(a)Electrocardiography
(1)An exercise electrocardiogram (ECG) when required as part of a cardiovascular assessment should be symptom-limited and completed to a minimum of Bruce Stage IV or equivalent.
(2)Reporting of resting and exercise ECGs should be carried out by the AME or an appropriate specialist.
(b)General
(1)Cardiovascular risk factor assessment
(i)Serum/plasma lipid estimation is case finding and significant abnormalities should require investigation and management under the supervision of the AeMC or AME in consultation with the licensing authority if necessary.
(ii)An accumulation of risk factors (smoking, family history, lipid abnormalities, hypertension, etc.) should require cardiovascular evaluation by the AeMC or AME in consultation with the licensing authority if necessary.
(2)Extended cardiovascular assessment
(i)The extended cardiovascular assessment should be undertaken at an AeMC or by a cardiologist.
(ii)The extended cardiovascular assessment should include an exercise ECG or other test that will provide equivalent information.
(c)Peripheral arterial disease Applicants with peripheral arterial disease, before or after surgery, should undergo satisfactory cardiological evaluation including an exercise ECG and 2D echocardiography. Further tests may be required which should show no evidence of myocardial ischaemia or significant coronary artery stenosis. A fit assessment may be considered provided:
(1)the exercise ECG is satisfactory; and
(2)there is no sign of significant coronary artery disease or evidence of significant atheroma elsewhere, and no functional impairment of the end organ supplied.
(d)Aortic aneurysm
(1)Applicants with an aneurysm of the infra-renal abdominal aorta may be assessed as fit following a satisfactory cardiological evaluation.
(2)Applicants may be assessed as fit after surgery for an aneurysm of the thoracic or abdominal aorta if the blood pressure and cardiovascular evaluation are satisfactory. Regular evaluations by a cardiologist should be carried out.
(e)Cardiac valvular abnormalities
(1)Applicants with previously unrecognised cardiac murmurs should require cardiological evaluation. If considered significant, further investigation should include at least 2D Doppler echocardiography.
(2)Applicants with minor cardiac valvular abnormalities may be assessed as fit by the licensing authority. Applicants with significant abnormality of any of the heart valves should be assessed as unfit.
(3)Aortic valve disease
(i)Applicants with bicuspid aortic valve may be assessed as fit if no other cardiac or aortic abnormality is demonstrated. Regular cardiological follow-up, including 2D Doppler echocardiography, may be required.
(ii)Applicants with mild aortic stenosis may be assessed as fit. Annual cardiological follow-up may be required and should include 2D Doppler echocardiography.
(iii)Applicants with aortic regurgitation may be assessed as fit only if regurgitation is minor and there is no evidence of volume overload. There should be no demonstrable abnormality of the ascending aorta on 2D Doppler echocardiography. Cardiological follow-up including 2D Doppler echocardiography may be required.
(4)Mitral valve disease
(i)Applicants with rheumatic mitral stenosis may only be assessed as fit in favourable cases after cardiological evaluation including 2D echocardiography.
(ii)Applicants with uncomplicated minor regurgitation may be assessed as fit. Regular cardiological follow-up including 2D echocardiography may be required.
(iii)Applicants with mitral valve prolapse and mild mitral regurgitation may be assessed as fit.
(iv)Applicants with evidence of volume overloading of the left ventricle demonstrated by increased left ventricular end-diastolic diameter should be assessed as unfit.
(f)Valvular surgery Applicants with cardiac valve replacement/repair should be assessed as unfit. After a satisfactory cardiological evaluation, fit assessment may be considered.
(1)Asymptomatic applicants may be assessed as fit by the licensing authority six months after valvular surgery subject to:
(i)normal valvular and ventricular function as judged by 2D Doppler echocardiography;
(ii)satisfactory symptom-limited exercise ECG or equivalent;
(iii)demonstrated absence of coronary artery disease unless this has been satisfactorily treated by re-vascularisation;
(iv)no cardioactive medication is required;
(v)annual cardiological follow-up to include an exercise ECG and 2D Doppler echocardiography. Longer periods may be acceptable once a stable condition has been confirmed by cardiological evaluations.
(2)Applicants with implanted mechanical valves may be assessed as fit subject to documented exemplary control of their anti-coagulant therapy. Age factors should form part of the risk assessment.
(g)Thromboembolic disorders Applicants with arterial or venous thrombosis or pulmonary embolism should be assessed as unfit during the first six months of anticoagulation. A fit assessment, with a limitation if necessary, may be considered by the licensing authority after six months of stable anticoagulation. Anticoagulation should be considered stable if, within the last six months, at least five international normalised ratio (INR) values are documented, of which at least four are within the INR target range and the haemorrhagic risk is acceptable. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment may be considered after review by the licensing authority after a period of three months. Applicants with pulmonary embolism should also be evaluated by a cardiologist. Following cessation of anticoagulant therapy, for any indication, applicants should undergo a reassessment by the licensing authority.
(h)Other cardiac disorders
(1)Applicants with a primary or secondary abnormality of the pericardium, myocardium or endocardium should be assessed as unfit. A fit assessment may be considered following complete resolution and satisfactory cardiological evaluation which may include 2D Doppler echocardiography, exercise ECG, 24-hour ambulatory ECG, and/or myocardial perfusion scan or equivalent test. Coronary angiography may be indicated. Regular cardiological follow-up may be required.
(2)Applicants with a congenital abnormality of the heart should be assessed as unfit. Applicants following surgical correction or with minor abnormalities that are functionally unimportant may be assessed as fit following cardiological assessment. No cardioactive medication is acceptable. Investigations may include 2D Doppler echocardiography, exercise ECG and 24-hour ambulatory ECG. Regular cardiological follow-up may be required.
(i)Syncope
(1)Applicants with a history of recurrent episodes of syncope should be assessed as unfit. A fit assessment may be considered after a sufficient period of time without recurrence provided cardiological evaluation is satisfactory.
(2)A cardiological evaluation should include:
(i)a satisfactory symptom exercise ECG. If the exercise ECG is abnormal, a myocardial perfusion scan or equivalent test should be required;
(ii)a 2D Doppler echocardiogram showing neither significant selective chamber enlargement nor structural or functional abnormality of the heart, valves or myocardium;
(iii)a 24-hour ambulatory ECG recording showing no conduction disturbance, complex or sustained rhythm disturbance or evidence of myocardial ischaemia;
(iv)a tilt test carried out to a standard protocol showing no evidence of vasomotor instability.
(3)Neurological review should be required.
(j)Blood pressure
(1)Anti-hypertensive treatment should be agreed by the licensing authority. Medication may include:
(i)non-loop diuretic agents;
(ii)Angiotensin Converting Enzyme (ACE) inhibitors;
(iii)angiotensin II receptor blocking agents;
(iv)long-acting slow channel calcium blocking agents;
(v)certain (generally hydrophilic) beta-blocking agents.
(2)Following initiation of medication for the control of blood pressure, applicants should be re-assessed to verify that the treatment is compatible with the safe exercise of the privileges of the licence.
(k)Coronary artery disease
(1)Applicants with chest pain of an uncertain cause should undergo a full investigation before a fit assessment may be considered. Applicants with angina pectoris should be assessed as unfit, whether or not it is abolished by medication.
(2)Applicants with suspected asymptomatic coronary artery disease should undergo a cardiological evaluation including exercise ECG. Further tests (myocardial perfusion scanning, stress echocardiography, coronary angiography or equivalent) may be required, which should show no evidence of myocardial ischaemia or significant coronary artery stenosis.
(3)After an ischaemic cardiac event, including revascularisation, applicants without symptoms should have reduced any vascular risk factors to an appropriate level. Medication, when used to control cardiac symptoms, is not acceptable. All applicants should be on acceptable secondary prevention treatment.
(i)A coronary angiogram obtained around the time of, or during, the ischaemic myocardial event and a complete, detailed clinical report of the ischaemic event and of any operative procedures should be available.
(A)there should be no stenosis more than 50 % in any major untreated vessel, in any vein or artery graft or at the site of an angioplasty/stent, except in a vessel subtending a myocardial infarction;
(B)the whole coronary vascular tree should be assessed as satisfactory by a cardiologist, and particular attention should be paid to multiple stenoses and/or multiple revascularisations;
(C)an untreated stenosis greater than 30 % in the left main or proximal left anterior descending coronary artery should not be acceptable.
(ii)At least six months from the ischaemic myocardial event, including revascularisation, the following investigations should be completed:
(A)an exercise ECG showing neither evidence of myocardial ischaemia nor rhythm or conduction disturbance;
(B)an echocardiogram or equivalent test showing satisfactory left ventricular function with no important abnormality of wall motion (such as dyskinesia or akinesia) and a left ventricular ejection fraction of 50 % or more;
(C)in cases of angioplasty/stenting, a myocardial perfusion scan or equivalent test, which should show no evidence of reversible myocardial ischaemia. If there is any doubt about myocardial perfusion, in other cases (infarction or bypass grafting), a perfusion scan should also be required;
(D)further investigations, such as a 24-hour ECG, may be necessary to assess the risk of any significant rhythm disturbance.
(iii)Follow-up should be conducted annually (or more frequently, if necessary) to ensure that there is no deterioration of the cardiovascular status. It should include a cardiological evaluation, exercise ECG and cardiovascular risk assessment. Additional investigations may be required.
(iv)After coronary artery vein bypass grafting, a myocardial perfusion scan or equivalent test should be performed on clinical indication, and in all cases within five years from the procedure.
(v)In all cases, coronary angiography, or an equivalent test, should be considered at any time if symptoms, signs or non-invasive tests indicate myocardial ischaemia.
(vi)Applicants may be assessed as fit after successful completion of the three-month or subsequent review.
(l)Rhythm and conduction disturbances
(1)Applicants with any significant rhythm or conduction disturbance may be assessed as fit after cardiological evaluation and with appropriate follow-up. Such evaluation should include:
(i)exercise ECG which should show no significant abnormality of rhythm or conduction, and no evidence of myocardial ischaemia. Withdrawal of cardioactive medication prior to the test should be required;
(ii)24-hour ambulatory ECG which should demonstrate no significant rhythm or conduction disturbance;
(iii)2D Doppler echocardiogram which should show no significant selective chamber enlargement or significant structural or functional abnormality, and a left ventricular ejection fraction of at least 50 %. Further evaluation may include:
(iv)24-hour ECG recording repeated as necessary;
(v)electrophysiological study;
(vi)myocardial perfusion imaging or equivalent test;
(vii)cardiac magnetic resonance imaging (MRI) or equivalent test;
(viii)coronary angiogram or equivalent test.
(2)Applicants with supraventricular or ventricular ectopic complexes on a resting ECG may require no further evaluation, provided the frequency can be shown to be no greater than one per minute, for example on an extended ECG strip. Applicants with asymptomatic isolated uniform ventricular ectopic complexes may be assessed as fit, but frequent or complex forms require full cardiological evaluation.
(3)Where anticoagulation is needed for a rhythm disturbance, a fit assessment may be considered if the haemorrhagic risk is acceptable and the anticoagulation is stable. Anticoagulation should be considered stable if, within the last six months, at least five INR values are documented, of which at least four are within the INR target range. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment with an appropriate limitation may be considered after review by the licensing authority after a period of three months.
(4)Ablation
(i)Applicants who have undergone ablation therapy should be assessed as unfit for a minimum period of two months.
(ii)A fit assessment may be considered following successful catheter ablation provided an electrophysiological study (EPS) demonstrates satisfactory control has been achieved.
(iii)Where EPS is not performed, longer periods of unfitness and cardiological follow-up should be considered.
(iv)Follow-up should include a cardiological review.
(5)Supraventricular arrhythmias Applicants with significant disturbance of supraventricular rhythm, including sinoatrial dysfunction, whether intermittent or established, should be assessed as unfit. A fit assessment may be considered if cardiological evaluation is satisfactory.
(i)For initial applicants with atrial fibrillation/flutter, a fit assessment should be limited to those with a single episode of arrhythmia which is considered to be unlikely to recur.
(ii)For revalidation, applicants may be assessed as fit if cardiological evaluation is satisfactory and the stroke risk is sufficiently low. A fit assessment may be considered after a period of stable anticoagulation as prophylaxis, after review by the licensing authority. Anticoagulation should be considered stable if, within the last six months, at least five INR values are documented, of which at least four are within the INR target range. In cases of anticoagulation medication not requiring INR monitoring, a fit assessment may be considered after review by the licensing authority after a period of three months.
(iii)Applicants with asymptomatic sinus pauses up to 2.5 seconds on a resting ECG may be assessed as fit if exercise ECG, 2D echocardiography and 24-hour ambulatory ECG are satisfactory.
(iv)Applicants with symptomatic sino-atrial disease should be assessed as unfit.
(6)Mobitz type 2 atrio-ventricular block Applicants with Mobitz type 2 AV block may be assessed as fit after a full cardiological evaluation confirms the absence of distal conducting tissue disease.
(7)Complete right bundle branch block Applicants with complete right bundle branch block should require cardiological evaluation on first presentation.
(8)Complete left bundle branch block A fit assessment may be considered as follows:
(i)Initial applicants may be assessed as fit after full cardiological evaluation showing no pathology. Depending on the clinical situation, a period of stability may be required.
(ii)Applicants for revalidation or renewal of a medical certificate with a de-novo left bundle branch block may be assessed as fit after cardiological evaluation showing no pathology. A period of stability may be required.
(iii)A cardiological evaluation should be required after 12 months in all cases.
(9)Ventricular pre-excitation Applicants with pre-excitation may be assessed as fit if they are asymptomatic, and an electrophysiological study, including an adequate drug-induced autonomic stimulation protocol, reveals no inducible re-entry tachycardia and the existence of multiple pathways is excluded. Cardiological follow-up should be required including a 24-hour ambulatory ECG recording showing no tendency to symptomatic or asymptomatic tachy-arrhythmia.
(10)Pacemaker Applicants with a subendocardial pacemaker may be assessed as fit three months after insertion provided:
(i)there is no other disqualifying condition;
(ii)bipolar lead systems programmed in bipolar mode without automatic mode change have been used;
(iii)that the applicant is not pacemaker dependent;
(iv)regular cardiological follow-up should include a symptom-limited exercise ECG that shows no abnormality or evidence of myocardial ischaemia.
(11)QT prolongation Applicants with asymptomatic QT-prolongation may be assessed as fit subject to a satisfactory cardiological evaluation.
(12)Brugada pattern on electrocardiography Applicants with a Brugada pattern Type 1 should be assessed as unfit. Applicants with Type 2 or Type 3 may be assessed as fit, with limitations as appropriate, subject to satisfactory cardiological evaluation.