Atrial Fibrillation

Guidance for medical examiners when assessing a patient for either a general topic or condition – Atrial Fibrillation.

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 - information 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 or New (Novel) Oral Anticoagulants (NOAC) as indicated
    • aspirin - unrestricted
    • warfarin - Class 1 and 3- multi-crew operations/proximity restrictions only respectively
    • NOAC - Class 1 and 3- multi-crew operations/proximity restrictions only respectively
    • (see separate Anticoagulation)
  • 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

Pilot and 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

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.

Last updated:
Online version available at: https://www.casa.gov.au//licences-and-certificates/medical-professionals/dames-clinical-practice-guidelines/atrial-fibrillation
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