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Guide for Aviation Medical Examiners

Decision Considerations
Disease Protocols - Graded Exercise Stress Test Bundle Branch Block Requirements

If the Bundle Branch Block (BBB) has been previously documented and evaluated, no further evaluation is required. A medical certificate should not be issued to any class if the applicant has a new onset of a BBB. A right BBB in an otherwise healthy person 30 years of age or younger should not require a CVE. All other individuals who do have a right BBB require a CVE but a radionuclide study should not be required unless the standard exercise stress test cannot be interpreted. A stress echocardiogram may be sufficient in most cases. A left BBB in a person of any age should have a CVE and should include a radionuclide perfusion study. Those individuals who have a negative work-up may be issued the appropriate class of medical certificate. No followup is required. If any future changes occur, a new current CVE will be required.

If areas of ischemia are noted, a coronary angiogram may be indicated for definitive diagnosis. According to the current literature, approximately 40% of individuals with LBBB will demonstrate a false positive thallium reperfusion defect in the septal area. If significant CAD is diagnosed, refer to Special Issuance guidelines. Some cases may be forwarded to a FAA-selected cardiology consultant specialist for review and recommendation for medical certification.

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