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• coronary angiography carried out at or around the time of the index event demonstrates <50 per
cent stenosis in any major untreated vessel or in any venous/arterial graft remote from any
infarction; < 30 per cent if the proximal the left anterior descending or left main-stem vessels are
involved
• Holter monitoring, if indicated, shows no significant rhythm disturbance
• Stress thallium MPI, or equivalent, shows no evidence of a reversible defect. A small fixed defect
is permissible, provided the ejection fraction is within the normal range. This investigation
should be carried out no sooner than six months following the index event
• Class 1 Assessment is restricted with an OML, indefinitely. Unrestricted Class 2 Assessment may
be permissible
• Annual follow-up by an accredited cardiologist with exercise ECG and review of vascular risk
factor status is arranged. Further investigation may be required, if indicated.
RATE AND RHYTHM DISTURBANCES
The human heart beats some 100 000 times a day and in health remains remarkably regular. An increase
in the heart rate — a tachycardia — is present when the rate is > 100 beats/min and a bradycardia when
the rate is < 50 beats/min. A sinus bradycardia in a subject of aircrew age is rarely of importance and may
reflect only physical fitness. A sinus tachycardia in an otherwise fit individual may suggest anxiety, and
although most aircrew become used to routine scrutiny, some continue to demonstrate an alarm reaction,
which may be associated with so-called “white-coat hypertension”. Rhythm and conduction disturbances
continue to form the single largest problem group and together they form some of the more difficult
problems encountered in aviation cardiology.
Atrial and ventricular premature beats
The routine aircrew ECG should be recorded on a three-channel system (see above). With a three-lead
presentation, the recording will last 12 seconds on a page of A4 size at the standard paper speed of
25mm/s; further rhythm “strips” are unlikely to be longer than another 12 seconds. If an isolated atrial or
ventricular premature contraction is recorded, it may be a coincidence; if more than one is present, it is
1 Simpson’s rule, also also known as ‘the parabolic rule’ as it uses sums of areas under parabolas to determine
approximate values of definite integrals, is a geometric algorithm for calculating ventricular mass and volume
based on two-dimensional measurements. After Thomas Simpson, English mathematician (1710-1761).
ICAO Preliminary Unedited Version — October 2008 III-1-21
more likely that such events are sufficiently frequent to justify review. With increasing age the probability
of rhythm disturbance increases. As a rule, a single atrial or ventricular premature beat is not of
prognostic importance and is likely to pass unnoticed. Anxiety, excessive tea, coffee or alcohol, or
smoking, may be the explanation; if the subject becomes symptomatic, anxiety may contribute to their
continuation. Frequent atrial ectopy may predict atrial fibrillation.
More complex rhythm disturbances including frequent ventricular premature complexes, with or without
multiformity or multifocality, couplets and salvoes may or may not be of prognostic importance in the
otherwise normal heart. In the aviation environment cardiological assessment with echocardiography,
Holter monitoring and exercise ECG is nevertheless required.
As a general rule, ventricular premature complexes with a density of < 200 per hour are acceptable if the
non-invasive investigations are satisfactory. As complexity increases, even in an asymptomatic and
otherwise normal individual, a multi-crew endorsement may have to be applied in view of our inability to
predict outcome with confidence.
Sinoatrial disease (sick sinus syndrome; bradytachy syndrome)
Sinoatrial disease (evidenced by sinus pauses, sinoatrial block and paroxysmal atrial tachyarrhythmia
from a variety of causes) is not commonly seen in subjects of pilot age. The sinoatrial node and atrial
myocardium are primarily affected, although the atrioventricular (AV node) and more distal conducting
tissue may also be involved. There is a tendency towards excessive bradycardia, especially at night when
sinus arrest may occur. Pauses of >2.5 s are likely to be abnormal if the subject is in sinus rhythm.
Characteristic salvoes of atrial and/or junctional complexes followed by prolonged sinus node recovery
time are a feature. There is an increased risk of thromboembolic stroke. There may be overlap with
“athlete’s heart”, which tends to be associated with excessive vagal inhibitory activity and which is a not
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Manual of Civil Aviation Medicine 1(84)
