Driving restrictions for Dutch patients with an implantable cardioverter defibrillator : Compliance and associated factors

How to assess fitness to drive in patients with cardiac rhythm disturbances through an applicable decision support system

Disturbances in cardiac rhythm affect a significant fraction of the population; they can have an ample range of repercussions on one person's quality of life, from negligible to lethal. As an implication, arrhythmias concern many private, commercial and public-passenger-vehicle driving licence holders. In their practice, medical professionals can be asked to assess an arrhythmia patient's fitness to drive effectively. Due to the subject's complexity (requiring an extent of multidisciplinary competencies), the current guidances' heterogeneity and the possible ethical conflicts, the decision-making process becomes challenging and of particular concern to the doctor. To offer an applicable decision support system to doctors of various backgrounds to implement in their practice when asked to assess for fitness to drive in a patient with a suspected disease, a formulated diagnosis or subjected to therapy for cardiac rhythm disturbances, we started gathering the issues concerning the fitness assessment of drivers (or candidates) who present with any condition, symptom or treatment possibly or knowingly caused by cardiac rhythm disturbances. Subsequently, we reviewed the English-based literature, including various countries' published medical standards. Then, the overview was revised by local medical experts in clinical arrhythmology, electrophysiology and traffic medicine to reach a consensus statement at a local level. The result is an easily consultable operational protocol that lists conditions, symptoms or treatments caused or possibly caused by cardiac rhythm disturbances; the certifications required for the assessment of the driver (or candidate); the orientation about the fitness or unfitness to drive under the enlisted medical conditions (distinguishing between private and professional drivers); and the recommended time limits to revise the case. A particular focus is applied to patients subject to the remote monitoring system of an implantable cardiac device, as this innovative approach constitutes a solid and efficient instrument for an accurate evaluation of the patient's cardiovascular situation. Despite some limitations, mainly concerning the lack of information at the moment of the evaluation or the infrequency of the medical condition, this proposal offers a ready-to-use solution for doctors who are asked to give their professional (clinical or medico-legal) opinion about the fitness to drive of patients with an arrhythmia problem. As an advantage, the constant cooperation among professionals from different backgrounds, like electrophysiologists and traffic medicine experts, allows a more individual, less predetermined evaluation of the specific case.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study

BACKGROUND

Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

METHODS

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

RESULTS

The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

CONCLUSIONS

The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.

Driving with cardiac devices in Australia. Does a review of recent evidence prompt a change in guidelines?

Australian Driving Guidelines for patients with pacemakers and implanted cardioverter defibrillators are in line with many around the world, with some minor differences. Some aspects of these guidelines lack contemporary evidence in key decision-making areas and make broad recommendations regarding groups with heterogeneous populations. In addition, more recent studies suggest lower rates of adverse events in some patients with these devices than previously thought. Through a systematic literature review, along with discussion of current guidelines, we combine new evidence with well established risk assessment tools to ask the following questions: (i) Given the heterogeneity of patient risk within the defibrillator population, should guidelines allow for further individualisation of risk and subsequent licensing restrictions?; and (ii) Could some patients with primary prevention automated cardioverter defibrillators be able to hold a commercial driving licence?