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Bjerre J, Rosenkranz SH, Schou M, Jøns C, Philbert BT, Larroudé C, Nielsen JC, Johansen JB, Riahi S, Melchior TM, Torp-Pedersen C, Hlatky M, Gislason G, Ruwald AC. Driving following defibrillator implantation: a nationwide register-linked survey study. Eur Heart J 2021; 42:3529-3537. [PMID: 33954626 DOI: 10.1093/eurheartj/ehab253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/04/2021] [Accepted: 04/13/2021] [Indexed: 01/09/2023] Open
Abstract
AIMS Patients are restricted from driving following implantable cardioverter defibrillator (ICD) implantation or shock. We sought to investigate how many patients are aware of, and adhere to, the driving restrictions, and what proportion experience an ICD shock or other cardiac symptoms while driving. METHODS AND RESULTS We performed a nationwide survey of all living Danish residents 18 years or older who received a first-time ICD between 2013 and 2016 (n = 3913) and linked their responses with nationwide registers. Of 2741 respondents (47% primary prevention, 83% male, median age 67 years), 2513 (92%) held a valid driver's license at ICD implantation, 175 (7%) of whom had a license for professional driving. Many drivers were unaware of driving restrictions: primary prevention 58%; secondary prevention 36%; post-appropriate shock 28%; professional drivers 55%. Almost all (94%) resumed non-professional driving after ICD implantation, more than one-third during the restricted period; 35% resumed professional driving. During a median follow-up of 2.3 years, 5 (0.2%) reported receiving an ICD shock while driving, one of which resulted in a traffic accident. The estimated risk of harm was 0.0002% per person-year. CONCLUSION In this nationwide study, many ICD patients were unaware of driving restrictions, and more than one third resumed driving during a driving restriction period. However, the rate of reported ICD shocks while driving was very low.
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Affiliation(s)
- Jenny Bjerre
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark.,Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Simone Hofman Rosenkranz
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark
| | - Christian Jøns
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Berit Thornvig Philbert
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Charlotte Larroudé
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark
| | - Jens Cosedis Nielsen
- Department of Clinical Medicine, Aarhus University Hospital, Palle Juul-Jensens Blvd. 82, 8200 Aarhus, Denmark
| | - Jens Brock Johansen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9200 Aalborg, Denmark
| | - Thomas Maria Melchior
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Research, Nordsjællands Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Mark Hlatky
- Department of Medicine, Stanford University School of Medicine, 615 Crothers Way Encina Commons, Stanford, CA 94305, USA
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark.,Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Anne-Christine Ruwald
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte Hospitalsvej 6, 3rd Floor, Hellerup 2900, Denmark.,Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
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2
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Sinclair DC, Hegmann KT, Holland JP. Acceptable Risk of Sudden Incapacitation Among Safety Critical Transportation Workers: A Comprehensive Synthesis. J Occup Environ Med 2021; 63:329-342. [PMID: 33769399 DOI: 10.1097/jom.0000000000002140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Identify a risk threshold for sudden incapacitation for safety critical positions in transportation industries supporting medical fitness for duty standards. METHODS Systematic literature searches were performed examining acceptable risk criteria for medically related incapacitation using PubMed Central and Google Scholar databases. Websites for professional societies and national and international governmental agencies were also accessed. Article abstracts were reviewed and exhaustive searches were performed. RESULTS International regulatory bodies have adopted definitions of acceptable risk typically with a threshold of 1% to 2% absolute risk of sudden incapacitation per annum. Several "risk-of-harm" models have been proposed that incorporate factors modulating an absolute risk constant derived from epidemiological studies. CONCLUSION A 1% absolute annual risk of sudden incapacitation should be adopted as the threshold for determining medical fitness for duty among employees in safety critical positions in transportation industries.
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Affiliation(s)
- Donald C Sinclair
- Steptoe & Johnson PLLC, 1233 Main St., Ste. 3000, Wheeling, West Virginia (Mr Sinclair); Director Rocky Mountain Center for Occupational and Environmental Health, University of Utah, Salt Lake City, Utah (Dr Hegmann); Puyallup, Washington (Dr Holland)
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Cooper M, Berent T, Auer J, Berent R. Recommendations for driving after implantable cardioverter defibrillator implantation and the use of a wearable cardioverter defibrillator. Wien Klin Wochenschr 2020; 132:770-781. [DOI: 10.1007/s00508-020-01675-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
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Pezawas T. Fitness to Drive After Syncope and/or in Cardiovascular Disease - An Overview and Practical Advice. Curr Probl Cardiol 2020; 46:100677. [PMID: 32888697 DOI: 10.1016/j.cpcardiol.2020.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/26/2020] [Indexed: 10/23/2022]
Abstract
The risk of syncope occurring while driving has implications for personal and public safety. Little is thought about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire basic competences to be able to advise them about their fitness to drive. Current knowledge, governmental regulations, and recommendations concerning fitness to drive in patients with syncope and/or cardiovascular disease are presented. Narrative review with educational and clinical advice. Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (eg, syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, etc.) and marked general weakness (eg, after major surgery or in heart failure). Patients with syncope and/or cardiovascular disease should be properly advised by their physicians about their fitness to drive, and restrictions should be documented.
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5
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Imberti JF, Vitolo M, Proietti M, Diemberger I, Ziacchi M, Biffi M, Boriani G. Driving restriction in patients with cardiac implantable electronic devices: an overview of worldwide regulations. Expert Rev Med Devices 2020; 17:297-308. [DOI: 10.1080/17434440.2020.1742108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jacopo F. Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Natural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Natural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan and Geriatric Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Igor Diemberger
- Cardiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
| | - Mauro Biffi
- Cardiology Unit, Department of Experimental, Diagnostic and Speciality Medicine, Sant’Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Natural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
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6
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Mijic D, Lemke B, Bogossian H. [Fitness to drive in patients with cardiovascular implantable electronic devices]. Herzschrittmacherther Elektrophysiol 2019; 30:150-155. [PMID: 31073643 DOI: 10.1007/s00399-019-0626-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/15/2019] [Indexed: 12/01/2022]
Abstract
The term CIED (cardiovascular implantable electronic devices) merges two groups of devices: pacemakers (PM) and defibrillators (ICD). PMs improve the symptoms of patients with bradycardic disorders, while ICDs reduce mortality in patients with increased risk for sudden cardiac death. However, these patients are still at risk of suffering malignant arrhythmias. Even after implantation of a pacemaker, syncope may occur. If these arrhythmias arise while driving, other individuals could be endangered. Therefore, it is important and obligatory for the treating physician to clarify this issue regarding driving restrictions to all patients, who present an indication for device treatment. The present publication focuses on the principal points of present guidelines and recommendations regarding fitness to drive in patients with cardiac disorders (especially with CIED).
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Affiliation(s)
- Dejan Mijic
- Gemeinschaftspraxis für Kardiologie und Kardiochirurgie, Friedrich-Ebert-Str. 128a, 42117, Wuppertal, Deutschland.
| | - Bernd Lemke
- Märkische Kliniken GmbH, Abteilung für Kardiologie und Angiologie, Klinikum Lüdenscheid, Lüdenscheid, Deutschland
| | - Harilaos Bogossian
- Märkische Kliniken GmbH, Abteilung für Kardiologie und Angiologie, Klinikum Lüdenscheid, Lüdenscheid, Deutschland.,Universität Witten/Herdecke, Witten, Deutschland
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7
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Margulescu AD, Anderson MH. A Review of Driving Restrictions in Patients at Risk of Syncope and Cardiac Arrhythmias Associated with Sudden Incapacity: Differing Global Approaches to Regulation and Risk. Arrhythm Electrophysiol Rev 2019; 8:90-98. [PMID: 31114682 PMCID: PMC6528027 DOI: 10.15420/aer.2019.13.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The ability to drive is a highly valued freedom in the developed world. Sudden incapacitation while driving can result in injury or death for the driver and passengers or bystanders. Cardiovascular conditions are a primary cause for sudden incapacitation and regulations have long existed to restrict driving for patients with cardiac conditions at high risk of sudden incapacitation. Significant variation occurs between these rules in different countries and legislatures. Quantification of the potential risk of harm associated with various categories of drivers has attempted to make these regulations more objective. The assumptions on which these calculations are based are now old and less likely to reflect the reality of modern driving. Ultimately, a more individual assessment of risk with a combined assessment of the medical condition and the patient's driving behaviour may be appropriate. The development of driverless technologies may also have an impact on decision making in this field.
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Affiliation(s)
- Andrei D Margulescu
- Morriston Cardiac Centre, Department of Cardiology, Morriston Hospital NHS Trust Swansea, UK
| | - Mark H Anderson
- Morriston Cardiac Centre, Department of Cardiology, Morriston Hospital NHS Trust Swansea, UK
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Lovibond SW, Odell M, Mariani JA. Driving with cardiac devices in Australia. Does a review of recent evidence prompt a change in guidelines? Intern Med J 2019; 50:271-277. [PMID: 30724433 DOI: 10.1111/imj.14243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/30/2019] [Accepted: 01/31/2019] [Indexed: 11/30/2022]
Abstract
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?
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Affiliation(s)
- Samuel W Lovibond
- Heart Centre, Melbourne, Victoria, Australia.,Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Morris Odell
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Pacing Service, Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Cardiac Investigation Unit, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Justin A Mariani
- Clinical Forensic Medicine, Forensic Services, Victorian Institute of Forensic Medicine, Melbourne, Victoria, Australia.,Department of Forensic Medicine, Melbourne, Victoria, Australia
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9
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Decreased Quality of Life Due to Driving Restrictions After Cardioverter Defibrillator Implantation. J Cardiovasc Nurs 2018; 33:474-480. [DOI: 10.1097/jcn.0000000000000474] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Baalman SWE, de Groot JR. Do we understand the rationale behind driving restrictions in patients with an implantable cardioverter defibrillator? Neth Heart J 2018; 26:53-54. [PMID: 29330685 PMCID: PMC5783895 DOI: 10.1007/s12471-017-1072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- S W E Baalman
- Heart Center, Department of Cardiology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
| | - J R de Groot
- Heart Center, Department of Cardiology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands.
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11
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Inappropriate implantable cardioverter defibrillator shocks-incidence, effect, and implications for driver licensing. J Interv Card Electrophysiol 2017; 49:271-280. [PMID: 28730420 PMCID: PMC5543197 DOI: 10.1007/s10840-017-0272-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/10/2017] [Indexed: 11/22/2022]
Abstract
Purpose Patients with implantable cardioverter defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause traffic accidents. However, there are limited data on the magnitude of this risk after inappropriate ICD therapies. We studied the rate of syncope associated with inappropriate ICD therapies to provide a scientific basis for formulating driving restrictions. Methods Inappropriate ICD therapy event data between 1997 and 2014 from 50 Japanese institutions were analyzed retrospectively. The annual risk of harm (RH) to others posed by a driver with an ICD was calculated for private driving habits. We used a commonly employed annual RH to others of 5 in 100,000 (0.005%) as an acceptable risk threshold. Results Of the 4089 patients, 772 inappropriate ICD therapies occurred in 417 patients (age 61 ± 15 years, 74% male, and 65% secondary prevention). Patients experiencing inappropriate therapies had a mean number of 1.8 ± 1.5 therapy episodes during a median follow-up period of 3.9 years. No significant differences were found in the age, sex, or number of inappropriate therapies between patients receiving ICDs for primary or secondary prevention. Only three patients (0.7%) experienced syncope associated with inappropriate therapies. The maximum annual RH to others after the first therapy in primary and secondary prevention patients was calculated to be 0.11 in 100,000 and 0.12 in 100,000, respectively. Conclusions We found that the annual RH from driving was far below the commonly cited acceptable risk threshold. Our data provide useful information to supplement current recommendations on driving restrictions in ICD patients with private driving habits. Electronic supplementary material The online version of this article (doi:10.1007/s10840-017-0272-4) contains supplementary material, which is available to authorized users.
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