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Management of cardiac conduction abnormalities and arrhythmia in aircrew
  1. Norbert Guettler1,
  2. Dennis Bron2,
  3. Olivier Manen3,
  4. Gary Gray4,
  5. Thomas Syburra5,
  6. Rienk Rienks6,
  7. Joanna d’Arcy7,
  8. Eddie D Davenport8,
  9. Edward D Nicol7
  1. 1 German Air Force Center for Aerospace Medicine, Fuerstenfeldbruck, Germany
  2. 2 Aeromedical Centre, Swiss Air Force, Dubendorf, Switzerland
  3. 3 Aviation Medicine Department, AeMC, Percy Military Hospital, Clamart, France
  4. 4 Canadian Forces Environmental Medical Establishment, Toronto, Ontario, Canada
  5. 5 Cardiac Surgery Department, Luzerner Kantonsspital, Luzern, Switzerland
  6. 6 Department of Cardiology, University Medical Center Utrecht and Central Military Hospital, Utrecht, The Netherlands
  7. 7 Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire, UK
  8. 8 Aeromedical Consult Service, USAF School of Aerospace Medicine, Wright-Patterson AFB, Ohio, USA
  1. Correspondence to Dr Edward D Nicol, Royal Air Force Aviation Clinical Medicine Service, RAF Centre of Aviation Medicine, RAF Henlow, Bedfordshire SG16 6DN, UK; e.nicol{at}


Cardiovascular diseasesi are the most common cause of loss of flying licence globally, and cardiac arrhythmia is the main disqualifier in a substantial proportion of aircrew. Aircrewii often operate within a demanding physiological environment, that potentially includes exposure to sustained acceleration (usually resulting in a positive gravitational force, from head to feet (+Gz)) in high performance aircraft. Aeromedical assessment is complicated further when trying to discriminate between benign and potentially significant rhythm abnormalities in aircrew, many of whom are young and fit, have a resultant high vagal tone, and among whom underlying cardiac disease has a low prevalence. In cases where a significant underlying aetiology is plausible, extensive investigation is often required and where appropriate should include review by an electrophysiologist. The decision regarding restriction of flying activity will be dependent on several factors including the underlying arrhythmia, associated pathology, risk of incapacitation and/or distraction, the type of aircraft operated, and the specific flight or mission criticality of the role performed by the individual aircrew.

  • electrophysiology
  • catheter ablation
  • cardiac arrhythmias and resuscitation science
  • ecg/electrocardiogram
  • health care delivery

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  • i Preamble: Evidence-based cardiovascular risk assessment in aircrew poses significant challenges in the aviation environment as data to support decision making at the low level of tolerable risk in aviation is rarely available from the published literature. As a result, there are discrepancies between aviation authorities’ recommendations in different countries, and even between licensing organisations within single countries. The North Atlantic Treaty Organization (NATO) HFM-251 Occupational Cardiology in Military Aircrew working group comprises full-time aviation medicine and aviation cardiology experts who advise both their military and civil aviation organisations including, but not limited to, the US Federal Aviation Authority (FAA), the UK Civil Aviation Authority (CAA), the European Aviation Safety Agency (EASA) and the US National Aeronautics Space Administration (NASA). The recommendations of this group are as a result of a 3 year working group that considered best clinical cardiovascular practice guidelines within the context of aviation medicine and risk principles. This work was conducted independently of existing national and transnational regulators, both military and civilian, but considered all available policies, in an attempt to determine best evidence-based practice in this field. The recommendations presented in this document, and associated manuscripts, are based on expert consensus opinion of the NATO group. This body of work has been produced to develop the evidence base for military aviation cardiology and to continue to update the relevant civilian aviation cardiology advice following the 1998 European Cardiology Society aviation cardiology meeting.

  • ii Aircrew: Aircrew are defined somewhat differently in civil and military aviation. NATO and the International Civil Aviation Organization (ICAO) delegates the definition of aircrew to national authorities. In the civilian sector aircrew are often categorised as flight crew (pilots)/technical crew members and cabin crew, with separate regulation for air traffic controllers (ATCO). The military define aircrew more broadly as “persons having duties concerned with the flying or operation of the air system, or with passengers or cargo when in flight”. From a risk perspective, professional (commercial) pilots have a higher attributable risk than private pilots and non-pilot aircrew. Controllers are considered to have an attributable risk equivalent to professional pilots. From a cardiovascular perspective, aircrew whose flying role includes repetitive exposure to high acceleration forces (Gz) comprise a subgroup who, due to the unique physiological stressors of this flight environment, often require specific aeromedical recommendations. A more detailed description of aircrew is available in table 1 of the accompanying introductory paper on aviation cardiology [ref Intro paper].

  • Contributors All authors were part of the NATO aviation cardiology WG and all contributed to the design and writing of this article.

  • Funding Produced with support from NATO CSO and HFM-251 Partner Nations.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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