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United States Department of TransportationUnited States Department of Transportation

Guide for Aviation Medical Examiners

Decision Considerations
Disease Protocols for Bundle Branch Block (BBB)

  1. PREVIOUSLY DOCUMENTED AND EVALUATED: No further evaluation required unless there is a change in condition.
  2. RIGHT (RBBB): If a complete RBBB is identified at:
    • Age 35* or younger - If otherwise healthy, will usually not require a CVE (unless there is some other indication). Annotate Block 60.
    • Age 36 or older (or other indication) - Will require a cardiac evaluation to include:
    •      ☐ Cardiovascular Evaluation (CVE) = Narrative+lab (FBS+Lipid Panel)
           ☐ Stress echo
  3. LEFT (LBBB): A LBBB in a person of any age will require a cardiac evaluation to include:
                ☐ CVE
                ☐ Pharmaceutical radionuclide perfusion study
  4. Note: The exercise radionuclide stress test can often show a false-positive reversible septal defect due to the wall motion abnormality associated with the LBBB. Specifically, according to the current literature, approximately 40% of individuals with LBBB will demonstrate a false positive radionuclide reperfusion defect in the septal area.


  • Individuals with a negative work-up may be issued the appropriate class of medical certificate with notes in Item 60 and submission of evaluation documents for retention in the file. No follow-up is required. If any future changes occur, a new current CVE may be required.
  • If areas of ischemia are noted, a coronary angiogram will usually be indicated for definitive diagnosis. If significant CAD is diagnosed, refer to Special Issuance guidelines.

*Age updated to 35 (4/2021)

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