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FAA cardiology guidance: stress-test triad, congenital case workups, transplant surveillance and HCM rules
Summary
FAA medical officers outlined cardiology documentation and testing expectations for aviation medical examiners, including the stress-test/echo/Holter "triad," requirements for congenital and post-procedure evaluations, annual surveillance for transplant recipients seeking third-class certification, and that mavacamten (Camzyos) is not accepted for hypertrophic cardiomyopathy cases.
Dr. Greg Bendrick, staff physician and medical officer in the Aerospace Medical Certification Division at the Civil Aerospace Medical Institute, led a detailed review of cardiology issues that AMEs should defer to AMCD for evaluation.
On routine murmurs, Dr. Greg Bendrick said low-grade systolic physiological murmurs in asymptomatic pilots should be documented on the AME exam and typically do not require follow-up, but any diastolic murmur, grade-3-or-higher murmur, new-onset murmur, or symptomatic case requires echocardiography and cardiology evaluation. For congenital heart disease (patent foramen ovale, atrial septal defect, transposition, Tetralogy of Fallot and others), he told AMEs to defer and upload imaging, the detailed clinical progress note (EHR office note), and operative/procedure reports; when procedures have been performed, FAA generally wants imaging and monitoring at least 90 days after the procedure before making a certification determination.
Dr. Greg Bendrick emphasized the FAA's preferred evaluation 'triad' for complex cardiac cases: a Bruce-protocol exercise stress test (3-minute stages, ideally 9 minutes to reach maximum predicted heart rate), a transthoracic echocardiogram, and extended cardiac monitoring (Holter or event monitor). He said detailed clinical progress notes from the treating cardiologist are preferred to short narrative letters, and that imaging (echo and stress tracings) should be uploaded in readable form rather than poor photocopies or faxed images.
For rhythm disorders and Wolff-Parkinson-White patterns, Bendrick said many patterns are benign but first-time applicants or symptomatic cases require deferral and cardiology workup; ablation cases usually require a 90-day recovery with repeat testing. On hypertrophic cardiomyopathy (HCM), FAA requires a 5-year sudden cardiac death risk score (European or ACC/AHA versions); cardiac MRI reports are desirable if done. He stated that the FAA will not accept the medication Camzyos (mavacamten) as an acceptable treatment for HCM in certification evaluations because of an unacceptable side-effect profile: "we do not accept CAM Zios as a medication, that's a disqualifying medication for the hypertrophic cardiomyopathy."
On heart transplantation, Bendrick described that the FAA treats the condition under the regulatory term 'heart replacement': special issuances for first- and second-class pilots are not generally entertained; third-class applicants may be considered with comprehensive documentation, ongoing surveillance including annual cardiac catheterization and stress imaging, and detailed hospital and operative records. He noted the agency's practice of sending complex cases to consultants or cardiac panels for individualized assessment. The session closed without votes or formal actions; presenters urged AMEs to defer complex cardiology cases and to upload complete, high-quality documentation to AMCS.
