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maximum recommended daily or weekly intake of alcohol1), and frequent exercise. Pilots, on the basis of
their regular medical review and need to maintain medical fitness, should be in an ideal position to
instigate preventative strategies with the object of health maintenance. It remains a lamentable fact that
often this opportunity is lost on account of inadequate advice on the part of the AME/physician or failure
of its uptake by the pilot, usually based on the misconception that preventative and regulatory medicine
are incompatible and must be kept separate from each other. The result is that careers are destroyed and
future health impaired.
Atherosclerotic disease of the great vessels (i.e. the aorta) and the medium-sized vessels (i.e. the coronary
and cerebral arteries) is insidious in onset, often having an origin in early adulthood. It has a trajectory of
many years’ duration and may present abruptly with some cerebrovascular or myocardial event. In
Europe, there is a north-south gradient, death from coronary heart disease being three times more
common in the north than in the southern “olive belt”. There is also an East-West gradient: heart-attack
rates in Western Europe are generally lower than those in Eastern Europe. The dietary, environmental and
genetic factors involved have been demonstrated in the INTERHEART study2 to be shared worldwide by
both sexes in all regions.
Historically, some nations have experienced low heart-attack rates. In some of these nations, this finding
has changed. South Asians, for example, both locally and following emigration, now demonstrate rates
that are generally some 50 to 60 per cent higher than those observed in the West. Numerous factors,
1 Maximum daily or weekly alcohol intake, recommended by the public health authorities in several States, is
usually expressed in ‘units of alcohol’, the definition of which varies from one State to another. In one Contracting
State, a unit of alcohol is defined as 15 mL of pure alcohol (ethyl alcohol, ethanol), which is equivalent to one
standard serving of beer, wine or spirits. If not accompanied by food, one unit of alcohol will entail a blood alcohol
concentration of c. 0.2g/L in a man (70 kg) and of c. 0.3g/L in a woman (55 kg). The recommended weekly
maximum intake for males is 21 units and for women 14 units.
2 INTERHEART: A global case-control study of risk factors for acute myocardial infarction, led by Dr. Salim Yusuf of
McMaster University, Canada, involving >29 000 people in 52 countries (published in 2004).
ICAO Preliminary Unedited Version — October 2008 III-1-14
including inherited metabolic anomalies and insulin resistance, are involved. Japan and China, sharing
with other countries in the Far East commendably low mean levels of plasma cholesterol and some of the
lowest heart-attack rates in the world, are showing signs of increase in the prevalence of coronary artery
disease. Japanese who emigrate to the United States tend, like other migrant populations, to assume the
risk of their country of adoption. This global burden is thus reflected unevenly in the aviation
environment.
CORONARY ARTERY DISEASE
The presence of coronary artery disease, in general, predicts an adverse outcome. The presence of one or
more vascular risk factors implies a greater probability of event in an individual without identifying
whether or when it might occur. It remains what has been called the “prevention paradox” that the
greatest number of events will be seen in those individuals with a near-normal vascular risk profile - on
account of their far greater numbers. Predictions on the probability of an event, which should be over a
defined period, often a year, should be based on data from an age and sex-matched control population.
Coronary artery disease remains a significant cause of premature death. Death from coronary artery
disease is falling in the West, but elsewhere the trend is less favourable or may even be reversed. In
northern Europe, nearly 40 per cent of the population die from cardiovascular disease. One in four men
and one in six women die from coronary artery disease. Ten per cent of the population die from stroke.
One-third of cardiovascular deaths in males and one-quarter in women are premature (<age 75 years).
Of those presenting with a new coronary syndrome, one-sixth will present as sudden cardiac death (SCD)
without recognizable premonitory symptoms; two-fifths will present with angina pectoris and two-fifths
with myocardial infarction. The remainder will suffer an unstable ischaemic syndrome. Of the untreated
third that die within 28 days following acute myocardial infarction, about half will do so within 15
minutes of the onset of symptoms, 60 per cent being dead at one hour and 70 per cent within 24 hours. As
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Manual of Civil Aviation Medicine 1(78)
