[Atrial fibrillation--incidence on flying safety--practical implication on military and civil aircrew]

Recent epidemiological studies and new approaches in the management of atrial fibrillation (AF) incite to reconsider its incidence on medical aircrew certification. Paroxysmal as well as chronic AF are common diseases and are found among pilots particularly when advanced in years. It is usually associated with heart disease, especially with rheumatic valvulopathies. However idiopathic or "lone" AF is observed in subjects apparently-free of any heart disease. Mortality is twice higher in patient suffering from AF. It is responsible for miscellaneous symptoms among which palpitations or even syncope. Thromboembolism is however the most severe complication occurring even in cases of AF unrelated to rheumatic heart disease. Nevertheless, this risk would be less in paroxysmal AF and "lone" AF. The management of AF aims at restoring sinus rhythm and preventing recurrences or, at least, at controlling heart rate. Recurrences are frequent after cardioversion despite the use of antiarrhythmic drugs. Moreover the latter can induce adverse effects and are potentially proarrhythmogenic, which can lead to sudden death. Anticoagulant therapy significantly lowers the rate of cerebral embolism but at the risk of haemorrhages. New invasive techniques therapy are still experimental and can be responsible for severe complications. The risk of sudden incapacitation remains a reality in crew members suffering from AF. This increases with age, with frequency of the attacks or chronicity, in presence of heart disease or in case of antiarrhythmic or anticoagulant treatment. Paroxysmal forms have a lower rate of complications but are more frequently responsible for symptoms incompatible with flight, while chronic forms, although less symptomatic when heart rate is properly controlled, present more complications. Some cases of chronic idiopathic AF could be considered for restricted certification but submitted to regular follow-up. However, a pilot developing an isolated episode of AF triggered off by reversible conditions and free of risk factors has little chance of frequent recurrences or complications and might be eligible for flight.