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Anticoagulation case-based scenario
Racing heart can't stop Eric in his tracks
Eric was optimistic the atrial fibrillation he suffered when playing tennis one day might prove to be a one-off, especially after he made some significant life style changes in response. It wasn't to be, but even a repeat episode two years' later hasn't been enough to stop him flying for charity.
Now approaching his 70th birthday, Eric has been spending much more time with his aircraft over the last two years as he has eased himself into retirement, and has been investing considerable energy in aviation-related charitable activities.
Eric has held a Private Pilot’s Licence (PPL) for 32 years with a Class 2 medical certificate. Eric has been seeing his designated aviation medical examiner (DAME) and cardiologist every year since being diagnosed with atrial fibrillation (AF) a couple of years ago.
Eric has enjoyed very good health throughout his life. His GP started him on medication for high blood pressure seven years ago. About two years ago he had a ‘dizzy spell’ playing tennis and was diagnosed with AF. Fortunately Eric’s heart returned to a normal and there weren’t any changes to his medication. There was one positive outcome from the event though - Eric finally started to heed the calls of his doctors and cut back significantly on his alcohol intake. He almost immediately lost 5kg, much to his doctors’ delight.
On the downside, AvMed insisted on several changes to Eric’s medical certificate conditions after the AF. His certificate duration was reduced to 12 months, and he was required to see his cardiologist every year. Initially annoyed, Eric became more accepting of the changes after discussion with his DAME and cardiologist.
"Everything went well for two years, then one morning with no warning at all my heart suddenly starting racing again", Eric says. "I didn’t feel unwell, but I made an appointment to see my GP that morning. The GP connected the electrodes to my chest, and then told me I was in atrial fibrillation again. At least this time my heart rate was a fair bit slower than when I collapsed on the tennis court. Even so, he rang the cardiologist’s rooms and organised an appointment."
The cardiologist explained to Eric that there were two broad options in dealing with his condition. They could try to get the heart out of AF by various means, or they could leave it in AF and use medications to reduce the speed of the heartbeat, and anticoagulants to reduce the risk of strokes.
Eric elected to try and get his heart back to normal and was admitted to hospital. Sadly this time Eric’s heart seemed stubbornly determined to remain in atrial fibrillation no matter what was tried.
With no other symptoms apparent, the cardiologist felt confident there was no need to medicate Eric, particularly since he had performed well on a 24 hour ECG and during a stress test. The echocardiogram hadn’t changed since he was first diagnosed two years ago.
"Then came to conversation I was expecting, but dreading," he says. "The cardiologist said given my age, my hypertension and my AF, I should start taking tablets to reduce the risk of my blood clotting and causing strokes. I had read all about warfarin and many of my friends were already taking it. I didn’t like the idea of regular blood tests, and I was anxious about the impact all this would have on my flying."
Visit to DAME
When he contacted his Designated Aviation Medical Examiner (DAME) to inform him of the new diagnosis the DAME notified the Aviation Medicine (Av Med) branch of a change in medical condition in accordance with their obligations under the Civil Aviation Safety Regulations. The DAME also advised Eric not to fly until he received a clearance from CASA or from the DAME himself.
The DAME forwarded copies of the latest cardiologist reports to AvMed with the notification email. By the time AvMed reviewed the supplied information Eric had started taking warfarin and already had some blood test results available for his DAME to forward to AvMed as they became available.
AvMed advised Eric he would need some additional blood test results to show that he had stabilised on the warfarin. After supplying these he was pleasantly surprised to find that he was cleared back to flying on his Class 2 medical certificate with some minor changes to his requirements.