What tests does the FAA require if you have atrial fibrillation?

*An earlier version of this article incorrectly stated the observation time required after cardioversion to treat heart arrhythmias. Cardioversion requires a 30-day period. AOPA regrets the error.

AOPA Pilot Protection Services has had some questions recently about what information the FAA needs from an airman who has an episode of atrial fibrillation (A-Fib). 

Atrial fibrillation occurs when instead of one area in your atrium (the upper chambers in the heart) controlling the electrical beating of the heart, there are many areas where the electrical impulse originates, most times up to 250 atrial beats. Not all of these beats make it through to the ventricles and thus cause the heart to beat. This is because the area that they pass through, called the atrial-ventricular (AV) node, has a resting phase so that electrical impulses that reach it will not allow the impulse to fire the ventricles. When a person first gets atrial fibrillation, many of these impulses are getting through so the heart is usually beating quite fast. The name of the game is to prevent the abnormal rhythm or to increase the resting phase through the AV node. 

Several things can cause atrial fibrillation: a heart attack; a thyroid condition; conditions that cause enlargement of the atria chambers, such as heart valve problems; and excessive alcohol consumption, to name some of the common ones. The FAA wants the airman to show that his or her treating physician has ruled in/out these conditions, so when initially presenting one’s case, they agency wants you to have this documentation:

  1. A maximal exercise stress test, to rule out coronary disease;
  2. An echocardiogram of the heart to see whether there are valve problems or enlargement of the heart chambers;
  3. A good evaluation by your treating internist or cardiologist that should explain how you presented, what was done to treat the condition, and what will be the treatment; and 
  4. A set of thyroid function studies.  

The FAA will want the atrial fibrillation to be controlled, meaning either to slow the electrical impulses bombarding the ventricles or to get you out of the abnormal rhythm altogether. This can be accomplished by electrically shocking the heart into a regular rhythm, called cardioversion; actually eradicating the areas in the atria that are causing these beats to occur, called radiofrequency ablation; or by giving you drugs that will cause the rhythm to go away. If your physician decides to use the cardioversion or ablation procedures, the FAA has a policy to keep you grounded for 30 days*. However, a radiofrequency ablation needs 90 days of stability.  Both treatments will require the same treatment and procedure records, a 24 hour Holter monitor and ECG, and a status report from the treating physician.  

The phenomenon of atrial fibrillation causes blood to stagnate in the atria and ultimately form clot. This clot can break loose and cause you to have a stroke. For many years the main treatment to prevent clot formation has been what lay people call blood thinners. Actually, this medication called warfarin causes your blood to take a longer time to clot. There are several newer medications on the market. Several of the common ones are Pradaxa (dabigatran), Xarelto (rivaroxaban), and Eliquis (apixaban). These medications affect the cycle of coagulation in your blood. All of these medications are acceptable to the FAA for treatment with some stipulations. 

The FAA does accept the majority of medications that are used to prevent one from re-developing atrial fibrillation.

Topics: Pilot Protection Services, AOPA Products and Services

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