Health Nuts and Bolts

Cited: MedPage Today

European guidelines have changed to allow patients a shorter waiting.  Get back on the road after receiving an implantable cardioverter defibrillator (ICD).  They only have to wait three months after the ICD placement for secondary prevention of sudden cardiac arrest according to new European Heart Rhythm Association (EHRA) guidelines

This update cuts in half the length of time before a return to driving previously recommended by the EHRA and still recommended by the American Heart Association and Heart Rhythm Society.  Richard L. Page, MD, president of the Heart Rhythm Society, said that the change is reasonable and follows a general trend to reduce the duration of driving restrictions, although no changes in the AHA/HRS guidelines are expected.

Action Points

Explain to interested patients that American guidelines recommend waiting six months to return to driving after implantation of an ICD for secondary prevention and one week after implantation for primary prevention.

Note that the guidelines do not reflect national or state regulations or law enforcement on driving restrictions after ICD placement.

“It can be very frustrating for patients who have this sort of limitation on driving when it’s much longer than this,” he said, “especially in comparison to previous years when patients were required to wait six or 12 months if they were allowed to resume driving at all.”

Compliance with the recommendations has been a problem, he noted.  The EHRA taskforce behind the guideline update — led by Johan Vijgen, MD, of Virga Jesse Hospital in Hasselt, Belgium — agreed that improving adherence is a pivotal issue along with adequate education at discharge and follow-up.

The taskforce emphasized that the risk of sudden incapacitation in these patients while driving — which could pose a public safety threat — stems mainly from their underlying condition rather than the ICD itself.

The taskforce’s review of the literature in the secondary prevention population turned up retrospective and survey- or interview-based studies suggesting no higher risk of patient fatality or traffic accident risk than seen in the general population.

Nevertheless, the most influential evidence in making the six-month recommendation was from a prospective study of patients largely treated with antiarrhythmic drug therapy rather than ICDs.  It showed that most syncope, sudden death, and recurrent ventricular fibrillation or hemodynamically-compromising tachycardia events occurred in the first month after discharge from the hospital and was only moderately elevated for the next seven months.  Compelling evidence came out to challenge these recommendations, though, in 2007.

The prospective TOVA study revealed that the absolute risk of an ICD shock within one hour of driving was low and occurred primarily in the 30 minutes after driving (relative risk 4.46, 95% confidence interval 2.92 to 6.82) rather than during driving itself (RR 1.05, 95% CI 0.48 to 2.30).

Based on those findings, the guidelines taskforce decided to shorten the driving restrictions but not below three months, “since patients resuscitated for cardiac arrest very often need extensive time to recover from the event,” they said.

“Patients should have an assessment of their functional class and cognitive functions before resumption of driving,” they added.  The literature review for risks after ICD implantation for primary prevention confirmed the generally lower risk for sudden incapacitation while driving; leading the taskforce to conclude that there is no need for driving restrictions after recovery from the procedure.

However, because patients need to refrain from extensive use of the arm on the side of implantation in the first weeks after the procedure to prevent complications, the updated guidelines recommend delaying driving until after a system integrity check at least four weeks post implant.

This is a more conservative recommendation than the one-week restriction imposed by the AHA/HRS guidelines, Dr. Page noted.  Other recommendations in the European guideline update include:

• A three-month driving restriction after an appropriate ICD shock
• No driving after an inappropriate ICD shock until measures are taken to prevent another
• A one-week delay in return to driving after replacement of the ICD
• A four-week driving restriction after replacement of the lead system
• No restriction for patients refusing an ICD for primary prevention
• A seven-month restriction for patients refusing ICD implantation for secondary prevention

Of course, these guidelines are for noncommercial drivers and not professional drivers of commercial vehicles who were recommended to have permanent restrictions.  The guidelines, hopefully, will serve to unify the varying national driving policies across Europe; at least that is what the taskforce hopes for.  It was noted by Dr. Page that in the US, individual states do not have consistent regulations, but they do have uniform national guidelines.

“In every case, I would just recommend that doctors be aware of their local regulations and that they advise their patients to make sure that they are aware and abide by the local rules regarding driving,” he said.

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My Take: These guidelines sound very reasonable to me.  I just wonder why the US has not followed their example.  Do we hear in the US know something your does not?  Maybe a little research into the matter might reveal a few things.

I do know that the US has many restrictions for people who have any kind of medical problem.  I also understand the reasoning behind those restrictions.  If someone, who has a severe disability, has the chance of causing an accident, it is best to restrict that person’s ability to drive.  I for one, have a disability that could conceivably result in a car accident.  However, I beat my Dr. to the punch and stop driving before they could restrict me.  I know, that there is a possibility of not being able to use my hands to properly steer the vehicle and avoid an accident.  However, many people are too stubborn to admit that they may not be able to drive.

As teenagers, we fight hard to get that driver’s license because it is a symbol of adulthood.  Once we have it, we do not want to lose it because it is part of being an adult.  I think many people who face the possibility of losing their license because of a disability or impairment seem to think it reduces their status as an adult.  Others, lose their license because of simple stupidity like driving while intoxicated or not paying all of their tickets.

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