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

Abstract

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.

Inappropriate implantable cardioverter defibrillator shocks—incidence, effect, and implications for driver licensing

“…Implantable cardioverter defibrillators (ICDs) improve survival in patients at risk of sudden cardiac death [ 1 ]. However, these patients have an ongoing risk of sudden incapacitation that may cause harm to themselves and others when driving [ 2 – 10 ]. An obvious concern is the effect of arrhythmias and/or discharges of devices on a patient’s level of consciousness and ability to drive.…”

Driving restrictions for patients with reflex syncope

“…Therefore, the clinical approach to syncope evaluation, and the recommendations for driving, should not differ with regard to the time or activity related to the presentation of the syncopal episode [14] . Several mechanisms or factors may trigger reflex syncope while driving: the passively seated position without muscle tension (enhances venous pooling in the legs), preexisting dehydration or intravascular depletion, the warm environment of a car (leads to cutaneous vasodilatation), and strong emotional stimulation while driving [1] , [14] , [15] , [16] .…”

“…The benefits of pharmacological treatment such as beta-blockers, alpha-antagonists, and mineral corticoids have not been confirmed in long-term placebo-controlled trials, but these agents have shown some benefit in shorter-duration trials [16] . Non-pharmacological treatments such as counter-pressure maneuvers (including leg crossing, hand gripping, and arm tensing) could increase blood pressure significantly enough to delay or avoid loss of consciousness [16] , although it may be difficult to perform such a maneuver during driving. However, these recommendations are speculative and based on common sense, and there is insufficient evidence to support them at present [1] .…”

“…Generally, encouraging frequent breaks while driving, maintaining an optimal environment in the vehicle, and taking appropriate salts and fluids are recommended for most syncope patients [1,14–16]. The benefits of pharmacological treatment such as beta‐blockers, alpha‐antagonists, and mineral corticoids have not been confirmed in long‐term placebo‐controlled trials, but these agents have shown some benefit in shorter‐duration trials [16].…”

“…Generally, encouraging frequent breaks while driving, maintaining an optimal environment in the vehicle, and taking appropriate salts and fluids are recommended for most syncope patients [1,14–16]. The benefits of pharmacological treatment such as beta‐blockers, alpha‐antagonists, and mineral corticoids have not been confirmed in long‐term placebo‐controlled trials, but these agents have shown some benefit in shorter‐duration trials [16]. Non‐pharmacological treatments such as counter‐pressure maneuvers (including leg crossing, hand gripping, and arm tensing) could increase blood pressure significantly enough to delay or avoid loss of consciousness [16], although it may be difficult to perform such a maneuver during driving.…”