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Guide for Aviation Medical Examiners

Decision Considerations
Disease Protocols - Graded Exercise Stress Test Requirements

  • If a plain GXT is required and is uninterpretable for any reason, a radionuclide GXT will then be required before further consideration
    • In patients with bundle branch blocks (BBB), LVH, or diffuse ST/T wave changes at rest, a stress echo or nuclear stress test will be required.
  • GXT requirements:
    • 100% of predicted maximal heart rate (PMHR), unless medically contraindicated or prevented either by symptoms or medications;
    • Complete Stage 3 (equivalent to at least 9 minutes);
    • Studies of less than 85% of maximum predicted heart rate and less than 9 minutes of exercise (6 minutes for age 70 or greater) may serve a basis for denial; and
    • Beta blockers and calcium channel blockers (specifically diltiazem and verapamil) or digitalis preparations should be discontinued for 24-48 hours prior to testing (if not contraindicated and only with the consent of the treating physician) in order to obtain maximum heart rate.
      • If the GXT is done on beta blockers, calcium blockers, or digitalis medications, the applicant must provide explanation from the treating cardiologist as to why the medication(s) cannot be held.
  • The worksheet with blood pressure/pulse recordings at various stages, interpretive report, and actual ECG tracings* must be submitted.
    • Tracings must include a rhythm strip;
    • A full 12-lead ECG recorded at rest (supine and standing); and
    • One or more times during each stage of exercise, at the end of each stage, at peak exercise, and every minute during recovery for at least 5 minutes or until the tracings return to baseline level. *Computer generated, sample-cycle ECG tracings are unacceptable in lieu of the standard tracings. If submitted alone, this may result in deferment until this requirement is met.

Remember, a phone call to either AMCD or RFS may avoid unnecessary deferral.

Reasons for not renewing an AASI [based on GXT]: The applicant reports any other disqualifying medical condition or undergoes therapy not previously reported OR:

Exercise stress test (EST) PMHR less than 85%; (predicted maximal heart rate)

Time less than 9 minutes--under age 70;
Time less than 6 minutes --age 70 or greater

1 mm ST depression or greater at any time during stress testing - UNLESS the applicant has additional medical evidence such as a nuclear imaging study or a stress echocardiogram showing the absence of reversible ischemia or wall motion abnormalities reviewed and reported by a qualified cardiologist.

Nuclear stress test Evidence of reversible ischemia OR
Negative change from the prior study of the same type OR
Ejection Fraction (EF) reported as 40% or less OR
EF decrease by 10% or more from a prior study
Stress echo Exercised induced wall motion abnormalities (WMA) OR
Negative change from the prior study of the same type OR
EF 40% or less OR
EF decreased by 10% or more from a prior study

NOTE: AASI CHD or single valve replacement for all classes: If ANY of the items from the regular Bruce EST are not acceptable, the AME MUST DEFER. An AME is NOT authorized to recertify a CHD or single valve replacement for any class AASI if a nuclear stress test or stress echo is required.

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