**1. Introduction**

Aircrew represent a particular group among " high cardiovascular disease (CVD) risk individuals". In addition to common life strain, aircrew face typical stress such as repeatedly proficiency simulator checks, intermittent medical exams and total flight hour obligations, employer pressure, responsibility, and scheduled accomplishment. These factors may lead to CVD, either directly or indirectly. They interact with traditional risk factors (genetic risk factors: aging, gender, ethnicity, chromosomes, HLA, genes, inflight incapacitation) and behavioral risk factors (inactivity, alcohol drinking, smoking, unhealthy diet) and emerging cardiovascular risk factors. The consequence is cardiovascular remodeling triggered by oxidative stress, inflammation and endothelial dysfunction. Unexpected in-flight medical incapacitation or distraction of a pilot may result in aviation accident, which is of public interest, harming himself, aircrafts, passengers and environment. Notwithstanding progress in prevention and early disease intervention, ischemic events secondary to coronary artery disease (CAD) remains among the commonest causes of unheralded acute incapacitation in the Western population. Thus, aeromedical providers should help aircrew to prevent CVD. It is essential to assess and stabilize the patient, control risk factors and optimize pharmacological treatments. Controlling weight and managing obesity, providing healthy diet and promoting physical activity, and educating aircrew and instituting home-based care monitoring is an important tool to preventing CVD. Aircrew with CVD are at high-risk and require a multifaceted and multidisciplinary intervention that should be started as soon as possible.

The health of aircrew is an imperative requirement for safe travels of millions of people worldwide. The presence or development of CVD in aircrew, with the risk of potential clinical manifestations, continues to be a major concern to aviation medical practitioners. Despite the rigorously medical screen of pilots compared with several other professions, the presence of multi-crew environment, and the cockpit resource management with incapacitation training, acute coronary artery events remain an important cause of in-flight incapacitation or distraction ending in aircraft accidents and fatalities [1]. Few, if any, aircrew involved in accidents and incidents suffer from antecedent symptomatic coronary disease. Cardiovascular incapacitation of a pilot though rare event represents a seriously potential threat for flight safety [2]. In addition, CVDs linked to unexpected in-flight medical incapacitation or impairment account for half of human factor-related causes of aviation accidents [1]. In military operation, using single-pilot, high-performance aircraft, and even in dual-pilot, cardiac events were found to be second cause of aircraft accidents due to acute incapacitation [3].

From 1962 to 2015, Gray et al. listed 10 accidents and incidents in commercial passenger flights related to coronary artery events which concerned either the commandant or the first officer and resulted in 240 fatalities [4]. Moreover, 10 out of the 98 in-flight medical events addressed by the Australian Transport Safety Bureau (ATSB) between 1 January 1975 and 31 March 2006, consisted of heart attack explaining the high-observed mortality rate [5]. Autopsy studies of young military personnel and aircrew have demonstrated atherosclerosis as a common finding, including cases of severe disease and aeromedically disqualifying findings [6–8].
