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ICAO Preliminary Unedited Version — October 2008 III-1-23
measured and thyrotoxicosis treated, if necessary. Likewise, the liver function tests (LFTs) and mean
corpuscular volume (MCV) should be checked to review potential alcohol abuse. After one year, about 50
per cent are likely to have relapsed at least once; a minority (< 25 per cent) will maintain sinus rhythm at
three years.
Aircrew certification in the context of atrial fibrillation requires:
• freedom from symptoms
• sinus rhythm and normotension
• normal TSH, LFTs and MCV
• no history of transient ischaemic attack (TIA)
• absence of other risk factors for recurrence and/or for thromboembolic stroke, including age > 65
years, hypertension, diabetes, left ventricular hypertrophy, valvar heart disease, coronary heart
disease (predicating need for warfarin)
• normal cavity and structural dimensions of the heart, normal valves and normal Doppler1 flows
on echocardiography. The left atrial internal diameter should be <4.5 cm
• exercise walking time to be normal (> 10 minutes). In atrial fibrillation, the maximum heart rate
should be < 230 bpm and the longest pause <3.5 s
• three Holter recordings over two to three months to have shown no evidence of atrial fibrillation
_- arbitrarily defined as at least three to five consecutive normally conducted complexes
• restriction of the licence with a multi-crew limitation. After an event-free period of two years, the
restriction may be considered for removal, subject to review.
These are rigorous standards, which will be achieved by only a minority. Subjects of pilot age not
fulfilling the above and who demonstrate paroxysmal/permanent atrial fibrillation in spite of medication
may require anticoagulation with warfarin, which itself is disqualifying in many Contracting States.
Aspirin/clopidogrel may be recommended by the supervising cardiologist in the absence of treatment with
warfarin. In the event of default, further fitness consideration will require satisfactory answers to the
following:
• is the thromboembolic rate acceptable without warfarin?
• are there symptoms at any time, i.e. on switching rhythm, and if so are they minimal?
• is the heart rate controlled well at rest and on exercise?
• is an approved /non-approved drug being taken?
Products that are permitted include:
• digoxin (mainly of value in controlling resting heart rate in the established condition)
• beta-blocking agents, usually atenolol or bisoprolol, which may to help preserve sinus rhythm
and reduce the heart rate in atrial fibrillation. Sotalol also has some class III effect (as well as
some pro-arrhythmic effect) and is permitted provided there is no demonstrated pro-arrhythmic
effect
• verapamil, which may help to preserve sinus rhythm and control the heart rate
• diltiazem, both alone and combined with the foregoing (with care in the presence of betablockade)
is helpful in rate management.
None of these products is particularly effective, and in the long term atrial fibrillation is likely to become
established. Their side-effect profile, however, is generally not high.
1 Doppler: ultrasonography. After Christian Doppler, Austrian physicist (1803-1853).
ICAO Preliminary Unedited Version — October 2008 III-1-24
Products not permitted include the following:
• Class Ia anti-arrhythmic agents, such as:
– quinidine (excessive risk of torsades de pointes and sudden cardiac death (SCD))
– disopyramide (excessive anti-cholinergic side effects)
– procainamide (lupus-like syndrome and occasionally agranulocytosis).
• Class Ib drugs (e.g. mexiletine) which are ineffective in atrial rhythm disturbances,
• Class Ic agents (flecainide, propafenone) which are effective in bringing about the restoration of
sinus rhythm and its maintenance but which have undesirable effects such as tremor and visual
disturbances. Both may provoke atrial flutter in a minority (about five per cent).
• The most effective class III drug, amiodarone, which has a high-side effect profile and thus
cannot be considered. The most common side effect, photo-sensitisation, is less important than
the disturbance of sleep and sedation that it may cause. Patients receiving this drug develop
corneal micro-deposits, which may give a halo effect around lights at night.
• Class III drugs — moricizine, dofetilide and ibutilide.
• Warfarin
Neither flecainide nor propafenone is permitted in aviators although some Contracting States have
approved flecainide at a dose of 50mg twice daily on an individual basis following special consideration.
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Manual of Civil Aviation Medicine 1(86)
