Hypertension represents a long term risk factor for cardiovascular, cerebrovascular and peripheral vascular disease. Isolated mild to moderate hypertension seldom represents an immediate risk of incapacitation but has to be considered when conducting the cardiovascular risk assessment in accordance with the General Direction Examination Procedures [PDF 1.6 MB].
Blood pressure that is difficult to control or requiring multiple antihypertensive agents should alert the ME of the possibility of medical causes that require excluding.
Treatment of hypertension should be compatible with flying activities. ACE inhibitors, Betablockers, Calcium antagonist and mild Diuretics are generally compatible. A period of grounding should be observed when initiating treatment, lasting from a few days to one month depending on the agent. Dose increments should be more cautious than for the general population to ensure absence of side effects, including electrolytes imbalance, hypotension and decreased G tolerance.
Clonidine and Methyldopa and other centrally acting agents are not acceptable. Loop diuretics are generally not acceptable. Sympatholytics such as Guanethidine are not acceptable except that low dose Alpha-blockers may be used with caution. Selective Alphablockers such as Tamsulozin are preferred when used for benign prostate hyperplasia.
Alpha-blockers should be avoided by pilots doing aerobatics. They generally require a longer, up to one month, ground trial. BP determination lying and standing to observe for postural drop should be recorded on several occasions prior to authorising a return to flying.
Particular care must be taken in assessing applicants working in a hot environment, with possible resulting dehydration, or exposure to high G loads (i.e. agricultural pilots, aerobatic pilots).
The blood pressure is measured in the sitting position. The arm must be supported and held at the level of the Atria. If the BP is outside the range 90-140 systolic, lying and standing BP readings should also be taken.
If initial two readings are below 140 systolic and 90 diastolic no further action is required.
If levels are 140/90 or higher two further readings at several minutes’ intervals should be taken together with pulse rate.
The same applies to people on antihypertensive medication. Standing and lying readings should also be taken for those on medication to assess for postural drop. See:
Blood Pressure Examination Report form 24067-214 [PDF 22 KB]
If three blood pressure readings exceed 140/90, hypertension is likely and further readings over several days should be taken. This can be done by the applicant’s own GP or their nursing staff. Persistently elevated blood pressure should not be dismissed as due to 'white coat'. If hypertension is suspected a fundus examination should be done.
Pre-existing records from the GP, community readings or ambulatory monitoring can assist in confirming if an individual suffers from unacceptable hypertension. They should be obtained whenever in doubt.
If still in doubt a 24 h blood pressure recording should be considered and the applicant be referred to their treating physician if hypertension is confirmed.
The mean Blood Pressure can be estimated with the following formula: [Diast+(SystDiast)/3]. The normal mean blood pressure range is 70 – 110 mmHg.
A fast pulse rate may mean that the applicant is particularly anxious; a slow pulse may reveal good cardiovascular conditioning or undeclared use of beta blockers.
| Beta-blockers: | Hydrophilic drugs are preferred (i.e. Atenolol, Metoprolol). Only a few days’ grounding is necessary. Observe for any bronchospasm and fatigue. |
| ACE inhibitors: | Long acting ACE inhibitors are preferred; 1 to 3 weeks period off flying duty are recommended; Observe for postural hypotension and electrolytes imbalance. Do several lying and standing BP measurements. |
| Angiotensin Receptor Blocker (ARB): | Permitted, see ACE inhibitors, excellent first line. |
| Calcium channel antagonists: | Long acting permitted, i.e. Amlodipine. Nifedipine not permitted, unless it is a controlled release preparation, taken once daily. A one week period off flying duty is recommended. |
| Thiazide diuretics & Spironolactone: |
Low dose diuretics only. Avoid in people with a history of gout. Watch for hyponatremia, hypokalaemia / hyperkalaemia. Only a few days off flying duty are necessary unless introduced as second line. |
| α-Blockers | Observe for postural hypotension. Do several lying and standing BP measurements. Avoid in aerobatic pilots. 3 to 4 weeks period off duty are recommended. Slow increase in dosage (For prostatism, selective alpha blockers should be used i.e. Tamsulozin rather than Prazocin). |
| Loop diuretics: | Generally not permitted – of aeromedical significance. |
| Centrally acting medication: | Not permitted. |
Applicants with untreated hypertension should be referred back to their GP for review and treatment as appropriate.
Controlled or mild hypertension is generally allowable at all levels of medical certification.
An applicant with hypertension may be considered as having a condition that is not of aeromedical significance if:
The certificate duration may be reduced and / or surveillance imposed if the ME considers it appropriate.
