Driving restrictions after implantable cardioverter defibrillator implantation: An evidence-based approach

Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, The Netherlands.
European Heart Journal (Impact Factor: 15.2). 06/2011; 32(21):2678-87. DOI: 10.1093/eurheartj/ehr161
Source: PubMed


Little evidence is available regarding restrictions from driving following implantable cardioverter defibrillator (ICD) implantation or following first appropriate or inappropriate shock. The purpose of the current analysis was to provide evidence for driving restrictions based on real-world incidences of shocks (appropriate and inappropriate).
A total of 2786 primary and secondary prevention ICD patients were included. The occurrence of shocks was noted during a median follow-up of 996 days (inter-quartile range, 428-1833 days). With the risk of harm (RH) formula, using the incidence of sudden cardiac incapacitation, the annual RH to others posed by a driver with an ICD was calculated. Based on Canadian data, the annual RH to others of 5 in 100 000 (0.005%) was used as a cut-off value. In both primary and secondary prevention ICD patients with private driving habits, no restrictions to drive directly following implantation, or an inappropriate shock are warranted. However, following an appropriate shock, these patients are at an increased risk to cause harm to other road users and therefore should be restricted to drive for a period of 2 and 4 months, respectively. In addition, all ICD patients with professional driving habits have a substantial elevated risk to cause harm to other road users during the complete follow-up after both implantation and shock and should therefore be restricted to drive permanently.
The current analysis provides a clinically applicable tool for guideline committees to establish evidence-based driving restrictions.

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Available from: Joep Thijssen
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    ABSTRACT: A physician who takes care for patients with implanted cardioverter-defibrillator (ICD) must inform them about their fitness to drive since these patients carry a higher risk for the occurrence of syncope or sudden cardiac death at the wheel. The driver´s license law in Germany does not mention patients with ICD. The fitness to drive of patients with ICD is covered by the Advisory Board for Traffic Medicine in Germany (Bundesanstalt für Straßenwesen). These guidelines, however, are outdated and cannot be used to inform patients. Actually, these guidelines are under revision. Currently, the position paper of the German Society of Cardiology on "Fitness to drive and cardiovascular diseases" together with a recently published Dutch paper on this topic forms the basis of these recommendations. One week after ICD implantation for primary or one month after implantation for secondary prevention the patient may resume to drive. After adequate shocks the fitness to drive can be expected 2-4 months (3 months) later. The assessment of the fitness to drive has to be performed individually, taking into account also possible other influencing factors. In individual cases it appears to be justified that patients with ICD work as professional drivers.
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    ABSTRACT: AIMS: We sought to characterise driving habits of contemporary implantable cardioverter defibrillator (ICD) patients.METHODS AND RESULTS: We performed a multicentre prospective observational study of consecutive ICD recipients. Non-commercial drivers with a valid licence were eligible. Patient and ICD data were recorded. All patients completed an anonymous questionnaire regarding their driving habits. Among 275 patients, 25 (9.1%) stopped driving permanently after ICD implantation. During a mean follow-up of 26.5 ± 4.5 months, 25.3% of patients received an ICD shock (52.5% appropriate). The median time to first shock was 7.0 (2.5, 17.5) months and was not significantly different between primary and secondary ICD patients. However, shocks (36.5 vs. 21.3%, P = 0.027) and recurrent shock episodes (17.5 vs. 6.2%, P = 0.011) were more common in secondary ICD patients. Physician-recommended driving restrictions were not recalled by 37.9% and not followed by 23.0% of patients. Overall, the mean duration of driving abstinence was 2.2 ± 2.9 and 3.6 ± 5.3 months for primary and secondary patients, respectively. Notably, 36.5% of secondary patients drove within 1 month. Eight patients (3.3%) received a shock while driving, five of which resulted in road traffic accidents. The annual risk of a shock while driving was 1.5%.CONCLUSIONS: Patient driving behaviour following ICD implantation is variable, with over one-third not remembering and almost one-quarter not adhering to physician-directed driving restrictions. Over one-third of secondary ICD patients drive within 1 month despite physician recommendations. Further studies are required to establish the optimal duration of driving restriction in ICD recipients.
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