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.

The 2026 rule: your QRISK3 score decides

Since May 2026 the CAA's cardiovascular risk assessment guidance (v1.0) has made the exercise ECG far more common. At your first medical after the age of 40, and at intervals after that, your AME works out your 10-year cardiovascular risk using the latest QRISK calculator, which at present is QRISK3, the version NICE recommends and GP systems use. If the score reaches the limit for your class, you need a heart screening test before you can be certified:

• Class 1 (commercial pilots): 10% or more
• Class 2 (private pilots) and Class 3 (air traffic controllers): 15% or more
• LAPL: 25% or more

The score is repeated roughly every five years in your forties, every three in your fifties and every two from sixty, and sooner if a new risk factor appears, such as high blood pressure, type 2 diabetes, kidney disease, sleep apnoea, high cholesterol or a BMI of 30 or more. Some conditions call for screening whatever the score: resistant hypertension, diabetes with organ damage or three or more other risk factors, moderate kidney disease with protein in the urine, and transplant recipients.

QRISK3 is driven largely by age, so a fit, non-smoking private pilot in his late sixties can cross the 15% line with nothing wrong, and a commercial pilot in his fifties with mildly raised blood pressure can cross 10%. That is why many pilots who have never had a symptom are now being sent for a test.

An exercise ECG is also still requested for the older reasons: a resting ECG at your medical that needs clarifying, symptoms such as chest pain, or follow-up after a heart attack, a stent or bypass surgery. The same protocol applies to every class; what differs is how much paperwork must go back to the AME, covered below.

Four accepted tests, and how long each one lasts

The CAA accepts any one of four screening tests, with no preference between them. What differs is the cost, how long a normal result covers you, and what happens if something is found:

• Exercise ECG: a normal result covers 2 years. £250 at OneMedicine. The least expensive route, and the only one with a protocol sheet of its own, explained below.
• Stress echocardiogram: 3 years. £375 at OneMedicine. A treadmill test with ultrasound pictures of the heart before and straight after exercise.
• Perfusion scan (MPS or stress MRI): 3 years. Hospital-based; we do not offer it.
• CT coronary angiogram (CTCA): 6 years. Carried out by Prof Leyva, Consultant Cardiologist, who works closely with us, and arranged through the clinic: £1,250 for the scan, paid to Prof Leyva, plus a £60 OneMedicine fee for our part, which is reviewing your history and risk score, a referral letter setting out the CAA's reporting requirements, and checking the report and forwarding it to your AME. A CTCA sees plaque that an exercise test cannot, so a finding on it can lead to a further ischaemia test and, for Class 1, an operational limitation. A calcium score on its own is unlikely to be accepted.

Over its validity the exercise ECG and the stress echo both work out at about £125 a year; a CTCA is about £218 a year, dearer but the most definitive, and the only route for a pilot who cannot manage a treadmill. A test you had in the past year or two counts, provided it was done to the standard and is still inside its window.

Knowing your score before your medical

QRISK3 uses your age, sex, ethnicity, postcode, smoking, blood pressure, the ratio of total to HDL cholesterol, BMI, and any diabetes, kidney disease, atrial fibrillation, rheumatoid arthritis or family history of early heart disease, among other factors. Two of those are blood pressure and cholesterol, which a GP can measure and, where they are raised, treat. Treating them is ordinary good medicine, and it does lower a real score, but nobody can promise what a score will be, and an AME will use the figures in front of them on the day.

If you would rather know where you stand before your medical, a cholesterol profile (£49, fasting) and a GP appointment (£65), where your blood pressure is measured and your QRISK3 score worked out with you, give you the number and a plan. If it is over the line, the exercise ECG can be booked the same week.

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, by email the same working day. Your AME reviews it and, depending on the findings and your class, may need to refer it to the CAA's medical department. A normal result means no further heart screening for two years, provided your risk profile stays stable; a new diagnosis or a significant change in your risk factors brings the next assessment forward. If the test shows something significant, the CAA's flow chart for suspected coronary disease applies, and 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.

Repeating the test

Because a normal exercise ECG covers two years, most pilots over the threshold will be back for another one. We keep a note of your licence class and test date and, if you ask us to when you book, remind you about 22 months later, so the repeat is done before your next medical rather than after it has been deferred.

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, appointments are typically available within days, and the report is emailed the same working day. 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.

Sources

• UK CAA, Cardiovascular risk assessment, v1.0, May 2026
• UK CAA, Exercise Electrocardiogram (ECG) Test Protocol, GM 07/2026 v4.2, July 2026

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