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:
| TEST | IF ANY OF THE FOLLOWING ARE NOTED, THE AME MAY NOT ISSUE. |
|---|---|
| Exercise stress test (EST) | PMHR less than 85%; (predicted maximal heart rate) Time less than 9 minutes--under age 70; 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 or Repair 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 or repair for any class AASI if a nuclear stress test or stress echo is required.