain of acute
myocardial ischaemia may be disabling. Non-lethal cardiac arrhythmias may be sufficiently subtle to
cause distraction without the aircrew member being fully aware as to what is absorbing his or her
attention. In the single-crew environment major events have a high probability of a catastrophic outcome.
Fortunately, the very large database on natural history and the impact of intervention, notably in coronary
artery disease, has permitted the development of algorithms of aeromedical management that assist safe,
fair and evidence-based decisions.
ICAO Preliminary Unedited Version — October 2008 III-1-5
HISTORY AND MEDICAL EXAMINATION
There is some variation worldwide in the implementation of the ICAO Standards and Recommended
Practices. In many Contracting States, routine review of pilots is carried out by medical practitioners with
some training in the field of aviation medicine. Such physicians (normally identified as “designated” or
“authorized” medical examiners (DMEs or AMEs)) are usually family doctors without special training or
experience in cardiology. In some States the responsibility is devolved to the military. Almost universally,
a standardized form (see Part I Chapter 2 for an example of such a form) is used to record factors such as
age, past and family history, weight, blood pressure, smoking habit, use of medicines, and clinical
observations, such as changes in the fundus oculi, and heart murmurs, if present. Increasingly, these forms
are being computerized and transmitted online. Certain regulatory agencies, including the JAA, also
require routine measurement of the serum cholesterol at specified times. A few require routine exercise
ECG (see below) and this investigation is also a requirement of some airline employers.
Resting electrocardiography (ECG)
A regular 12-lead resting ECG is required in the routine scrutiny of aircrew, depending on age and level
of certification. It was not until 1957 that resting electrocardiography was made an ICAO Recommended
Practice (becoming mandatory as a Standard in 1963). Minor anomalies are common, requiring
comparison with earlier recordings (where available) in at least 10 to 15 per cent of cases. In a review,
three per cent of UK civilian personnel demonstrated abnormality of the ST segment and/or T wave on
routine scrutiny.
The resting ECG is an insensitive tool for the detection of pre-symptomatic coronary artery disease,
although it does identify a small number of people who have suffered a silent myocardial infarction. In
one ten-year period, 72 “silent” myocardial infarctions were detected in 48 633 aircrew screened at the
US School of Aerospace Medicine. Twenty-five per cent of those suffering such events in the
Framingham study1 did not experience symptoms that they recognized as significant and 15 per cent of
those dying suddenly do so without premonitory symptoms. As the risk of further cardiovascular events is
increased substantially following myocardial infarction, the identification of minor anomalies should
provoke further and fuller review. Sometimes ECG changes are variable, but it is a misconception that a
stable “abnormal” recording is necessarily acceptable on the grounds of its stability – a recording
demonstrating a pattern of myocardial infarction remains predictive of outcome even if it does not
change. Nevertheless, a stable but abnormal recording in follow-up ECGs subsequent to satisfactory
investigation may be relatively, although not absolutely, reassuring. A resting ECG is rather better at
detecting disturbances of rhythm and conduction than ischaemic heart disease.
1 Framingham Heart Study: a cardiovascular study based in Framingham, Massachusetts (USA). The study began
in 1948 with 5,209 adult subjects from Framingham, and is on its third generation of participants at present. Most of
the now common knowledge concerning heart disease, such as the effects of diet, exercise, and common
medications such as aspirin, are based on this longitudinal study. It is a project of the National Heart, Lung, and
Blood Institute, in collaboration with (since 1971) Boston University.
ICAO Preliminary Unedited Version — October 2008 III-1-6
Recording the resting electrocardiogram
A resting ECG should be recorded with the subject at rest in a warm environment. The skin should be
prepared with spirit or abrasive, or both. The position of the limb electrodes is not important, but those on
the chest must be placed accurately. Leads V1 and V2 should be placed in the fourth inter-costal spaces
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Manual of Civil Aviation Medicine 1(71)
