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which are associated with an increased risk of coronary (and cerebro-vascular) events. They include
hypertension, hyperlipidaemia, diabetes, smoking, obesity, and lack of exercise. The Metabolic Syndrome
(sometimes known as Syndrome X or Reaven’s Syndrome1 — hypertension, hyperlipidaemia, insulin
resistance and trunkal obesity) carries a significantly increased risk of such event. Vascular risk factors
predict coronary artery disease and coronary artery disease predicts coronary events. Hypertension has
been called the most powerful and predictive of all the vascular risk factors although in reality age is the
most important. To assess one risk factor in isolation is not appropriate as they all interact powerfully and
multiple risk factors present in minor extent are as lethal as a single one present in large extent. There is
no provision in Annex 1 which directly relates to vascular risk factors but in the introduction to Chapter
6, Note 2 states that “predisposing factors for disease, such as obesity and smoking, may be important for
determining whether further evaluation or investigation is necessary in an individual case”. 6.3.2.7 states
that the blood pressure shall be “within normal limits” and 6.3.2.5.1 states that a fit assessment following
a coronary event shall be in accordance with “best medical practice”.
Hypertension
The blood pressure should be <140/90 mm Hg, treated or untreated and this may be achieved by lifestyle
adjustment (reduction of alcohol intake, weight reduction) in those with modest elevation. If the 10-year
cardiovascular mortality is < 5 per cent and there is no evidence of target organ damage, slightly higher
levels are tolerable in the short term. If it is >5 per cent, medical treatment will be needed. In the presence
of diabetes and micro-albuminuria, the lower target of 130/80 mm Hg is applicable. A pressure
consistently >160/95 mmHg is disqualifying from all classes of medical certification. In aviation, most of
the currently employed agents are permissible as follows:
1. The sartans (angiotensin receptor blocking agents - ARB’s) — e.g. losartan, candesartan
2. The angiotensin converting enzyme (ACE) inhibitors — e.g. enalapril, lisinopril,
3. The slow channel calcium blocking agents (CCB’s) — e.g. amlodipine, nifedipine
4. The beta-blocking agents — e.g. atenolol, bisoprolol
5. The diuretic agents — e.g. bendroflumethazide, indapamide
The alpha 1 blocking agents, i.e. doxazosin, prazosin and the centrally acting products clonidine,
moxonidine and methyldopa, are not permitted. Anti-hypertensive therapy should be supervised by a
physician. On commencement or following change in treatment or its dosage, the pilot should be assessed
1 Reaven’s syndrome: named after Gerald M. Reaven, American endocrinologist (1928- )
ICAO Preliminary Unedited Version — October 2008 III-1-13
temporarily unfit until there is evidence of stable control and freedom from side effects, such as
orthostatic hypotension.
Serum cholesterol
Although some Licensing Authorities require measurement of the cholesterol, it is not an ICAO
requirement. However, a level >8 mmol/L (320 mg/dL) should be treated (best with a statin, eg
simvastatin, atorvastatin) whether or not there are other risk factors present. In the presence of overt
coronary artery disease, targets should be: total cholesterol <5 mmol/l (<190 mg/dL) and LDL
cholesterol <3 mmol/L (<115 mg/dL) or, in the presence of diabetes <4.5 mmol/L (<175 mg/dL) and <2.5
mmol/L (100 mg/dL) respectively.
Non-insulin dependent diabetes mellitus is permitted under ICAO SARPs “subject to satisfactory
control”. Intervention against vascular risk factors is influenced to some extent by the presence or absence
of other risk factors and whether or not there is evidence of target organ damage (left ventricular
hypertrophy, loss of vascular compliance, reduced renal function, micro-albuminuria in diabetes). From
the point of view of good clinical practice, which should be inseparable from good regulatory practice,
the European Society Committee for Practice Guidelines (like other groups) has developed risk tables,
calculating 10-year cardiovacsular mortality in males and females in high and low risk countries, which
relate age, systolic blood pressure, total cholesterol and smoking. A subject in middle age with a 10-year
mortality of >5 per cent is in need of specialist advice.
Prevention strategies, applicable to all, should start with attention to lifestyle — no smoking, maintenance
of optimum body weight, and avoidance of excessive alcohol intake (many States have developed a
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Manual of Civil Aviation Medicine 1(77)
