AME Guide Grand Rounds June 2026 Session

Good evening or good afternoon. Welcome to the June session two of AME Grand Rounds. My name is Christy Risley and I'm going to turn this over to our federal air surgeon for a momentarily or momentarily for a welcome. Dr. Northrop. Thank you, Christy. Welcome everyone to the June Grand Rounds. This is a really exciting one as I understand it from the one o'clock session. Okay, East Coast one o'clock session. It was well well received and went a of all the questions and I know you're going to enjoy my classmate and colleague, Dr. Greg Bendrick. So, pay attention, enjoy yourselves and we'll watch for the questions. Back to you, Christy. Thank you, Dr. Northrop. Next slide, please. These are our objectives for this particular session. We're going to discuss some communication issues between the AMEs and the Aerospace Medical Certification Division. We're also going to discuss some changes to protocol, I guess you would say, on the porcine thyroid khaki for armored thyroid. Then we also have AME guide updates in cardiology to discuss. We're going to look at heart murmurs, congenital heart conditions, endocarditis, Wolff-Parkinson-White, fibromuscular dysplasia, heart transplants, hypertrophic cardiomyopathy, and the FAA's stress test requirements. So, without further ado, I'm going to turn this over to Dr. Greg Bendrick, one of our medical officers here in the FAA. Dr. Bendrick. Thanks, Christy. Yeah, well before we get started on that first slide there, just for those who don't know me, I know I've talked with a lot of you on POD calls or may have encountered you, worked with you all at some of the prior seminars. I'm Greg Bendrick, one of the staff physicians, medical officers here in the Aeromedical Certification Division at the Civil Airspace Medical Institute here in Oklahoma City. I've been here nine years. I got here almost exactly nine years ago. Before that, I was 16 years as a NASA flight surgeon working at the NASA Dryden Flight Research Center out in California, located on Edwards Air Force Base. Prior to that, three years in the private sector as an occupational medicine physician. And then prior to that, a little over nine years in the Air Force where I was a practicing flight surgeon and did my residency training and got board certified in both aerospace medicine and occupational medicine. I work a lot of the medical appeals or the cardiology workflow here at the Aerospace Medical Certification Division. Although I am not a cardiologist, but I have some experience in dealing with the FAA policies on how we deal with cardiology conditions. So without further ado, I'm going to start off talking about non-cardiology. First of all, the thing is, for a number of reasons, we really have to tighten down on the sending of personally identifiable information to include a name with a date of birth or a social security number, that sort of stuff, in an email format. The email is not secure. And as a government agency, we have to ensure that we hold to all the applicable laws and standards for protecting personally identifiable information, not to mention protecting the private medical information that is associated with that. So do not email anything to AMCD or to any of us here at the FAA that has such information in it. Basically, it will be deleted. We must delete it. We cannot accept it. We must get it out of our system. All information should be now uploaded into AMCS. A lot of effort went into developing that over the years, actually getting that going. It's not perfect, I know, but we need information. That's our secure method for communicating private medical information, personally identifiable information to us here at the FAA. If you are not the AME of record, or you have not transmitted the exam yet to become the AME of record, then we'll need those documents sent to us by postal mail, and then we will scan them on our side. Now, I know we sometimes have sent out special issuance authorizations and certificates that have names and dates of birth and other private information. That's our bad. We're going to be tightening up on that also and looking at different ways of either sending things secure, password protection, or something that is in accordance with the applicable standards. But we do have to really toe the line on this because it's being brought to our attention by others that we need to be toeing the line on this, and so we are so informed. On the second thing, it's not cardiology yet, but this is really geared more for psychotherapists and counselors that may be treating pilots or air traffic controllers. And the FAA here now has put together a sheet specifically for them to inform them that you're treating either a pilot or air traffic control specialist that has safety sensitive duties with regard to the public safety and safety of the national airspace. So basically, it points this out. If pilots or ATC folks need counseling, we want them to get counseling. That's a good thing. Any kind of mental health situation or condition, loss of a spouse, a divorce, a child going to college, a child coming home from college, whatever, sometimes these things can be really stressful. Getting help, getting assistance earlier in the process is always a good thing. We want that. We encourage that. We want pilots to do that before things go much further, then it's much more difficult to treat the condition. However, we do want the treating psychologist, psychotherapist, licensed certified social worker, whoever, to realize that there is a safety aspect of this. It's basically to get consent to release from the pilot information to the FAA. We don't need the treatment notes each and every time that they come in, but we will want information in terms of a progress note, and specifically, if they have a condition or the condition is such that, in their professional opinion, they pose a risk to the national airspace, then they need to inform us here at the FAA on specifically calling AMCD here at the 421 number to let us know that. It's not acceptable just to well, you need to tell your employer, you need to tell the FAA that you need to be taken off the schedule. No, we really want the counselor or the treating psychotherapist to inform us of that if that situation develops. There's some other information there about the Z codes and the V codes and all these other things that go into these psychology reports, and that's really for the psychotherapist and stuff. Likewise, there is an email there. You see it, and it's on the form also for them to email the FAA for routine questions, what's going on, how do I do this, what's the process for this, how do I submit this and all that, and that's fine. But it's important to know that this email address here for the psychiatry branch, the psychiatry workflow, the mental health workflow is not for pilots. So please don't give that out to pilots to say, well, if you need an inquiry on how your case is going or where it's at in the process and stuff, email us. No, no, don't email them. Don't give them that email. That's not what that email is meant for. And moving on into the next topic, which seems to have become quite a topic in the past few weeks, is the whole situation with armor thyroid, but it also includes desiccated thyroid, nature's thyroid, basically the thyroid preparations that are not manufactured through a pharmaceutical company. They're compounded or in other ways that develop. Apparently, as I understand it, the FDA noted that the quality assurance in terms of the dosing cannot be guaranteed. Therefore, they're not going to allow these medications to be sold in lieu of a prescription medication for thyroid replacement. And so we don't typically allow medications that the FDA doesn't allow. So we said, okay, we're not going to allow armor thyroid or the other thyroid compounded preparations or similar preparations along those lines, the desiccated thyroid, et cetera. And those would be no longer allowed. And so in our internal med guide, in terms of what we allow, we said, okay, we're not going to allow that. And so our reviewers then, when we would see pilots that were on CACIs for hypothyroidism using armor thyroid, which was the most common one, they would send out withdraw SI letters. And that generated a lot of response, especially because we had not updated our CACI form yet that says that's no longer allowed. Okay. We've had some further discussion about it here at the FDA. And the bottom line is, yes, we get it. And I think all these preparations eventually will no longer be available on the shelves to be sold. And so the problem will eventually, everybody's going to need to eventually get on a pharmaceutical thyroid replacement. But in the meantime, we figured that, you know, if there's a hypo or hyperthyroid situation due to a dosing mismatch or something, that it's not going to present an acute, sudden, or even a subtle incapacitation in flight. It's going to present with symptoms over a period of time, which will declare themselves and then pilots would be able to take the appropriate measures to get treated appropriately. So we're going to continue the CACI thyroid as it is at this time. We're not going to withdraw people's SIs if they're on it for that or send them a denial if they're on it. But as an AME, just keep in mind to monitor your patients, your pilots. If there's any obvious signs of hypo or hyperthyroidism, we'll then just have them get evaluated appropriately, TSH level thyroid function test and get whatever treatment they may need. So hopefully this will settle down here. It has generated a lot of discussion on our physician of the day calls, but we are going to just let it be as is for the foreseeable future. And I think with the FDA approach that this problem eventually will no longer be any kind of a problem or situation in the future. Anyway, enough on arm or thyroid. Cardiology. Okay. Here's what we get to talk about for this evening. The main points. And a lot of what we're going to talk about is stuff that we've basically been doing here ever since I've gotten here nine years ago. It just hasn't necessarily been put in discreet, you know, policy writing and an AME guide or something like that. So now we're doing that. Okay. So start off with heart murmurs. You know, a low-grade heart murmur systolic, it's clearly a functional or physiological murmur. I mean, that's a nothing burger. I was always taught a one out of six murmur is something a cardiologist can hear, but the rest of us can't. So to me, it was always a two out of six. If it was anything, if I could hear it, it was at least a two out of six. But if they're fine, no symptoms, no exercise intolerance, nothing like that, note it in block 60. That'd be a good thing. We know that you at least did a physical exam appropriately. That's a good thing. But then we don't need any followup on that. We don't need an echo. We don't need anything like that. However, if it's something other than that, a higher grade three or higher, any kind of a diastolic murmur, that should be concerning. Certainly if they have any symptoms and particularly if it's a new onset murmur, you've been following this pilot, you know, how many years, and now you hear a murmur that you hadn't heard before, you know, that's concerning. So yes, we want them to get an evaluation, particularly an echocardiogram and a detailed clinical progress note from the cardiologist about what they think is going on. And then as the AME, you'll need to defer that to us, and then we'll need to make a decision on that. If it's very straightforward, this is something that would be a good physician of the day call, POD call. If it's not straightforward, then just send us the, or upload the documents and we will review it. I mentioned their detailed clinical progress note. That's basically the office note, the EHR. It's what, you know, the scribe is typing in while the pilot is being evaluated by the doctor. We prefer that because typically the EHR will tell us what all the medications are actually on. They'll tell us a lot about their medical history that the pilot may have forgotten to tell us about. And it gives us much more information than just a narrative that we sometimes get that says, I've evaluated, you know, Mr. So-and-so, he's on appropriate medication and he's doing fine. If there's any questions, please contact my office. Those types of narratives aren't particularly helpful. We really want the office note there. So that our term for that now is detailed clinical progress note. Okay. Congenital heart conditions. There's, you know, you know, it's like, well, they're not an issue unless they're an issue. Okay. So, but not issues. Uncomplicated PFOs, patent foramen ovalis. Pilot ends up getting an echo for some reason for whatever and incidentally noted is a PFO is uncomplicated. They're asymptomatic. Nothing's going on. Again, just note that if you have the echo report uploaded and that the regular issuance, if they're otherwise qualified, we don't, we're not going to special issuance that or anything, that's fine. However, if it's something more complicated, a true atrial septal defect, or if they've had a PFO or SD surgically corrected, most of these nowadays are going to, of course, going to be by catheter correction with either an implants or a Watchman, kind of a patch device that goes over that. But in any case, that's going to be a deferral. You'll need to defer that. We do want detailed clinical progress note. Anytime a procedure is done of any sort, we want the procedure or the operative note. We definitely want that. And if the procedure was done no sooner than 90 days after the procedure, we want an echocardiogram, pardon me, an echocardiogram, as well as a cardiac monitor to ensure everything's okay, particularly with the closures. Sometimes we can see atrial arrhythmias after that, not surprisingly. So we want everything to settle down for 90 days and then we want a Holter monitor or other extended cardiac event monitoring, you know, seven day, 14 days is fine. It's perfectly acceptable. In fact, it's preferable. The more data, the better, but that's what we need. Usually we're going to get the yes on these. And usually it's going to be a regular issue. Sometimes we do have to special issuance and follow these for some period of time. The more complex congenital heart conditions, and these are all the things you see here, the transposition of the great vessels or the great arteries, total anomalous venous return. What's the other one I'm thinking of? Tetralogy of Fallot. We'll see that. We've seen a number of those. These other ones, double outlet right ventricles, all the ones you see here. From the AME standpoint, the disposition's easy. You need to defer. And with all of these, you can pretty much guess. In fact, with most cardiac conditions, just as a general rule, you know, if you don't really know what we want, we're going to want to try it. Okay. You can't go wrong. You know, if you're talking to the cardiologist, get the triad. The triad is a stress test, an echo, and a Holter. Stress test, echo, Holter. And then the cardiologist narrative, the office note, the EHR note that goes with the stress test, echo, and a Holter that they've ordered to let us know how they're doing it. Again, if they've had any kind of an operation procedure and stuff, yes, we want that report. If they've had any advanced imaging studies done, like a CT angiogram or something like that, we want those reports. And then for the echo, the current echo, we will want the imaging for that echo. And we would like the imaging for any kind of CT angiogram or anything else that they get, but we really, really need the imaging for the echo because for congenital heart conditions that have been surgically treated, then frequently we're going to send those out to a cardiology, a CT surgery consultant to review. Typically, we see these 16, 17, 18-year-old first-time applicants that have had such surgery, usually as an infant, and now they're applying for a first-class medical and they want to be a commercial airline transport pilot, which is all fine and dandy, but we just want to make sure that their heart situation is okay to do that. And this is the information we need to ensure that. We sometimes hear, well, their surgery was performed 17 years ago when they were five days old. The hospital doesn't keep records that long. True. But it's interesting how often in the cases I've worked, a lot of times the mother has kept a copy of the operative report. So, you know, a little bit of poking and prodding and say, you sure you haven't got it? Talk to your parents. Maybe they kept a copy of the report. And sure enough, a lot of times we've I've not, I don't think I've yet had, not been able to, for them to get a copy of the operative report. And it's really important because a lot of times these folks, what they, what they think they had done is not exactly or not entirely what they've had done. So they said, yeah, I had tetralogy of flow and it was surgically corrected. Okay. Well, they may have done some other things in that surgical procedure in addition to the tetralogy of flow, or it may have actually been a transposition of the great arteries and they thought it was a tetralogy of flow because that's what they heard or whatever. So things can get confusing. We really, really do need that operative report. Other things, sometimes we're not going to get the yes on these. I've had one case, it was, I think it was double outlet right ventricle or hypoplastic right ventricle. And basically this individual didn't generate much, you know, or any right ventricle, right ventricular pressure for circulation. Of course, if you get into a hypoxic environment, your lungs manifest the hypoxic pulmonary vasoconstriction reflex, which constricts those arteries, you know, the pulmonary arteries and the vasculature. So your resistance goes up. And if you haven't got any kind of right ventricle, then that can be really a compromising situation. So that was one where basically we, you know, we really tried, but we couldn't get to yes on that particular individual, unfortunately. Most of the time we can, most of the time it requires some follow-up, especially for pulmonic stenosis that inevitably develops, but we will follow that on special issues. Okay. Moving on. Endocarditis. Okay. If there is such a thing as straightforward, simple endocarditis, I guess then that's fine. For the AME, you're going to need to defer this. Yes. You know, it never hurts to get a stress test, Equinhalter, but especially the echo and especially the detailed clinical progress note. In this case is a lot of times we're going to get it from the infectious disease specialist. That's fine. That's cool. If they've been admitted, yes, we want the hospital records. We really, especially if we can get it, we want the discharge summary, not the discharge instructions to the patient. Okay. Or the pilot. We want to discharge summary with what the physician has dictated, not what the pilot has downloaded from their record online. But most of the time, if it's all resolved and no residual sequelae to the heart, then we're going to get the yes on that. We may follow for a period of time, sometimes not. However, if there's a severe, you know, or significant structural issue with the heart leading to some sort of, you know, bacterial chronic bacterial endocarditis or something like that, or if they've had a valve replacement and now it's infected and there's ongoing problems, obviously that's a much more complicated situation. We're going to deal with those on a case by case basis. We may bring them to panel. We may send it to a consultant. In any case, as the AME defer, if there's a question about whether we need the record or the imaging or the test result, you can pretty much guess, yes, we will. But we've listed that there now for the AME guide. So, exactly, you know, what we want on these cases. Now, on the rhythm side of the house, Wolf, Parkinson, White. Again, you know, no problem or problem cases I've seen come my way. And I do a lot of the EKG reviews, so I see a lot of Wolf, Parkinson, White patterns that are not a problem. They've been worked up. They're not a problem. But basically, especially on the first-time applicants, now we don't require an EKG on the first-time applicants, which is not to say, you know, one's breaking the law if you do an EKG on a first-time applicant. But a lot of times, they've already had the EKG outside their AME exam before they've come there. And especially if they've been symptomatic, and certainly if they've had an ablation performed for symptomatic Wolf, Parkinson, White. But basically, if they have not had anything done, they know they have Wolf, Parkinson, White, we want the office note, the detailed clinical progress note from the cardiologist. For any rhythm disorder, including Wolf, Parkinson, White, yes, we'd prefer that that be from an electrophysiologist, you know, EP cardiologist. But we don't require that. We don't mandate that. We're not going to deny it if it's not an EP. But we do want the cardiologist to talk about it. And specifically, is this a Wolf, Parkinson, White pattern, i.e. no symptoms, no clinical manifestations whatsoever, no arrhythmias? Or is this a Wolf, Parkinson, White syndrome with the arrhythmias with the symptoms? Or is it something else? And so we've listed that there in now in the AME guide. Again, the first time around, the AMEs, you're going to need to defer that and submit this information to the FAA, preferably uploaded. But yes, we want the stress test, echo and halter, the triad, we want the detailed clinical progress note. If they've had a procedure, we're going to want that. If they've had any other testing done, we're going to want that. And if they have this, particularly if they have the syndrome, and if they've been ablated, was that successful? Or are they having continuing issues? Or if it's not been ablated, but they need medication, what's medication? What are the issues with that? Again, anytime we ablate the myocardium, whether it's atrial or ventricular, 90-day or three-month downtime, then we want echocardiogram, we're going to want a halter monitor, as we'll see here on the next page, and of course, a detailed clinical progress note. With these both Parkinson's Y or really any arrhythmias, we want both the halter and a stress test. The stress test, we're not necessarily looking for ischemia per se, but the thing is, is that we're looking for arrhythmias. And so with the halter monitor, 24-hour, you're going to get it during the day, they're active and stuff and whatever they're doing. You also get it at night when they're sleeping, when they have a higher vagal tone. Sometimes we'll see pauses or blocks or something like that. On the other hand, with the stress test, we're seeing what happens when they're under an adrenergic load and their heart rate's going up and the catecholamines are kicking in. Do we induce an arrhythmia that way? So that's why we want all that information. Typically, at least the cases that I've seen, and I've seen a few, just enough to make me really dangerous, I'll tell you. No, I've seen a few and the ablations seem to be very, very successful. If they can find that bypass track, they go in there, they ablate it, and basically they're cured. And so, I messed up the slides here a little bit. And typically, we're going to get to a regular issuance with that. If there's some ongoing sequelae, symptoms, arrhythmias, paroxysmal arrhythmias, whatever, then we may need to follow that for a while. Usually, we can get the yes on these. Okay. Back to some structural stuff, arterial stuff. Fibromuscular dysplasia. This is basically a disease or a condition of disease of the arterial walls that include anywhere you have arteries in the body. So that's like everywhere. And particularly in the brain, the head and the neck, the coronaries, and the abdomen and pelvis, where you have this large artery called the aorta. And basically, the arterial wall, as they say, ain't quite right. Okay. It's not as strong as a normal arterial wall. That means, especially when it's facing the pressure of the blood, the blood pressure, over time, you're likely to see tears in the arterial wall, leading to dissections, aneurysms, and of course, you're at risk of rupture with that. Typically, this is found, there's characteristic imaging patterns on CT angiograms or MR angiograms that you'll see. And usually, they're getting a workup for something and then they discover this and it's like, oh, of course, for us, we're going to, if it's seen anywhere, we're going to also want imaging of CTA or MRA of the brain, the head and the neck, the coronary arteries, i.e., a coronary CT angiogram, as well as a CTA of the abdomen and pelvis. And so, we want the detailed clinical progress note, of course. And then as the AME, you'll need to defer that. We're going to look at that. Chances are, we're going to be sending that out to one of the FAA consultants and I can tell you that if it's a true diagnosis of fibromuscular dysplasia, we're going to have a difficult time getting the yes on that, even with special issuance, because the risk of dissection, aneurysm, and rupture are really just too high with that. But if you see that, send us the information. We do individualized assessment on every case. And we'll see if we can get the yes. We're always working to get the yes if we can. Now, heart transplant. In the Code of Federal Regulations, it's known as called heart replacement. Okay. And for some who've been around a while, like myself, I remember when the FAA would entertain special issuances for heart transplant for all classes. However, a number of years ago, there was an issue, an event with a commercial pilot. I don't remember if he was class one or two, but it was not a major aircraft accident, but there was an event and that led the FAA to reassess how much air medical risk we're actually taking here. And since that time then, special issuance is entertained only for third class pilots with a heart transplant. First and second class, we do need the detailed clinical progress note from either the cardiologist or the cardiac surgeon actually saying, yes, they've had a heart transplant. Okay. Once we get qualified medical judgment, it's not just the pilot says he had a heart transplant and, okay, well, that's it. No, we need qualified medical judgment. But once we get that, then that will be denied. And we're really not going to entertain a special issuance on that. Third class, however, we will entertain a special issuance. There's no mandatory recovery period. We're not able to do that anymore by law. The basic med law in 2017 that was passed, part of that legislation said you cannot mandate any wait times for third class applicants. Okay. But we do ask, and we really need to see a detailed clinical progress note that says they are released to regular activity. Plus for the heart transplant, we're going to want a lot more information. Of course, the stress test echo and halter. We want the hospital records, the operative report. Of course, we want any information about the donor heart and any medical conditions, diseases it may have encountered. We're going to want to know, particularly with the hospital course and the post-operative course, did they experience any infections, particularly CMV infections, because they are going to be on immunosuppression due to the transplant. Likewise, we want to know how the coronary artery disease is progressing, because one of the problems with the transplants is allograft vasculopathy. In other words, the transplanted heart, for some reason, they tend to develop coronary artery disease much more quickly and aggressively than otherwise in normal patients with risk factor control. And so, as a result, that's one of the biggest aeromedical risks to flying is the development specifically of obstructive coronary artery disease. Now, keep in mind, if they had a heart transplant, then their afferent nerves, innervation of the heart, i.e. the nerves going to the heart and being able to sense the chest pain, the angina due to myocardial ischemia or an infarct, they're not there. I mean, certainly, well, at least not to any degree that they are in a non-transplanted heart. And so, we don't have that as an indicator to tell us that their coronary artery disease has progressed to the point of being symptomatic and obstructive. And so, the way then that the FAA will monitor that is, yes, we do require a cardiac cath once a year on these pilots to ensure that their coronary artery disease, which we know is going to be there, is not of aeromedical concern at this point. And as I think I've already mentioned, yes, we want a stress test echo and halter. And in this case, we also specifically want a stress echo with that to determine how it's doing under stress, the heart is doing under stress. And then all of these are sent out to a consultant. Even the research are sent to a consultant for review to make sure that the risk is appropriately accepted, appropriately mitigated. The follow-up on that has been very good. Now, if somebody has a special issuance after, was it 2006 or whatever it was in that legislation, and they want to go basic med, they can do that. And I think a lot of the folks that we had, I don't know, we had about maybe six or seven, maybe 10, I don't think it was quite 10 that we were following on research, but the basic med legislation, like they all disappeared. So I think they all went to basic med, which is the law of the land, that's their prerogative. But I'm wondering if their risk is mitigated as well as it can be as if they were on a third class special issuance. But anyway, that's what we require. And of course, you'll need to defer all of those cases. Now, moving right along, hypertrophic cardiomyopathy. This is not cardiac remodeling due to hypertension or something like that, some asymmetrical hypertrophy due to hypertension, but longstanding hypertension. No, this is the actual genetic condition of the heart where you develop abnormal myocytes. They get very large. And when a lot of them grow together, then typically the septum of the heart gets very, very thick. It can be two, three centimeters, as many of you know, with that. Now, there is a variant of this called apical variant hypertrophic cardiomyopathy. But in any case, it's the same underlying condition, more or less. Some people call it hypertrophic obstructive cardiomyopathy because of the obstruction that develops. Back in the day, I learned it as idiopathic hypertrophic subaortic stenosis, or IHSS. It's all the same underlying disease. And basically, the issue here with the hypertrophic cardiomyopathy, folks, is you got two issues. One is the obstruction through the left ventricular outflow tract due to this big, thick septum there that's blocking blood flow going out of there. Okay, that's one. And if necessary, you can have surgical intervention on that. The other thing, though, is these abnormal myocytes that are sitting in the myocardium, it's like an infiltrate of cardiomyopathy in a sense that these abnormal myocytes can trigger and be a nidus for arrhythmias, particularly ventricular arrhythmias. And, you know, especially things like VTAC, sustained VTAC and VFIB, which, of course, we don't like to see in flight. And so, it's not just the obstruction or the mechanical issue, it's also the electrical issue with these folks. So, along those lines, of course, you know, we want, yes, stress test, echo, and Holter monitor. We want the detailed clinical progress note from the cardiologist. But in addition to that, that detailed clinical progress note, we got to have the five-year sudden cardiac death risk score. And this is based on a number of factors that have been demonstrated epidemiologically to be associated with particularly the electrical component of this. If there's obstruction, you know, we'll see that on the echo typically. And we really like them to be followed by a cardiologist that has some kind of specialist training or at a center where they're doing hypertrophic cardiomyopathy, because they'll go ahead and do the Valsalva maneuver on the resting echo to properly get the gradient we need to take a look at that. But that's one thing we can monitor that. The other thing, though, is this risk of sudden cardiac death. So, looking at such factors as a family history of unexplained sudden cardiac death, or any history of VTAC, non-sustained or particularly sustained, i.e. 30 seconds or more of VTAC, ventricular tachycardia, or any unexplained syncope. These are all factors that go into the calculation of a five-year sudden cardiac death risk score. There's two major organizations that have developed a risk score. One's the European Society of Cardiology, and we've used that for a number of years. More recently, the American College of Cardiology combined with the American Heart Association has developed their own, but it's a very similar risk score. But the American score includes assessment of a cardiac MRI, and specifically the degree of late gadolinium enhancement on that cardiac MRI, which corresponds to the amount of these abnormal myocytes. No surprise, the more abnormal myocytes you have, the more likely you are to have arrhythmias, and your risk goes up. Now, we at the FAA currently do not require a cardiac MRI for people with hypertrophic cardiomyopathy. However, that is more or less, it seems like, becoming a clinical standard of care. So if they have the cardiac MRI done, yes, we want that report. We don't need the imaging, but we do want that report. And in any case, we need a five-year risk score, whether it's the American version or the European Society of Cardiology. Some folks for a while, we were looking at folks being treated with the medication Camzios, which is a good medication, but it's only indicated with people with really severe HCM. So they've got bad disease to begin with. But then as we reviewed these cases in our cardiac panel, they all went to cardiac panel, that the Camzios just had just really an unacceptable side effect profile. And so we finally developed the policy now is that we do not accept Camzios as a medication. That's a disqualifying medication for the hypertrophic cardiomyopathy. But otherwise, if their risk is controlled, their gradient is not too bad, then we will entertain a special issuance on them. In any case, we got to defer these. Now, specifically for hypertrophic cardiomyopathy, but really for any stress test, we want a standard Bruce protocol treadmill exercise stress test, the three-minute version. There's some two-minute versions out there where they try to kind of get the heart rate up faster or whatever. I don't know. But we really want the three-minute version. We want them to go at least nine minutes. And especially for hypertrophic cardiomyopathy, we really want them to get to 100% maximum predicted heart rate. Because we want to know, A, are they developing obstruction with stress? As the heart rate goes up, are they able to augment their blood pressure with the stress? And if they're not able to do that, then that can be an issue if they're in the cockpit. Because I'm not a pilot, but I've flown enough to know that occasionally you deal with these things called in-flight emergencies, and occasionally your heart rate will go up under the influence of catecholamines. So yeah, we want to know, can they augment their blood pressure? Likewise, we want to know, are they having arrhythmias at stress? Under the adrenergic load, are they having arrhythmias as a result of their hypertrophic cardiomyopathy? So we really, really want the treating physician to stop the beta blockers or the calcium channel blockers. If they can't do that, we want to know, or, you know, narrative saying why they're not doing that, in which case, you know, if they're not safe enough to be off the beta blockers or their medication, is it a good idea to give them a certificate to fly an aircraft, especially if they're a class one with a couple hundred people in the back? Likewise, if they, for some reason, they cannot do the treadmill, they've got, just had ankle surgery or, you know, knee surgery, whatever, knee replacement and stuff, then we want to know to that effect. And then we still want to see if they have any obstructive coronary disease with a radionuclide or with a pharmaceutical nuclear stress test. And yes, we want the printouts on this. This has caused some consternation because we only have, you know, three megabyte limit on the upload of the AMCS. That's changing. They're in the works to change that. But yes, sometimes you've got to upload a couple different batches to the AMCS to get the full stress test. But we really, we do take a look at those. We want to know what's going on. And if we have to bring a case to a cardiac panel or to a consultant, they're definitely going to be looking at those tracings. So we want those. The computerized, generated, summarized tracings, those really don't help us. And likewise, you know, if we can have something that's at least readable, i.e. it hasn't been copied and faxed, you know, three different times before uploading it, that would be nice also because we do have to try to interpret these things. So yeah, faxes or photocopies of the tracings are not acceptable. Thank you all for coming. We appreciate the work that you do as an AME. We literally could not do it without you. Thank you for joining us for AME Grand Rounds.