Exercise ECG for Pilots and Air Traffic Controllers: The CAA Protocol Explained

When an aeromedical examiner asks for an exercise ECG, the CAA does not simply want to know that you passed. It wants the test performed and reported in a specific way, set out in its own guidance sheet, and it warns that a test done differently may have to be repeated. Pilots and controllers often find this out only after paying for a test that their AME cannot use. This guide explains what the CAA asks for, why each point matters, and how to make sure your test is accepted first time.

When an AME asks for one

An exercise ECG is not a routine part of every medical. The CAA's cardiovascular guidance calls for it when it is needed as part of a cardiovascular assessment, which in practice means:

• a resting ECG at your medical shows something that needs clarifying,
• your cardiovascular risk assessment puts you in a group where the CAA wants a functional test,
• you have had symptoms, such as chest pain, that need investigating, or
• you are being followed up after a heart attack, a stent or bypass surgery.

The same protocol applies to Class 1 (commercial pilots), Class 2 (private pilots), Class 3 (air traffic controllers) and LAPL certificates. What differs between classes is how much paperwork must go back to the AME, which we cover below.

What the CAA protocol requires

The CAA's Exercise Electrocardiogram (ECG) Test Protocol, version 4.2 of July 2026, is a one-page sheet the CAA tells you to hand to your cardiologist before the test. Its requirements are:

• The Bruce protocol. A standard treadmill test that gets faster and steeper every three minutes, ending in a rapid walk. Not a modified or gentler version.
• 12 leads, recorded at the end of every minute of exercise and for ten minutes of recovery. This is the point most often missed. Many clinics record a trace at the end of each three-minute stage and stop after a short recovery. The CAA wants every minute, and a full ten minutes afterwards, because some changes only appear in recovery.
• Symptom-limited. You exercise until you genuinely cannot continue, not until you reach a target heart rate. The CAA expects a minimum of nine minutes of walking for certification. If you stop earlier, the cardiologist must state why.
• Beta-blockers. If you take a beta-blocker it may be appropriate to pause it for the test, but only after discussion with, and under the supervision of, your own clinician. Either way the cardiologist must record whether you take one and whether it was stopped.
• No holding the handrails, and no running.

The CAA's wider cardiology guidance adds that, when required, the test should be completed to a minimum of Bruce stage IV or equivalent, which is twelve minutes. Stage IV is a fast walk on a steep slope, so fitness matters: if you know a test is coming, a few weeks of regular brisk walking or running beforehand is time well spent.

What the report must contain

The CAA's sheet tells you to forward the cardiologist's report, including the results of all investigations, to your AME or GP, unless you have been asked to send it to the CAA directly. Then it splits by class:

• Class 1 and Class 3: you must also submit the full exercise ECG report with the ECG tracings, not just a summary letter.
• Class 2 and LAPL: a detailed cardiologist's report is usually sufficient, though your AME or GP may still ask for the full report with tracings.

Two practical points follow. First, ask for the full report with tracings whatever your class, so you are never sent back for it. Second, tell the CAA, your AME or your GP if you need the tracings returned to you. The CAA also notes that any fees are your responsibility, which is true of every private aeromedical investigation.

Preparing for the test

• Bring the CAA protocol sheet and your AME's request, and tell the clinic when you book that the test is for an aviation medical, so it is set up to the protocol from the start.
• Bring a list of your medications. If you take a beta-blocker, raise it when you book rather than on the day, so any decision to pause it can be made properly and in advance with your own clinician.
• Wear trainers and clothes you can walk fast uphill in. Eat lightly two hours before; avoid caffeine, alcohol, smoking and hard exercise for three hours before.
• Expect the appointment to take about an hour, including the ten-minute recovery recording.

What happens next

You receive the cardiologist's report and the full exercise ECG report with tracings as a single PDF, written for onward submission. Your AME reviews it and, depending on the findings and your class, may need to refer it to the CAA's medical department. If the test shows something significant, that is a conversation between you, your cardiologist and your AME; occasionally a certificate is issued with a limitation rather than refused. A clear, protocol-compliant report makes that process as short as it can be.

Why pilots come to us

Every aeromedical exercise ECG at OneMedicine is performed to the CAA protocol and supervised and reported by a consultant cardiologist, on a hospital-grade GE stress-testing system with continuous 12-lead ECG, automated blood pressure and oxygen monitoring. The price is £250, fixed, with no consultation fee, and appointments are typically available within days. The clinic is in Kings Heath, Birmingham, about half an hour by car from Birmingham Airport, opposite Kings Heath railway station and with on-site parking. You do not need a referral: bring your AME's request and the protocol sheet.

When to see a doctor first

If you are having chest pain, breathlessness or palpitations now, see a doctor before booking any exercise test. Severe chest pain, breathlessness or collapse is a 999 call.

Written by Dr Ibrar Ahmed — MBChB MRCP MRCGP PhD PG Dip (Cardiology)
Specialist interest: Cardiovascular Medicine · OneMedicine, CQC-registered clinic