- 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.
- 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.
- Tracings must include a rhythm strip;
- A full 12-lead ECG recorded at rest - supine and standing. (Anything less than a full 12-lead will not be accepted); 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.
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;
Time less than 6 minutes --age 70 or greater1 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.
