I'm having fluttering in my chest!

Here's a follow-up to one of my previous articles, but this one is about a more serious problem. I am speaking of the very common cardiac irregularity called atrial fibrillation (AFIB). The electrical impulse in your heart originates in an area known as the sinus node. This area is located in one of the atria of the heart, which are the upper chambers in the heart. This electrical impulse then travels to the other atria and down into what is known as the AV node. Here the impulse is slowed down and then travels down into both ventricles (the lower chambers of the heart). It is the electrical impulses that result in the heart contracting, generally from 50 to 99 beats per minute. The heart can go slower than 50 or higher than 99, which presents other issues for medical certification.  

In AFIB, there are multiple areas where the electrical impulse is originating, up to 250 times per minute. However, all of them cannot result in a contraction of the heart, as the AV node must “recharge” itself after it discharges (electrical terminology since we are speaking about electrical activity!). The main health problem with this irregularity is that the atria are not contracting strongly enough to completely empty themselves of blood, so that some of that residual blood pools in the atria, increasing the risk of clot formation. That clot can then break loose and travel out of the heart all the way to the brain, where a stroke can result.   

What are some of the common causes of AFIB?  Well, excessive alcohol consumption, an overactive thyroid gland, or coronary artery disease are some of the common causes. A person can also have AFIB and the cause cannot be found, called “idiopathic,” meaning it is just an electrical abnormality of the heart’s conduction system!   

The FAA considers AFIB a disqualifying condition; however, in the majority of cases, if the airman can get the heart rate under control, discover the origin of the problem, and significantly reduce the likelihood of a clot breaking loose and causing a stroke, a special issuance can be granted for any class of medical.    

So, when one is diagnosed with this condition for the first time, what does the FAA want you to do? First, you should self-ground until the cause of the arrhythmia can be defined and evaluated. Then, your physician needs to control the heart rate, and reduce the likelihood for clot formation and stroke risk.

You will need to provide the FAA with the following test results.  

A current report of an echocardiogram to evaluate the status of the heart valves, as valvular disease can sometimes cause atrial fibrillation. Next, a maximal exercise stress test to rule out coronary artery disease that affects blood supply to the heart. Thyroid function tests should also be done to rule out problems with that gland. Once your doctor controls the rate, rules out the possible causes, and gets you on a stable treatment program, the FAA will want a good letter that summarizes how this condition presented, discusses the test results, and what treatment he/she is going to use.   

The FAA accepts most treatments at this time, including rate controlling agents and radiofrequency ablation, where the cardiologist places a catheter into your heart and uses radio-type waves to destroy the conduction sites where these aberrant beats are coming from. Most patients have the abnormal rhythm stopped and are back in their regular heart rhythm, but the FAA has granted waivers to airmen who remain in AFIB but who have the heart rate well controlled. 

Your physician will also place you on a medication that will reduce your likelihood of developing a clot that could cause a stroke. You may have seen the television commercial advertising a new drug that can be used for this condition, called Xarelto (rivaroxaban), a relatively new medication that is frequently prescribed and is allowed by the FAA. You may be prescribed warfarin (Coumadin), a medication that results in your blood taking a longer time to clot, or a simple 81 mg baby aspirin. 

If you have more detailed questions about your particular condition, please call AOPA's Medical Certification specialists at 800/ 872-2672.

Topics: Pilot Protection Services, AOPA Products and Services

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