AINsight: The Screening Electrocardiogram for Pilots

All pilots maintaining a first-class FAA medical certificate must periodically obtain a screening electrocardiogram (ECG). The initial screening ECG is done at age 35, then annually after 40. While most ECGs are done at the AME’s office at the time of exam, there are certain circumstances when an ECG done elsewhere may be acceptable to the AME and FAA if it can be verified that the ECG does represent the pilot in question.

For those who are unsure of what I mean by ECG, they will quickly recognize the colloquially used, but outdated, EKG acronym. They are one and the same.

This test screens for electrical activity in the heart. We are all familiar with the seemingly “state of the ancient” process of hooking up a bunch of wires all over the body in a seemingly bizarre macrame pattern. The actual locations are one lead on each limb and then another six across the chest.

If there is an amputated limb, the lead is simply placed as close to the amputation site as is possible. I have several pilots in my practice who have either arm or leg amputations, and their ECGs appear unaffected by the slight shift in lead positioning.

When all of the wires are hooked up and it is a pilot’s initial ECG, I reassure them that the process is only to measure their own internal conductivity. There is no electricity running from the ECG machine into the pilot—it only measures the pilot’s individual output. There is no concern for any kind of electrical shock for the pilot.

All cardiac muscle has some inherent conductivity, and there are also the primary bundle branches that conduct the electrical impulses to the various cardiac musculature. These impulses cause the heart muscle to contract, hence pumping blood to the brain and body. The ECG computer analyzes these impulses and outputs this data.

Most pilots have seen their ECG tracings by now. The formal term for this test is the “12-lead ECG,” even though only 10 actual leads are placed on the body. The printout appears as a series of squiggly lines across a graph paper with 1 mm boxes. It is far more recognizable than I am making it sound right now.

The printout of the ECG is scanned as a PDF and then attached by the AME to the individual examination transmission for that pilot.

Before I go any further, many pilots reading this discussion are already thinking that their smart watches give them the same information that an ECG at the AMEs office does. At least that is what was advertised to them at the time of purchase (and, as we all know, advertising is never misleading).

Kidding aside, smart watches do give excellent information, but it does not substitute for a full ECG. The watches may give an early warning of an arrhythmia (irregular heartbeat) that perhaps the wearer does not sense. Many, if not most, arrhythmias cause some kind of symptoms, but at times they do not. Hence, the value of a smart watch. 

The kind of arrhythmia that is among the most troubling is atrial fibrillation. This is an “irregularly irregular” heartbeat that can dramatically increase the risk for stroke (cerebrovascular accident, or CVA). Atrial fibrillation, and pretty much all arrhythmias, should be evaluated—and treated, if necessary—thus reducing long-term cardiac and cerebrovascular risk factors.

At a pilot examination, long before I hook up the ECG leads, I already know if there is an arrhythmia and likely what general type it is. Simply taking the pulse and listening to the heart with a stethoscope (auscultation) gives me the information that the ECG itself will only confirm. However, the ECG will help refine my understanding of the arrhythmia I have already auscultated. This helps guide me as to whether a full cardiology evaluation will be required.

For many arrhythmias, the pilot will have to see a cardiologist. Often, this will be a one-time assessment that determines whether the arrhythmia is concerning enough to require treatment. Many minor arrhythmias do not require treatment and do not unduly increase long-term health risks.

If, however, the arrhythmia is something concerning, such as atrial fibrillation, the pilot must receive appropriate treatment to stabilize the heartbeat, thus reducing cardiovascular risks, including those for stroke. That pilot will likely then be followed under a special issuance authorization.

Pilots ask me whether the ECG is a good predictive tool for assessing future heart attack risks (myocardial infarction, or MI). While the ECG can give reasonable information to assess if the pilot has had an MI in the past, it is unfortunately not that great for future heart attack risk assessment.

However, the ECG is still a great tool, and the pilot and their treating physician can outline the best risk-modification program for the pilot, considering family history, individual medical conditions, and the ECG itself.

A stress test on a treadmill provides an ongoing series of ECG tracings at various times during increased exercise demands. This test, which sometimes includes cardiac imaging during the study by either an echocardiogram (ultrasound of the heart structure) or nuclear isotope injection, gives a far more thorough understanding of the functional capacity of the heart. These tests are not part of a routine FAA examination, though.

If, however, the pilot does have increased risks noted in any aspect of their medical screening—either at the FAA exam, during a continuity care evaluation, or by unusual or concerning symptoms—then any/all additional screening and diagnostic testing is definitely indicated and fair game.

I remind pilots not to avoid getting cardiac testing simply because they are worried about opening the proverbial can of worms with the FAA. As I have said many times, “It is easier to keep you flying if you are still alive.”

Take-home message: if cardiac testing appears indicated and is recommended by the treating physician or mandated per FAA protocols on a case-by-case basis, doing so may be a lifesaver and can also facilitate ongoing FAA medical certification. A period of temporary grounding may ensue, but that is certainly better than the outcome of an MI or CVA.

The screening ECG is a mandatory part of the FAA first-class examination at various ages of the pilot. It is non-invasive, simple to perform, and provides useful information. If the AME discovers something concerning on the ECG (or during the hands-on examination itself), they may have to refer the pilot for additional evaluations before issuing the medical certificate or defer the decision for an FAA opinion.

There are many variants of normal on ECGs, and therefore each pilot has their own unique signature, so to speak. The challenge sometimes is to determine whether an unusual ECG finding is a variant of normal versus something potentially concerning. A cardiology opinion may be required to make that determination.

The vast majority of screening ECGs will not mandate the pilot to receive additional cardiac evaluations. A minority will indeed lead to further evaluations, but again, the purpose of these referrals is to protect both the health of the pilot and the safety of the aviation system itself.

The opinions expressed in this column are those of the author and are not necessarily endorsed by AIN Media Group.