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Atrial Fibrillation

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Aeromedical Implications

Effect of aviation on condition

  • Triggers
    • hypoxia
    • stress response
    • fatigue

Effect of condition on aviation

  • overt incapacitation
    • big increase in risk of stroke
    • haemodynamic instability
    • loss of Gz-tolerance
    • thromboembolic risk
  • subtle incapacitation
  • distraction due to
    • symptoms
    • dyspnoea

Effect of treatment on aviation

  • anticoagulation complications
  • anti-arrhythmic effects e.g. beta-blockers

Approach to medical certification

Based on the condition

  • Type of AF (PAF / Lone / Permanent)
  • symptoms
  • acceptable cardiac function (LVEF>50%)
  • no underlying cardiac pathology

Based on treatment

  • rhythm control
    • ablation
    • pharmacological (ß-blocker, amiodarone)
  • rate control (ß-blocker, digoxin)
    • no pauses more than 3 secs
    • resting HR less than 100bpm
    • exercise max HR less than 110% Max predicted heart rate
  • prophylaxis against thromboembolism (CHA2DS2VASc)

Demonstrated stability

  • Absence of symptoms
  • Absence of recurrence (Holter)
  • INR levels in specified range - infomration can be found on the Anticoagulation page.

Risk assessment protocol - Information required

New cases and Renewal

  • Confirmed diagnosis
  • Clinical status
    • details of any symptoms and of any recurrence or change
    • current rate control
    • identified precipitating causes (ischaemia, alcohol, thyroid disease etc)
    • adverse sequelae
    • estimate of cardiovascular risk
    • CHA2DS2VASc score
  • Investigations conducted
    • 24 or 48hr Holter - please comment on pauses and rate control
    • echocardiogram
    • please attach results of stress test
  • Management
    • Treatment: rate control, anticoagulant/antiplatelet therapy
    • Monitoring regime including compliance with and stability of antiplatelet and anticoagulant medication
    • Any side-effects
  • Follow-up plan

Indicative outcomes

  • Symptomatology is an important consideration in assessing atrial fibrillation
  • Treatment and the use of anticoagulants or antiplatelet agents should be determined by the treating physician
  • Assessment involves consideration of both the complication rate of atrial fibrillation as well as any additional treatment-related matters
  • Aeromedical risks usually require restrictions to be applied to Medical Certificates
  • Ablation treatments for AF have a variable outcome and are therefore considered on a case-by-case basis. Usually an initial period of grounding and then restriction is required.

Favourable

  • Satisfactory rate control OR Rhythm control
  • Acceptable mitigation of thromboembolic risk with aspirin OR warfarin as indicated
    • aspirin - unrestricted
    • warfarin - Class 1 multi-crew ops only
  • Ablation on case by case as variable prognosis

Unfavourable

  • Significant symptoms (chest pain, syncope, pre-syncope, dyspnoea)
  • Underlying pathology (including reversible cardiac ischaemia, valve disease, significant cardiac dysfunction, problematic use of alcohol, thyroid disease)
  • Inadequate rate or rhythm control
  • Unstable or inadequate prophylaxis against thromboembolism (this includes inadequate testing by the applicant). See below.
  • Newer anticoagulants (eg dabigatran etc. see separate Anticoagulation) are not acceptable

Pilot & Controller Information

  • Any recurrence of significant  symptoms mandate grounding and reporting to the DAME
  • Any recurrence of symptoms post RF ablation mandate grounding and reporting to the DAME
  • INR testing must be performed at least once a month, and more frequently if required by the treating doctor or CASA
  • Warfarin INR tests outside the range 1.5 - 4.0 are not acceptable. Ground until in range and cleared by DAME

Disclaimer

The Clinical Practice Guideline is provided by way of guidance only and subject to the Clinical practice guidelines disclaimer