Advertisement

Driving Guidelines and Restrictions in Patients With a History of Cardiac Arrhythmias, Syncope,or Implantable Devices

  • Dan Sorajja
  • Win-Kuang Shen
Arrhythmias

Opinion statement

The need to drive is universal in many countries. Patients with syncope, cardiac arrhythmias, or implantable cardioverter–defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause harm to themselves and/or others when driving. Restrictions on driving and driving guidelines have been developed with the intent to reduce and prevent motor vehicle accidents, thereby improving personal and public safety. Several guidelines and consensus statements recently were updated. This review focuses on the syncope-related driving guidelines and restrictions. Driving issues related to other causes of loss of consciousness, such as drug or alcohol intoxication, epilepsy, or metabolic disorders, are not included in this review. Approximately 1% to 3% of all motor vehicle accidents are caused by the driver’s sudden incapacitation; of these accidents, 5% to 10% are related to cardiac causes, with or without syncope. Major cardiac causes of syncope are neurally mediated mechanisms, bradycardia, and tachycardia. When the cause of syncope is determined and adequately treated, no driving restrictions are usually required after treatment is implemented. Patients who receive ICD therapy for primary or secondary sudden cardiac death prevention are at risk for future device discharges and sudden incapacitation whether or not they are driving. When the cause of syncope is unknown, the response to treatment is uncertain (such as treating the neurocardiogenic/vasovagal syncope), or ICD discharge is possible, driving recommendations are based on the estimation of “risk of harm while driving” and the general consensus on the threshold of “acceptable risk of harm.” The annual risk of harm while driving can be estimated by the following formula: driving time (%) × vehicle type (commercial to private) × annual risk of syncope or incapacitation × probability of injury or accident.

Keywords

Arrhythmogenic Right Ventricular Dysplasia Catecholaminergic Polymorphic Ventricular Tachycardia Neurocardiogenic Syncope Antiarrhythmic Versus Implantable Defibrillator Driving Restriction 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Traffic Safety Facts: 2008 Data. Washington, DC: National Highway Traffic Safety Administration’s National Center for Statistics and Analysis; 2009:1–12.Google Scholar
  2. 2.
    Petch MC: Driving and heart disease. Eur Heart J 1998, 19:1165–1177.CrossRefPubMedGoogle Scholar
  3. 3.
    Epstein AE, Miles WM, Benditt DG, et al.: Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation 1996, 94:1147–1166.PubMedGoogle Scholar
  4. 4.
    Ostrom M, Eriksson A: Natural death while driving. J Forensic Sci 1987, 32:988–998.PubMedGoogle Scholar
  5. 5.
    Parsons M: Fits and other causes of loss of consciousness while driving. Q J Med 1986, 58:295–303.PubMedGoogle Scholar
  6. 6.
    Simpson C, Dorian P, Gupta A, et al.: Assessment of the cardiac patient for fitness to drive: drive subgroup executive summary. Can J Cardiol 2004, 20:1314–1320.PubMedGoogle Scholar
  7. 7.
    Curtis AB, Epstein AE: Syncope while driving: how safe is safe? Circulation 2009, 120:921–923.CrossRefPubMedGoogle Scholar
  8. 8.
    Larsen GC, Stupey MR, Walance CG, et al.: Recurrent cardiac events in survivors of ventricular fibrillation or tachycardia. Implications for driving restrictions. JAMA 1994, 271:1335–1339.CrossRefPubMedGoogle Scholar
  9. 9.
    Epstein AE, Baessler CA, Curtis AB, et al.: Addendum to “Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology”: public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society. Circulation 2007, 115:1170–1176.CrossRefPubMedGoogle Scholar
  10. 10.
    Vijgen J, Botto G, Camm J, et al.: Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators. Europace 2009, 11:1097–1107.CrossRefPubMedGoogle Scholar
  11. 11.•
    Moya A, Sutton R, Ammirati F, et al.: Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J 2009, 30:2631–2671. This paper is the most recent guideline from the European Society of Cardiology regarding syncope. It covers everything from classification and evaluation to treatment, including recommendations on driving for these patientsCrossRefPubMedGoogle Scholar
  12. 12.
    Epstein AE, DiMarco JP, Ellenbogen KA, et al.: ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008, 51:e1–e62.CrossRefPubMedGoogle Scholar
  13. 13.
    Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al.: ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Circulation 2003, 108:1871–1909.CrossRefPubMedGoogle Scholar
  14. 14.
    Zipes DP, Camm AJ, Borggrefe M, et al.: ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006, 114:e385–e484.CrossRefPubMedGoogle Scholar
  15. 15.
    Kapoor WN. Syncope. N Engl J Med 2000, 343:1856–1862.CrossRefPubMedGoogle Scholar
  16. 16.
    Savage DD, Corwin L, McGee DL, et al.: Epidemiologic features of isolated syncope: the Framingham Study. Stroke 1985, 16:626–629.PubMedGoogle Scholar
  17. 17.
    Soteriades ES, Evans JC, Larson MG, et al.: Incidence and prognosis of syncope. N Engl J Med 2002, 347:878–885.CrossRefPubMedGoogle Scholar
  18. 18.
    Day SC, Cook EF, Funkenstein H, Goldman L: Evaluation and outcome of emergency room patients with transient loss of consciousness. Am J Med 1982, 73:15–23.CrossRefPubMedGoogle Scholar
  19. 19.
    Li H, Weitzel M, Easley A, et al.: Potential risk of vasovagal syncope for motor vehicle driving. Am J Cardiol 2000, 85:184–186.CrossRefPubMedGoogle Scholar
  20. 20.•
    Sorajja D, Nesbitt GC, Hodge DO, et al.: Syncope while driving: clinical characteristics, causes, and prognosis. Circulation 2009, 120:928–934. The latest data on syncope while driving, including recurrence and survival.CrossRefPubMedGoogle Scholar
  21. 21.
    Maas R, Ventura R, Kretzschmar C, et al.: Syncope, driving recommendations, and clinical reality: survey of patients. BMJ 2003, 326:21.CrossRefPubMedGoogle Scholar
  22. 22.
    Blitzer ML, Saliba BC, Ghantous AE, et al.: Causes of impaired consciousness while driving a motorized vehicle. Am J Cardiol 2003, 91:1373–1374.CrossRefPubMedGoogle Scholar
  23. 23.
    Brignole M: Diagnosis and treatment of syncope. Heart 2007, 93:130–136.CrossRefPubMedGoogle Scholar
  24. 24.
    Mosqueda-Garcia R, Furlan R, Tank J, Fernandez-Violante R: The elusive pathophysiology of neurally mediated syncope. Circulation 2000, 102:2898–2906.PubMedGoogle Scholar
  25. 25.
    Shen WK, Decker WW, Smars PA, et al.: Syncope Evaluation in the Emergency Department Study (SEEDS): a multidisciplinary approach to syncope management. Circulation 2004, 110:3636–3645.CrossRefPubMedGoogle Scholar
  26. 26.
    Sheldon R, Connolly S, Rose S, et al.: Prevention of Syncope Trial (POST): a randomized, placebo-controlled study of metoprolol in the prevention of vasovagal syncope. Circulation 2006, 113:1164–1170.CrossRefPubMedGoogle Scholar
  27. 27.
    Connolly SJ, Sheldon R, Thorpe KE, et al.: Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial. JAMA 2003, 289:2224–2229.CrossRefPubMedGoogle Scholar
  28. 28.
    Fenton AM, Hammill SC, Rea RF, et al.: Vasovagal syncope. Ann Intern Med 2000, 133:714–725.PubMedGoogle Scholar
  29. 29.
    Chen LY, Benditt DG, Shen WK: Management of syncope in adults: an update. Mayo Clin Proc 2008, 83:1280–1293.CrossRefPubMedGoogle Scholar
  30. 30.
    Monnig G, Ribbing M, Wasmer K, et al.: Recurrent syncope triggered by inappropriate sinus tachycardia. Pacing Clin Electrophysiol 2004, 27:1324–1326.CrossRefPubMedGoogle Scholar
  31. 31.
    Paul T, Guccione P, Garson A Jr: Relation of syncope in young patients with Wolff-Parkinson-White syndrome to rapid ventricular response during atrial fibrillation. Am J Cardiol 1990, 65:318–321.CrossRefPubMedGoogle Scholar
  32. 32.
    Dhala A, Bremner S, Blanck Z, et al.: Impairment of driving abilities in patients with supraventricular tachycardias. Am J Cardiol 1995, 75:516–518.CrossRefPubMedGoogle Scholar
  33. 33.
    Brignole M, Menozzi C, Bartoletti A, et al.: A new management of syncope: prospective systematic guideline-based evaluation of patients referred urgently to general hospitals. Eur Heart J 2006, 27:76–82.CrossRefPubMedGoogle Scholar
  34. 34.
    Hammill SC, Kremers MS, Stevenson LW, et al.: Review of the Registry’s second year, data collected, and plans to add lead and pediatric ICD procedures. Heart Rhythm 2008, 5:1359–1363.CrossRefPubMedGoogle Scholar
  35. 35.
    Moss AJ, Hall WJ, Cannom DS, et al.: Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996, 335:1933–1940.CrossRefPubMedGoogle Scholar
  36. 36.
    Bristow MR, Saxon LA, Boehmer J, et al.: Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004, 350:2140–2150.CrossRefPubMedGoogle Scholar
  37. 37.
    Kadish A, Dyer A, Daubert JP, et al.: Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004, 350:2151–2158.CrossRefPubMedGoogle Scholar
  38. 38.
    Bardy GH, Lee KL, Mark DB, et al.: Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005, 352:225–237.CrossRefPubMedGoogle Scholar
  39. 39.
    Tchou P, Axtell K, Anderson AJ, et al.: When is it safe not to replace an implantable cardioverter defibrillator generator? Pacing Clin Electrophysiol 1991, 14:1875–1880.CrossRefPubMedGoogle Scholar
  40. 40.
    Bansch D, Brunn J, Castrucci M, et al.: Syncope in patients with an implantable cardioverter-defibrillator: incidence, prediction and implications for driving restrictions. J Am Coll Cardiol 1998, 31:608–615.CrossRefPubMedGoogle Scholar
  41. 41.
    Freedberg NA, Hill JN, Fogel RI, Prystowsky EN: Recurrence of symptomatic ventricular arrhythmias in patients with implantable cardioverter defibrillator after the first device therapy: implications for antiarrhythmic therapy and driving restrictions. CARE Group. J Am Coll Cardiol 2001, 37:1910–1915.CrossRefPubMedGoogle Scholar
  42. 42.
    Levine JH, Mellits ED, Baumgardner RA, et al.: Predictors of first discharge and subsequent survival in patients with automatic implantable cardioverter-defibrillators. Circulation 1991, 84:558–566.PubMedGoogle Scholar
  43. 43.
    Kou WH, Calkins H, Lewis RR, et al.: Incidence of loss of consciousness during automatic implantable cardioverter-defibrillator shocks. Ann Intern Med 1991, 115:942–945.PubMedGoogle Scholar
  44. 44.
    Curtis AB, Conti JB, Tucker KJ, et al.: Motor vehicle accidents in patients with an implantable cardioverter-defibrillator. J Am Coll Cardiol 1995, 26:180–184.CrossRefPubMedGoogle Scholar
  45. 45.
    Akiyama T, Powell JL, Mitchell LB, et al.: Resumption of driving after life-threatening ventricular tachyarrhythmia. N Engl J Med 2001, 345:391–397.CrossRefPubMedGoogle Scholar
  46. 46.
    DiCarlo LA, Winston SA, Honoway S, Reed P: Driving restrictions advised by midwestern cardiologists implanting cardioverter defibrillators: present practices, criteria utilized, and compatibility with existing state laws. Pacing Clin Electrophysiol 1992, 15:1131–1136.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Division of Cardiovascular DiseasesMayo ClinicRochesterUSA

Personalised recommendations