Considerations
Atrial fibrillation is the commonest rhythm disorder, affecting 1% of the general population and 10 % of people over age 80. AF is commonly seen at a younger age in Maori and Pacific Island population, according to the NZ Ministry of Health. Its incidence is increasing.
It may be associated with structural heart disease, ischaemia, hyperthyroidism, high alcohol intake or an acute respiratory tract infection. The list is not exhaustive.
The term ‘Lone Atrial Fibrillation’ was coined in 1954. It is no longer relevant as our understanding of the condition has increased and there is no consistent definition of lone AF. A review published in the Journal of the American college of Cardiology in 2014 reads: 'This working group proposes that the category of lone (idiopathic) AF no longer has either mechanistic or clinical utility, causes confusion in the literature because of tremendous variability in its definitions, and should therefore be avoided'.
A cause for AF must be sought but often cannot be identified.
Pulmonary vein isolation (PVI) has become an accepted treatment option in patients with paroxysmal atrial fibrillation (AF). Single procedure success rates of around 60% have been achieved. About 30% of patients undergo a repeat ablation procedure because of AF recurrence. Thus a period of observation of three months is generally required following this procedure together with follow up Holter monitoring.
AF may be acceptable for certification provided that:
- Any underlying condition causing AF is acceptable;
- Any episode of AF remains asymptomatic or any symptoms are not likely to interfere with flight safety;
- The AF risk of recurrence is low or adequately minimised;
- The AF, when occurring, is at a heart rate unlikely to cause haemodynamic compromise, (i.e. maximum rate 90 bpm at rest, 200 bpm on exercise);
- The AF, if chronic, is asymptomatic and at a heart rate unlikely to cause haemodynamic compromise, even under effort, i.e. (90 bpm at rest, 200 bpm on exercise);
- Medication is acceptable and well tolerated;
- The thromboembolic risk is acceptably low;
- The bleeding risk is acceptably low if anticoagulants are used. See Use of novel oral anticoagulants (NOACs) and Use of Warfarin.
Information to be provided
On the first occasion that an applicant presents with a history of AF:
- Copy of any discharge summary;
- Copy of all specialists’ reports;
- Copy of all investigations reports, to include all laboratory results, full tracing of all ECGs, stress ECGs and Holter recordings, and all cardiac imaging;
- If Warfarin is used, a copy of all INR results for at least the past 6 months;
- If Flecainide is used, a recent trough level determination result.
On subsequent occasions:
- Copy of any interim cardiologist and investigations reports;
- A recent cardiologist report as recommended by the treating cardiologist or CAA.
Disposition
- An applicant with a history of Atrial Fibrillation should be considered as having a condition that is of aeromedical significance;
- An applicant with a history of Atrial Flutter should be considered as having a condition that is of aeromedical significance;
- An applicant with a history of Atrial Fibrillation and Pulmonary Veins isolation should be considered as having a condition that is of aeromedical significance.
