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Atrial fibrillation case-based scenario
Eric’s big but quivering heart
Eric was playing a game of tennis with some friends one warm summer’s day when he began to feel unwell. When ambulance officers told him his heart was beating not only abnormally, but up to 220 times a minute, he started to fear his flying days were over. Luckily it was a one-off, and doctors determined his risks of a repeat event – at least in the short term – were low.
A successful businessman who built up an engineering company from humble beginnings into a multi-million dollar operation exporting into the Asia Pacific, Eric has owned various aircraft which he has used for both recreational and business activities.
When he was approaching his 68th birthday, Eric began reducing his involvement with the company as he transitioned into retirement. With more time free for flying, Eric started expanding the philanthropic endeavours he has been involved in throughout his business career and getting involved in more aviation-related charitable activities.
Eric has held a Private Pilot's Licence (PPL) for 30 years with a Class 2 medical certificate. Eric visits his designated aviation medical examiner (DAME) in Sydney every two years to renew his medical certificate.
Until his sixth decade, Eric had enjoyed good health. His GP started him on medication for high blood pressure when he was 63, after weight loss and dietary changes failed. While he was also advised to cut back his alcohol intake, he still drank a little more than the National Health and Medical Research Council guidelines recommend.
Eric continued to exercise and he enjoyed his weekly tennis game.
When Eric first started to feel unwell during his weekly match he wasn't too fazed. He had been to a work function the night before and felt a little hung-over and dehydrated even before he began to play.
"At first I thought I was just paying the price for a boozy night out," he says. "Then, 10 minutes into the match I started to feel so dizzy I thought I was going to faint. My heart was racing so much I started to get really scared. I tried sitting down in the shade but that didn't help, so I lay down for a bit.
"When my heart kept pounding, my friends called an ambulance. The ambos had to help me onto the stretcher and carry me into the ambulance. I was utterly helpless"
The ambulance officers examined Eric and connected him up to a heart trace machine (ECG). Eric's heart was found to be beating up to 220 beats per minute and the ambulance officer explained that the ECG showed that Eric's heart was beating abnormally.
When Eric arrived at the hospital he still was not feeling well. His heart rate continued to be very fast. The emergency department doctors contacted the duty cardiologist to discuss Eric's presentation. Eventually they decided to try an injection into his blood stream to get his heart to return to normal.
"When the medication didn't work they decided to try bringing my heart rate back to normal by attaching electrodes to my chest and giving me an electric current. I can't tell you what a horrible experience that was," he says.
"It did work in the end though; my heart returned to normal, thank heavens, and they admitted me to hospital overnight just so they could keep an eye on me, really."
Eric was booked in for an appointment with the cardiologist for the next week. Before that, he was also referred for an ultrasound of the heart (echocardiogram) and for an exercise stress test. Some blood tests were also completed at a local pathology lab.
Armed with the test results, in due course he saw the cardiologist. The cardiologist explained to Eric that he had suffered an episode of atrial fibrillation. The test results were mostly normal, the cardiologist sad, although there was some enlargement of the chambers at the top of Eric's heart.
Visit to DAME
Eric contacted his DAME and told him of this new diagnosis. The DAME in turn contacted CASA to notify the Aviation Medicine (Av Med) branch of a change in medical condition in accordance with his obligations under the Civil Aviation Safety Regulations.
The DAME explained to Eric that AvMed was mostly concerned with the symptoms that Eric experienced during his episode and the rate at which his heart was beating. That meant they needed a follow up report from the cardiologist with another ECG to confirm that he was maintaining a normal heart beat.
AvMed was also interested in the cardiologist's opinion regarding the risk of either another episode or a stroke, because of the atrial fibrillation and the treatment being recommended.
Fortunately for Eric, the cardiologist decided Eric's risk of stroke or another episode in the next 12 months was low. The cardiologist confirmed that the results of a repeat ECG were normal and that Eric required no blood thinning drugs (anticoagulation /warfarin).
As a result AvMed cleared Eric back to flying, although with a requirement to his medical certificate that he underwent annual review with the specialist.