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whether sustained or not
• there is no family history of related SCD
• the interventricular septum is < 2.5 cm
• the airman is restricted to OML operation
A history of atrial fibrillation, whether paroxysmal or sustained, is disqualifying
Ongoing certification requires the absence of the above risk factors and long term cardiological follow
up with annual echocardiography to determine (left) ventricular configuration and performance, Holter
monitoring to search for life threatening rhythm disturbance, and exercise ECG to record an appropriate
blood pressure response (see above)
The athlete’s heart
Endurance training (running, swimming, bicycling) is associated with end-diastolic dilation of the left
ventricle with an increased ejection fraction, while power work (weight lifting) is associated with
hypertrophy. In the former, both the left ventricle muscle mass and the end-diastolic diameter are related
to lean body mass. Apart from the exercise history, the ECG is helpful. Both athletes and subjects with
HCM will have increased voltages but the latter will often show left axis deviation and a wide QRST
angle. Sometimes they will also show QS waves in the inferior or antero-septal leads while the athlete’s
heart is likely to demonstrate right axis deviation with no more than minor depolarisation change in the
ST-T segment. See Appendix 1b: 8. The echocardiogram in the athlete will show a normal left atrial
internal diameter (< 4 . 0 cm); in subjects with HCM, it will be > 4.5 cm. Likewise, in the athlete and HCM
respectively, the inter-ventricular septum will be < 1.5 cm and > 1.5 cm, and the left ventricular enddiastolic
diameter will be > 4 .5 cm and < 4.5 cm respectively.
Having established the diagnosis of the athlete’s heart and in the absence of any other anomaly,
unrestricted certification is to be expected
Restrictive cardiomyopathy
Restrictive cardiomyopathy is a rare disorder characterized by normal or near-normal dimensions of the
heart, sometimes with normal systolic function, but with failure of diastolic function due to increased
stiffness of the myocardium. The causes include infiltrative conditions such as amyloidosis and
sarcoidosis, storage diseases such as haemosiderosis and haemochromatosis, and endomyocardial disease,
including fibrosis, the eosinophilic syndromes, carcinoid syndrome and radiation damage.
The majority of patients with a restrictive myocardial defect will be unfit for any form of certification to
fly. Amyloidosis of the heart has a very poor prognosis by way of rapid deterioration of function
complicated by rhythm disturbance. Eosinophilic heart disease is equally problematic
Haemochromatosis that is controlled well by venesection in a patient with normal glucose tolerance,
normal echocardiogram, normal exercise ECG and normal ambulatory ECG may be considered for
restricted certification, subject to regular review. Those with transfusion-dependent anaemias will be
unfit.
Dilated cardiomyopathy
The causes of dilated cardiomyopathy are various, with 40 to 60 per cent being familial and transmitted,
predominantly by an autosomal dominant gene. The prognosis has improved strikingly since the 1980s,
and mortality is now about 20 per cent at five years. Thirty per cent will die suddenly, many from a life
ICAO Preliminary Unedited Version — October 2008 III-1-38
threatening tachyarrhythmia, this outcome not being restricted to severe disease. In one study, nearly 50
per cent of 673 subjects with dilated cardiomyopathy were labelled idiopathic, while a further 12 per cent
were considered to have myocarditis, and only three per cent were considered to be due to alcohol. An
earlier study, however, suggested that alcohol was responsible in up to one-third of cases. The
electrocardiographic changes are non-specific but incomplete left bundle branch aberration is common.
Echocardiography will demonstrate global reduction in wall motion with dilation of the left, right or both
ventricles. MRI scanning is a useful additional investigation. In the event of coronary artery disease being
suspected, a pharmacological stress thallium 201 scan or coronary angiogram may be indicated.
One group that bears special consideration is that in which the subjects have received an anthracycline,
often in childhood for malignant disease. There is some evidence of a dose relationship in the incidence of
subsequent myocardial abnormality; in one study of long-term survivors (median 8.9 years) of malignant
bone disease aged between ten and 45 years (mean 17.8 years), the incidence of cardiac abnormalities
increased with length of follow-up. These subjects often have only minor abnormalities on
echocardiography, and MRI scanning is more sensitive in detecting myocardial abnormality. Life-long
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Manual of Civil Aviation Medicine 1(97)
