Dr Justin Carter

Aviation Cardiology

Relevant to Aircrew, Air Traffic Controllers (ATCOs) and Cabin Crew and their Aviation Medical Examiners

Cardiac issues identified at routine aviation medical examinations are a common cause of aviation medical certificate denial or suspension.
The commonest issues picked up are ECG abnormalities, high blood pressure, symptoms such as chest discomfort or palpitations or heart murmurs heard by the AME during examination.

The ECG over-read process:

The process for ECG abnormalities is that the AME must use and approved ECG machine with a computer algorithm for interpreting the ECG. Provided this gives a normal (or ‘near’ normal) result, the ECG is recorded as acceptable on the record and no further action is needed. If the computer generated ECG report is unacceptable, the ECG will be referred by the AME to a cardiologist familiar with the CAA requirements to ‘over-read’ the ECG. The ECG will be interpreted by the Cardiologist usually including a comparison against any previous ECGs or cardiac history held in the pilots record. If the cardiologist’s over-read of the ECG is satisfactory, the over-read report will go back to the AME who will record the result on the pilot/ATCO’s record and no further action will be needed. If the ECG is unacceptable after the over-read, further investigation will be required. Depending on the severity of the abnormalities identified, the applicant may be issued with a medical certificate by the AME whist these investigations are undertaken. If a certificate was issued, usually a two month time limit is allowed to undertake the required investigations. If the abnormalities identified are more serious (ie more likely to cause incapacitation), a certificate will not be issued by the AME until the cardiac investigations are complete. Once the cardiologists report and investigations are available to the AME, they will be reviewed by the AME and depending on the circumstances, deemed acceptable, with the report and results being entered onto the applicants medical file but no onward referral to the Competent Authorities medical department (the UK CAA medical department for UK Licensed pilots and ATCO’s or the medical department of the State of Licence issue for non UK licensed pilots). In complex cases or where specific criteria are met including for example the requirement for application of a Multi-crew limitation (OML), the AME can be expected to refer the case for decision-making to the the relevant Competent Authority (UK or otherwise.)

If your AME (or Aeromedical centre) says you need Cardiology Investigations - who should you see?

If your AME identifies an issue that requires investigation by a cardiologist, you are at liberty to have the investigations undertaken at any qualified cardiologist (in the UK this will usually include any consultant cardiologist on the Specialist Register). You might wonder wether, if an abnormal ECG has been found, you might anticipate having the relevant investigations as an NHS patient. There would certainly be some logic to that except for two issues. Firstly the threshold for investigation mandated by the CAA (and other Competent Authority medical departments) is considerably lower in the aircrew and ATCO population than would be the case for the background population (which is serviced by NHS clinics). This is because the ability to tolerate risk (mainly of sudden incapacitation) is lower for the Aircrew and ATCO population than is the case foe the background population. So ECG (and other abnormalities) which trigger CAA mandatory investigation in these in the populations wouldn’t necessarily trigger investigations in NHS clinics which are aimed at the general public. Secondly, the investigation protocols laid out by the CAA and other national authorities are quite specific and require specific investigation sequences in the investigation of potential cardiac abnormalities which aren’t necessarily the way you would be investigated in an NHS clinic (if you met the threshold for investigation in an NHS clinic) so it would be likely that the CAA mandated sequence of tests wouldn’t be what was performed, were you to be seen in an NHS clinic. Finally, the waits and anticipated turnaround times in regular NHS clinics are really quite long especially at present and may well not meet the timelines laid out by the regulation for the investigation of aircrew and ATCOs with potential cardiac issues. So in summary, being seen in a regular NHS clinic isn’t likely to work out in this scenario.

The most efficient solution is usually to see a cardiologist who is familiar with the requirements laid out by the CAA (and other national authorities) since this is likely to result in a report most likely to meet the requirements of the authority with the lowest risk of the incorrect sequence of investigations having been performed in the shortest possible time with the lowest risk of ‘missed steps’ (and hence rejection of the report by the regulatory authority).

The right experience and accreditation:

As an experienced general, adult cardiologist and an approved Aviation Medical Examiner for both the UK and EASA Authorities I am well placed to undertake the relevant investigations for UK and European aviation authorities with flexible appointments and a rapid turnaround. Ill be able to ‘hit the mark’ first time, with an investigation plan which meets the requirements first time and a report which exceeds the authorities specification using language that both your AME and the Authority medical assessors understand with the result of minimising the risk of your being kept in limbo or held unfit where you needn’t be.

The lowest fees:

What’s more, together with local NHS Trust with whom I work to deliver these cardiac investigations, we are able to offer the service at the lowest (known) rates in the UK (see the fees page). This combination of quickly available assessment, accurate investigation plans which meet the requirements of all UK and European aviation authorities at the lowest UK fees proves appealing to many aircrew and ATCOs requiring cardiac assessment.