Hypertension

Developed in collaboration with CASA Medical.

Hypertension represents a long-term risk factor for cardiovascular, cerebrovascular, renal, and peripheral vascular disease. Isolated mild to moderate hypertension seldom represents an immediate risk of incapacitation but must be considered when conducting the cardiovascular risk assessment. Blood pressure that is difficult to control or requiring multiple antihypertensive agents should alert the ME of the possibility of secondary medical causes that require exclusion.

Blood pressure exceeding 140/90 mmHg should be treated using National guidelines.

Essential and secondary hypertension must be managed within these guidelines, with any underlying causes requiring separate aeromedical consideration. 

Pilot and controller information

Cease flying or operating and report to your ME or CAA for any of the following:

• Your blood pressure exceeds 160/95 mmHg as measured by a health professional
• You have any symptoms such as dizziness, chest pain, shortness of breath or stroke- like symptoms
• You are started on new medication for your hypertension
• You have any side effects that may be related to your medication

Aeromedical implications

Effect of condition on aviation

Overt incapacitation

• Uncontrolled severe hypertension can precipitate acute, incapacitating events such as:
  • Stroke (ischaemic or haemorrhagic)
  • Myocardial infarction
  • Acute heart failure
  • Hypertensive encephalopathy or crisis
• Chronic hypertension increases the risk of acute incapacitating events
  • Cardiomyopathy
  • Ischaemic heart disease
  • Arrhythmias eg atrial fibrillation
  • Cerebrovascular events eg TIA, stroke
  • Left Ventricular Hypertrophy (LVH) – associated with arrhythmia and sudden cardiac risk
  • Heart Failure – both preserved and reduced ejection fraction

Subtle incapacitation

• Fatigue, dizziness, orthostatic hypotension (especially with medication)
• Distraction due to chronic symptoms or medication side effects (e.g., decreased G-tolerance, electrolyte imbalance)
• End-organ effects – eg chronic kidney disease – can cause metabolic imbalance and fatigue

Complications with aeromedical relevance

• Stroke, cardiac disease, renal impairment, or hypertensive encephalopathy or crisis  

Effect of aviation on condition

• G-forces and postural changes may increase susceptibility to orthostatic hypotension, especially in applicants on alpha blockers or vasodilators
• Dehydration in flight may impair BP control and increase adverse medication effects
• Fatigue and circadian disruption may indirectly affect treatment adherence and BP variability

CAA hypertension report

• Complete the CAA Hypertension report (24067-214) [DOCX 43 KB]

Approach to medical certification

Based on blood pressure measurement

• Maximum clinic BP acceptable for certification: < 160/95 mmHg
  • If BP exceeds this limit: applicant must be grounded and be referred to their GP/primary care provider for management.

Based on management and risk

• Further evaluation and management
  • If BP is elevated, referred for management according to national guidelines
• Medication suitability
  • Acceptable: ACE inhibitors, ARBs, beta blockers, long-acting calcium channel blockers, low-dose thiazide-type diuretics, alpha blockers (with restrictions).
  • Alpha-blockers, beta blockers and peripherally acting calcium channel blockers should be avoided by pilots doing aerobatics.
  • Not acceptable: centrally acting agents (e.g., clonidine, methyldopa), loop diuretics, nitrates.
• Medication side effects
  • Must not cause safety relevant side effects (e.g. significant hypotension, fatigue, electrolyte imbalance, or reduced G-tolerance.)
• Orthostatic hypotension
  • Check lying and standing BP when on medication or if symptomatic.
  • Orthostatic hypotension (OH) is defined as a fall in systolic BP of at least 20 mmHg (or at least 30 mmHg in patients with supine hypertension) and/or a fall in diastolic BP of at least 10 mmHg within 3 minutes of standing
  • Ref: https://link.springer.com/article/10.1007/s10286-011-0119-5(external link)  
• Cardiovascular risk
  • Use PREDICT or AUSCVD risk calculator, and if elevated, refer to appropriate guidelines
  • OSA risk – use STOPBANG calculator and manage as appropriate

Aerobatic and agricultural flight restriction

• Applicants on alpha, beta blockers and peripherally acting calcium channel blockers: Apply restriction
  • “Not valid for aerobatic flight and agricultural flying”
  • Due to risk of postural hypotension and G intolerance.

Additional investigations (as clinically indicated)

• Blood tests: lipids, HbA1c or fasting glucose, creatinine, eGFR, electrolytes
• ECG: if newly diagnosed or clinical suspicion
• Echocardiogram: if LVH suspected or abnormal ECG
• Screening for secondary hypertension if indicated (e.g., renal or endocrine causes)

ME aeromedical decision guide

If ALL the following criteria are met the medical examiner may issue the pilot or controller a medical certificate.

ME must confirm	Tick
Treating physician finds condition is stable on current management and no changes recommended
Symptoms: Stable and well-controlled (either on or off medication)
Blood pressure recordings Less than 160/95 mmHg. Although this is acceptable for medical certification the applicant should be referred to their primary care provider for further management, if blood pressure above 140/90 mmHg.
Acceptable medication(s) and absence of side effects from medication Unacceptable medications: Centrally acting antihypertensives eg clonidine
PREDICT risk < 10%/5 years or if above myocardial ischaemia has been excluded * refer to cardiac risk guidelines
No evidence of LV hypertrophy on echocardiogram
No evidence of end organ or peripheral vascular disease
No known or suspected unresolved cause of hypertension such as alcohol related, reno-vascular disease, endocrine disorder, obstructive sleep apnoea
ME considers safe to certify

An AMC referral to CAA AvMed is required if a pilot’s or controller’s condition does not meet the above criteria and they consent to their condition being considered under flexibility to the CAR 67 rules.

ME letters

Hypertension medical certificate letter [DOCX 21 KB]

Hypertension 020 operational restrictions letter [DOCX 23 KB]