AINsight: Atrial Fibrillation in Pilots

 - August 13, 2021, 12:34 PM

The FAA recently issued new guidelines for the initial evaluations of pilots who have been diagnosed with atrial fibrillation or atrial flutter. These conditions involve irregular heartbeats (arrhythmia), either episodic or chronic.

Atrial fibrillation is not all that uncommon. It can run in families but doesn’t follow specific genetic patterns. A review of current literature shows that at least three to six million people in the U.S. have been diagnosed with atrial fibrillation, with higher rates noted in Europe.

While at first glance that doesn’t seem to be a high percentage of the population, other reports indicate perhaps a more significant one-in-four lifetime chance of developing at least one significant arrhythmia event. That figure got my attention.

Untreated atrial fibrillation can lead to stroke, heart failure, and an increased risk for Alzheimer’s disease. 

Risk factors include advancing age, ethnicity, hypertension, diabetes, smoking, obesity, lack of regular exercise, and excessive alcohol consumption. Other than ethnicity and age, most of the other risk factors are indeed modifiable.

In recent years, there has been identified an additional significant risk factor for atrial fibrillation—untreated obstructive sleep apnea (OSA). I have discussed OSA extensively in prior blogs.

While the treatment for OSA can be unwieldy at times, there are now other options beyond the traditional continuous positive airway pressure (CPAP) machines. Treating OSA can help the pilot sleep better, be more refreshed during wake periods, live more productively, and prevent all sorts of medical problems.

Regarding arrhythmia, sometimes the pilot is entirely asymptomatic and does not have any idea that there is a problem brewing until being examined by the AME. Typically, the AME will already know that there is an arrhythmia during the simple examination phase, and if the pilot is due for a screening ECG, the arrhythmia will be confirmed.

At other times, the pilot clearly knows something unusual is happening with the heart rhythm. There may be a sensation of irregular beats in the chest (palpitations) and at times the pilot might also experience fatigue, shortness of breath, or even chest pain or syncope (fainting). That pilot will likely have sought an evaluation long before arriving at the AME’s office.

Fortunately, most of the time, the arrhythmia can be controlled, and the pilot will be able to return to work. But—as is typical with all significant medical conditions, cardiac arrhythmias included—there will be a significant amount of documentation required to satisfy FAA requirements. Therefore, it won’t come as a surprise that such conditions are followed at least annually thereafter on a special issuance authorization.

In the past, the evaluation for an arrhythmia such as atrial fibrillation included a cardiac exercise stress test, echocardiogram, cardiac rhythm monitoring (for at least 24 hours), blood testing (routine screening tests), and a cardiology evaluation. If medications are being used to control the arrhythmia, or if the pilot underwent a cardiac ablation (a procedure where a catheter is threaded into the heart to electrically obliterate an aberrant conduction pathway that might be causing the arrhythmia), these treatments must be thoroughly discussed by the consulting cardiologist.

The required data is then sent to the FAA for review, and if the treatment appears effective, the pilot will be granted a special issuance authorization. Follow-up recertifications can typically be done “on the spot” at the time of exam by the AME, with appropriate annual medical data submission afterward (follow-up requirements are much less extensive than those for the initial evaluation).

The more recent association of OSA with atrial fibrillation has brought the FAA to include a requirement for an OSA evaluation with all new special issuance applications for pilots with atrial fibrillation (when the arrhythmia is not caused by a problem with a heart valve). These requirements include a formal sleep study to rule out OSA.

Additional blood testing is now also mandated, to include thyroid screening. An overactive thyroid, or hyperthyroidism, can contribute to atrial fibrillation risks.

As per a conversation I had directly with the FAA recently, for pilots already on special issuance authorizations for atrial fibrillation, there is no “intent” to require them to obtain OSA evaluations (unless the treating physician deems it worthwhile to do so). They are, in essence, “grandfathered” in as per their existing special issuance authorization letters. However, this is subject to change. The FAA could elect to issue new authorization letters that add in the OSA evaluation. Should there be any formal change to this policy, I will provide updates in my next submission.

Some pilots with atrial fibrillation may require anticoagulation medications (blood thinners) to reduce stroke risks. Many of these medications are approved in pilots, and the FAA will provide specific language in the special issuance authorization as to the follow-up requirements. The newer anticoagulants do not require the ongoing blood testing that the older anticoagulants did. However, both classes of anticoagulant medications are potentially approvable in pilots.

The diagnosis of atrial fibrillation, while disqualifying for pilots, is usually approvable through the special issuance process. Most pilots with well-controlled atrial fibrillation lead essentially normal lives and are able to fly, exercise, and participate in most of life’s usual activities.

The same goes for OSA. While it too must be approved through the special issuance process—and while an OSA evaluation is now a routine part of initial atrial fibrillation evaluations—for pilots with well-controlled OSA, flying and normal daily activities can continue routinely.

And finally, if you are diagnosed with an arrhythmia, let your AME know immediately. That will facilitate that your consulting physicians are given the proper protocols to conduct evaluations that meet the FAA requirements.