Abstract
Background
Medical students are taught little or nothing about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire competence in traffic medicine in order to be able to advise them about their fitness to drive.
Methods
We present the current governmental regulations and recommendations concerning fitness to drive in patients with cardiovascular disease. We also review pertinent publications that were retrieved by a selective search in PubMed with the search terms “cardiovascular disease and traffic accidents” and “cardiovascular disease and traffic deaths” for the decade 2007–2016, as well as further publications collected by us individually.
Results
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 (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, aneurysm rupture) and marked general weakness (e.g., after major surgery or in cardiac insufficiency).
Conclusion
Patients with cardiovascular disease should be advised by their physicians about their fitness to drive, and the discussion should be documented in writing. Because of the German law on the confidentiality of medical data, only the affected patient should receive this information, with very few exceptions.
With few exceptions, any person driving a motor vehicle on public roads must be in possession of a driving license. Individuals in possession of a driving license are regarded as fit to drive if they can meet the physical and mental demands of dealing with road traffic. If a person with a driving license has any physical or mental disability, § 2, paragraph 1 of the German Driving License Regulations (FeV, Fahrerlaubnisverordnung) provides that he or she may only drive if care is taken to ensure that other road users are not put at risk. This is a question that particularly affects patients with chronic diseases (1). Chronic diseases are covered in Appendix 4 of the German Driving License Regulations. They include visual and hearing impairments, impaired mobility, cardiovascular disease, diabetes mellitus, neurological disease, mental disorders, and drug and/or alcohol addiction. Appendix 4 of the German Driving License Regulations details the circumstances under which persons with any of these chronic conditions are fit to drive or have restrictions laid on their fitness to drive. Restricted fitness to drive usually involves regular testing, expert medical opinion, or restrictions on motor vehicle type or driving time, which are specified in reports from experts in traffic medicine. The term „fitness to drive“ (Fahreignung) refers to expected long-term capacity to drive, whereas the term „ability to drive“ (Fahrtüchtigkeit) refers to the driver‘s ability in their current state of health to control a vehicle over a long distance even in difficult traffic situations (1).
Permission to drive.
If the holder of a driving license has any physical or mental disability, he or she may only drive if precautions have been taken to ensure that other road users are not put at risk.
At medical school, medicine in relation to road safety is a subject that is barely touched upon, if at all (2). However, to be able to tell a patient with cardiovascular disease that he or she is not fit to drive, the treating physician must have acquired some knowledge of traffic medicine. Cardiovascular disease that can render a patient unfit to drive includes coronary heart disease, myocardial infarction, cardiac insufficiency of various etymologies, brady- or tachyarrhythmias with or without pacemaker/defibrillator implantation, and syncope. Assessment of fitness to drive is based on Appendix 4 of the German Driving License Regulations (FeV) and on the Assessment Guideline issued by the German Federal Highway Research Institute (BAST, Bundesanstalt für Straßenwesen), which implement European Union standards in Germany. The present article reproduces the contents of these documents in shortened form.
Learning goals
After reading this article, readers should
know which legal provisions govern assessment of a patient‘s fitness to drive.
be able to assess a patient‘s fitness to drive in accordance with current guidelines.
know when it would be appropriate to consult a physician specializing in traffic medicine.
Road accidents following cardiovascular events
Cardiovascular disease can lead to accidents due to sudden loss of control by drivers. The most important pathophysiological mechanisms behind sudden loss of control of this kind are:
cerebral perfusion disorders (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death in patients with ventricular fibrillation or asystole, stroke, aneurysm rupture) or
pronounced general weakness (after major surgery or severe heart failure).
Other diseases that can likewise lead to accidents include alcohol or drug consumption, epileptic seizures, hypoglycemia in patients with diabetes mellitus, daytime fatigue related to sleep apnea, cognitive disorders in persons suffering from psychosis, or disturbances of vision following a stroke.
Assessment of fitness to drive.
Assessment of fitness to drive is governed by Appendix 4 of the FeV and on the Assessment Guideline issued by the German Federal Highway Research Institute (BAST), which implement European Union standards in Germany.
Coronary heart disease the main cause of death.
According to a retrospective German study, about 0.4% of road deaths are of persons who die a sudden natural death at the wheel. Among these, the main cause of death is coronary heart disease.
Group 1 drivers.
Group 1 drivers can, for example, continue to drive with NYHA stage I, II, or III heart disease, even if their physical activity is limited or symptoms occur with only mild activity.
Group 2 drivers.
Group 2 drivers must always, or from a given age onwards, have their fitness to drive assessed every 5 years. The requirements relating to disease in this group are stricter than those for Group 1 drivers.
Disease as a cause of road traffic accidents is not recorded in Germany, and only a very vague estimate of its incidence can be made. Old (1963) data from England suggest that about 1.5 out of every 1000 accidents are caused by sudden illness of the driver, and chronic illness may have been a factor in 5 out of 1000 accidents (3). A retrospective study of fatal road accidents in Finland and Switzerland concluded that about 2.5% of road deaths in Finland between 1984 and 1989 and 6.4% of road deaths in the Swiss canton of Waadt between 1986 and 1989 were related to a driver‘s sudden loss of consciousness at the wheel (4). According to a retrospective study in Germany, about 0.4% of road deaths are of persons who die a sudden natural death at the wheel. Among these, the main cause of death is coronary heart disease (5). In Japan, between 2004 and 2006, 211 cases of sudden incapacity to drive were notified to the Ministry of Transport; these were due to cerebrovascular disease (28.4%), cardiac and aortic disease (26.1%), syncope (8.5%), and gastrointestinal disease (8.1%). In 64.7% of these cases an accident occurred. Thirty-six percent of the drivers died immediately of their illness (6). According to other studies, disease-related road traffic accidents occur more often. A retrospective study in Finland estimates that in 20% to 30% of all fatal road accidents involving persons over 65 years of age, impaired concentration due to disease may have been involved, and in most cases (70%) the disease is cardiovascular (7). An autopsy study from Canada also suggests that coronary heart disease in drivers over the age of 60 plays an important role in road accidents. In this age group, 86% of drivers who died at the wheel had significant coronary heart disease. Of these, 40% had been driving erratically before the accident, and this was inferred to be due to loss of control caused by acute myocardial ischemia (8). In patients with acute myocardial ischemia, the main concerns are tachyarrhythmias such as ventricular tachycardia or ventricular fibrillation. In Ontario, Canada, patients who were regarded by their physician as unfit to drive were reported to the licensing authority. Loss of fitness to drive could result from diseases such as alcoholism, epilepsy, dementia, syncope, or cardiovascular disease. From April 2006 to December 2009, more than 100 000 patients received a warning from over 6000 physicians about their fitness to drive. Before receiving the warning, each year 0.476% of these drivers had been treated in an emergency department in Ontario because of a road accident in which they had been involved as a driver. After the warning, the annual rate of emergency department visits due to a road accident dropped to 0.273%, meaning that in this patient group this preventive measure reduced the accident rate by about 45%. Nevertheless, the accident rate was still higher than among the general population in Ontario (9). It may be assumed that disease plays a significant part in road accidents, and that cardiovascular disease as a cause of accidents increases with age (box).
Box. Driving license categories.
For the purposes of assessing fitness to drive, German driving licenses fall into two groups. Group 1 contains categories A, A1, A2, B, BE, AM, L, and T. This group, referred to for simplicity as „private drivers,“ includes the driving of motorcycles, cars, trucks up to 3.5 tons weight overall, and tractors. Group 2, referred to for simplicity as „occupational drivers,“ includes the driving license categories C, C1, CE, C1E, D, DE, D1E, and FzF. These categories include the driving of trucks >3.5 tons weight overall or commercial vans and commercial passenger transport (e.g., buses, taxis, hire cars, ambulances). The medical standards applied to assessing group 2 drivers are generally higher than those applied to group 1 drivers. For example, Appendixes 5 and 6 of the German Driving License Regulations lay down that from a certain age onwards, drivers in group 2 must have their fitness to drive assessed every 5 years.
Loss of fitness to drive.
In Canada, loss of fitness to drive was caused by diseases such as alcoholism, epilepsy, dementia, syncope, and cardiovascular disease.
Confidentiality and the duty to inform
Treating physicians are under an obligation to tell their patients if they believe they are unfit to drive, and to record the fact that they have done so (10). This duty to inform, which previously was based on the medical treatment contract, has since February 2013 been formally laid down in the law governing patient rights as § 630 of the German Civil Code. Under this law, the physician is required to tell the patient all the important facts about his or her illness—and that includes the medical assessment of the patient‘s fitness or otherwise to drive. Withholding such information is held to be a medical treatment error (10).
Confidentiality and fitness to drive.
Because of the confidentiality laws in Germany, the treating physician informs only the patient that he or she is unfit to drive. Informing the authorities is neither required nor permitted.
Because of the confidentiality law in Germany, the only person informed by the physician about a loss of fitness to drive is the patient concerned. Informing the authorities (licensing authority, police) is not required and indeed is not permitted. The topic of patient confidentiality and fitness to drive was discussed extensively at the 50th Road Traffic Law Conference in Goslar in 2012 in Working Group III: Risk to Road Traffic from Disease-Related Impairments of Fitness to Drive and Driving Safety. This working group confirmed what had already been affirmed at the Road Traffic Law Conference in 2005—that in extreme cases the physician is not obligated to maintain confidentiality—and supported the view that in cases of extreme risk the physician has the right to report to the police a patient that the physician regards as medically unfit to drive but who does not agree with this view and is unwilling to cooperate (11). An example given was of a bus driver with acute myocardial infarction who refused admission to hospital for treatment, so that he could drive a class of schoolchildren in his bus. It was not concluded during this discussion that physicians are obligated to break patient confidentiality in cases where there is acute risk. If the patient asks the physician to produce a report on his or her fitness to drive, the obligation to maintain confidentiality is of course removed.
Risk stratification
Concerning risk stratification, the Canadian Cardiovascular Society’s “risk of harm”-formula has become the gold standard for Germany and for the other countries in the European Union (12). This formula says that the probability that cardiac disease in the driver of a vehicle will lead to serious injury to another road user is directly proportional to:
The time spent at the wheel
The type of vehicle being driven (private car, truck)
The annual probability of sudden loss of control („sudden cardiac incapacitation“, SCI).
Risk stratification.
In relation to cardiovascular diseases, the „risk of harm“ formula developed by the Canadian Cardiovascular Society has been adopted for risk stratification in assessment of fitness to drive in Germany and other countries of the European Union.
Given normal hours per day at the wheel (8 hours for commercial drivers, 30 minutes for private drivers), unfitness to drive is assumed when the probability of sudden loss of control (syncope, sudden cardiac death, stroke) is >1% per year for an occupational driver and >22% per year for a private driver (12). The use of the „risk of harm“ formula is discussed in detail in the German Cardiac Society‘s position paper on fitness to drive in patients with cardiovascular disease (13). This formula served as the basis for assessment of fitness to drive of persons with cardiovascular disease both in the German Cardiac Society‘s position paper (13) and in the unpublished recommendations of the European Union, „New Standards for Driving and Cardiovascular Diseases,“ Brussels 2013, which for Germany are implemented in the current BAST recommendations regarding fitness to drive in patients with cardiovascular disease. However, the distinction made in the „risk of harm“ formula between bus drivers and taxi drivers in regard to fitness to drive was not adopted by the Brussels Expert Advisory Panel, and hence was not adopted by the BAST in Germany either. The Brussels Expert Advisory Panel agreed to treat all occupational drivers of passenger transport vehicles as the same, even though the general risk of bus drivers is estimated to be much higher than that of taxi drivers.
Requirements and recommendations for the assessment of fitness to drive
At present, the currently applicable requirements of Appendix 4 of the German Driving License Regulations (14) and the BAST recommendations (15) relating to cardiovascular disease must be adhered to. Both of these are currently available only on the Internet. All the tables displayed in the present article are drawn from the official requirements of the Driving License Regulations and the assessment guidelines of the BAST.
Compared with the BAST recommendations, Appendix 4 of the Driving License Regulations is couched in more general terms and goes into fewer diseases in detail. As a legal instrument, the requirements of this Appendix must be adhered to. Every assessment of fitness to drive must be undertaken on an individual basis. Factors that increase risk at the wheel—for example, several risk-promoting chronic diseases—or factors that reduce risk—for example, driving only rarely—must be included in the assessment. The position paper published by the German Cardiac Society on fitness to drive in patients with cardiovascular disease (13) helped to push forward a review of the official regulations and guidelines, and was used by the Expert Advisory Panel in Brussels as the basis for their recommendations. Today it has lost some of its importance since the revised official regulations reflect a more up-to-date state of scientific knowledge.
Regulations and recommendations regarding assessment of fitness to drive.
At the present time, the current regulations of Appendix 4 of the FeV and the recommendations of the BAST relating to cardiovascular disease must be adhered to.
An abbreviated extract from the current regulations in Appendix 4 of the German Driving License Regulations relating to fitness to drive in patients with cardiovascular disease (16) is shown in Table 1. Follow-up assessments are not shown in Table 1. Where „Case-by-case decision“ is shown for patients with systolic blood pressure >180mmHg, the physician must consider carefully whether he or she believes the patient to be fit to drive. A value >180 mmHg could be 185 mmHg, which could be tolerated, or it could be 250 mmHg, which in an occupational driver would suggest unfitness to drive. To date there have been no scientific studies to establish a threshold value for blood pressure in relation to fitness to drive. The entry „May be fit to drive after 4 to 6 weeks“ means that the patient will be fit to drive after this time so long as no events occur during in the interim that would count against fitness to drive. An example of such an event might be symptomatic ventricular tachycardia.
Table 1. Extract from Appendix 4 of the German Driving License Regulations relating to fitness to drive of individuals with cardiovascular disease.
| Diagnosis |
Group 1 (private) drivers Fit to drive: yes/no |
Group 2 (occupational) drivers Fit to drive: yes/no |
|
4.1 Cardiac arrhythmia with episodes of impaired consciousness or loss of consciousness – After successful treatment with medication or cardiac pacemaker |
No Yes |
No Yes |
|
4.2 Hypertension (blood pressure too high) 4.2.1 Elevated blood pressure with cerebral symptoms and/or visual disturbances 4.2.2 Blood pressure >180 mmHg (systolic) and/or 110 mmHg (diastolic) |
No Usually yes |
No Case-by-case decision |
|
4.3 Hypotension (blood pressure too low) 4.3.1 Usually no relevant health impairment 4.3.2 Rarely, hypotension-related sudden episodes of impaired consciousness |
Yes Yes, if blood pressure values are stabilized by treatment |
Yes Yes, if blood pressure values are stabilized by treatment |
|
4.4 Acute coronary syndrome (myocardial infarction) – EF >35% – EF <35% or acute decompensated heart failure in the context of acute myocardial infarction |
Yes if no complications May be fit to drive 4 weeks after the event |
May be fit to drive 6 weeks after the event Usually no |
|
4.5 Heart failure due to congenital or acquired heart defects or other causes – NYHA I (cardiac disease without limitation of physical activity) – NYHA II (slight limitation of physical activity) – NYHA III (symptoms occur during mild activity) – NYHA IV (symptoms occur at rest) |
Yes Yes Yes (if stable) No |
Yes, if EF >35% Yes, if EF >35% No No |
|
4.6 Peripheral arterial occlusive disease – With pain at rest – After intervention – After surgery – Aortic aneurysm, asymptomatic |
No Yes after 24 hours Yes after 1 week No restriction |
No Yes after 1 week Yes after 4 weeks No restriction if aneurysm diameter up to 5.5 cm. Unfit to drive if aneurysm diameter >5.5 cm |
EF, left ventricular ejection fraction; NYHA, New York Heart Association classification of heart failure
The BAST guidelines on fitness to drive in persons with cardiovascular disease, which have applied since December 2016, go into some detail about patients with various arrhythmias, cardiac pacemakers and/or implanted defibrillators (ICDs), arterial hypertension, coronary heart disease including acute myocardial infarction, arterial occlusive disease, aortic aneurysm, heart valve disease, cardiomyopathies, rare ion channel diseases, heart failure, and syncope. Some of the most important of these disease entities are dealt with in more detail below.
Blood pressure and fitness to drive.
No scientific studies have been carried out to define a threshold value for blood pressure in relation to fitness to drive.
Pacemakers and implanted defibrillators (ICDs) and fitness to drive
Pacemakers and ICDs.
Group 2 drivers with a functioning cardiac pacemaker are fit to drive after 1 week. Patients with ICDs are usually unfit to be group 2 drivers.
The indications for ICD and pacemaker treatment are given in the current guidelines of the European Society of Cardiology and the German Cardiac Society (17, 18). The now-updated recommendations from BAST on fitness to drive differ considerably from the previous ones in regard to patients with pacemakers and ICDs. Group 2 drivers with a functioning cardiac pacemaker are now held to be fit to drive after 1 week. Group 2 drivers who experienced syncope before the pacemaker was implanted, or who are is dependent on the pacemaker, are not fit to drive until 4 weeks have elapsed. Patients with ICDs are usually unfit to be group 2 drivers. However, it is not the presence of the ICD but the heart condition that makes them unfit to drive. In some cases, the heart condition of a patient with an ICD may improve (e.g., healing of myocarditis), so that after a time the ICD is no longer indicated. In an individual case of this kind, even a patient with an ICD could be an occupational driver. Table 2 shows the BAST guidelines for patients with cardiac pacemakers and defibrillators. After an appropriate ICD shock in a patient with ventricular tachycardia or ventricular fibrillation, fitness to drive may be assumed in the absence of any new dangerous arrhythmic event that is treated with a shock within the subsequent three months. This recommendation is also supported by the findings of a large study of 2786 patients who had ICDs placed for primary or secondary prevention of sudden cardiac death (19). Even though the driving restrictions for patients with ICDs have been scientifically proven to be well founded, it has been found that 35% do not obey these restrictions (20). If the treating physician is in doubt about the fitness of a patient with a pacemaker or defibrillator to drive, he or she should contact physicians in the center in which the device was implanted.
Table 2. Pacemakers/implanted defibrillators (ICDs) and fitness to drive*.
| Measure |
Group 1 (private) drivers |
Group 2 (occupational) drivers |
| With implanted pacemaker or replacement pacemaker | No restriction | Fit to drive after 1 week (after 4 weeks if history of syncope or dependent on pacemaker) |
| ICD | ||
| For primary prevention | Fit to drive after 1–2 weeks | Usually unfit to drive |
| For secondary prevention | Fit to drive after 3 months | Usually unfit to drive |
| After appropriate shock | Usually fit to drive after 3 months | Usually unfit to drive |
| After inappropriate shock | Fit to drive after underlying cause has been removed | Usually unfit to drive |
| After box change | Fit to drive after 1 week | Usually unfit to drive |
| After electrode change/revision | Usually fit to drive after 1–2 weeks | Usually unfit to drive |
| Recurrent ventricular tachycardia | Case-by-case decision, cardiological examination | Usually unfit to drive |
| ICD refused | For primary prevention: no restriction; For secondary prevention: fit to drive after 6 months |
Usually unfit to drive |
*Adapted from (14)
Fitness to drive after syncope
ICD shock in patients with ventricular tachycardia or ventricular fibrillation.
Fitness to drive is assumed if no new dangerous arrhythmia event has occurred in a 3-month period.
Fitness to drive after syncope.
It may be assumed that patients who experience syncope at the wheel show the same range of causes of syncope as those who experience syncope in other circumstances.
Patients with syncope are a very heterogeneous group, with varying degrees of severity of disease (21). In all cases, an attempt should be made to identify the precise cause of the syncope, so that a mechanism-specific treatment can be implemented. Causes of loss of consciousness include the vasovagal, cardiac, orthostatic, and neurological syncope, as well as those not otherwise classified (22). It may be assumed that patients who experience syncope at the steering wheel have the same range of causes of syncope as those who experience syncope in other circumstances (21). About 87% of patients with syncope at the wheel experience prodromal symptoms, which if correctly interpreted can allow them to find a safe place to stop (23). Syncope patients should be informed about the possibility that their syncope may recur, so that if they experience prodromal symptoms they can stop their vehicle. A defensive driving style should always be recommended. According to a recent Danish study, it may be assumed that the accident risk of individuals with syncope is double that of the general population for at least the 2 years following hospital admission for syncope (24). Table 3 shows the current BAST guidelines on fitness to drive of patients with syncope. Individual assessment may result in a judgment that the patient may be fit to drive despite recurrent syncope, if the syncope is not associated with driving. This is the case, for example, for syncope associated with medical procedures (e.g. venipuncture) or after being on the toilet (micturition, defecation).
Table 3. Syncope and fitness to drive.
|
Group 1 (private) drivers |
Group 2 (occupational) drivers |
|
| After first episode of syncope | No restriction | No restriction, in the absence of any indication of a high risk of recurrence |
| Recurrent (unexplained) syncope | Further diagnostic investigation; fit to drive after 6 months at the earliest; case-by-case decision | Usually unfit to drive; case-by-case decision |
Acute coronary syndrome (ACS) and/or stable coronary heart disease (CHD) and fitness to drive
Patients with syncope.
should be informed about the possibility of recurrence, so that if prodromal symptoms occur they can stop the car. A defensive driving style should always be recommended.
Table 4 shows the BAST guidelines on fitness to drive of persons with acute coronary syndrome and/or coronary heart disease. These recommendations also differ fundamentally from earlier BAST recommendations. Regarding myocardial infarction, no distinction is now made between a first myocardial infarction and a recurrence, nor between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). The highest risk of dying of a myocardial infarction is during the first 10 days after the onset of the infarction (25). It may be assumed that about one-third of cardiovascular deaths after myocardial infarction are sudden cardiac deaths (26). In the BAST guidelines, the most important prognostic parameter in determining fitness to drive is now left ventricular ejection fraction (EF). Since many large studies have set the primary preventive indication for an ICD at EF <35%, this threshold value for restricted ventricular function after myocardial infarction has also been chosen by the European Union Expert Advisory Panel for unfitness to drive. Patients with group 2 driving licenses and an EF <35% are always unfit to be occupational drivers.
Table 4. Acute coronary syndrome, stable coronary heart disease, and fitness to drive*.
|
Group 1 (private) drivers |
Group 2 (occupational) drivers |
|
| Acute coronary syndrome (myocardial infarction) | Fit to drive if no complications (EF >35%). EF <35% or acute decompensated heart failure in the context of an acute infarction: may be fit to drive after 4 weeks; case-by-case decision | EF >35%: may be fit to drive after 6 weeks. EF <35% unfit to drive |
| Stable angina pectoris | No restriction | Symptomatic angina on mild exertion: unfit to drive |
| After PCI | No restriction after PCI and good clinical result | Fit to drive 4 weeks after good clinical result; annual cardiological review |
| Coronary bypass operation | Fit to drive after 2–4 weeks | Fit to drive after 3 months |
EF, left ventricular ejection fraction; PCI, percutaneous coronary intervention
*Adapted from (14)
Acute coronary syndrome and stable coronary heart disease.
Group 2 drivers with these diseases and an EF <35% are always unfit to be occupational drivers.
Bradyarrhythmias and fitness to drive
Patients with bradyarrhythmias (heart rate <50 to 60/min) are at risk of reduced cerebral perfusion leading to syncope. The higher the estimated risk of syncope, the more likely it is that the patient is unfit to drive. If a patient fulfills the criteria defined in the current guidelines of the German Cardiac Society for implantation of a cardiac pacemaker, it must be carefully considered whether that patient is fit to drive without a pacemaker. The current BAST recommendations regarding fitness to drive and bradyarrhythmias are summarized in Table 5.
Table 5. Bradyarrhythmias and fitness to drive*.
|
Group 1 (private) drivers |
Group 2 (occupational) drivers |
|
|
SA block – Without syncope – With syncope |
No restriction Unfit to drive until treated effectively, thereafter see Pacemaker (PM) |
No restriction Unfit to drive until treated effectively, thereafter see Pacemaker (PM) |
| AV block I | No restriction | No restriction |
|
AV block II (Mobitz) – Without syncope – With syncope |
May be fit to drive until PM implanted Unfit to drive until treated effectively, usually with PM |
May be fit to drive until PM implanted Unfit to drive until treated effectively, usually with PM |
| AV block III (congenital) | No restriction provided no syncope and no criteria indicating PM implantation | Usually unfit to drive |
| AV block III (acquired) | Unfit to drive until treated effectively, thereafter see PM | Unfit to drive until treated effectively, thereafter see PM |
| Left bundle branch block/ right bundle branch block/ hemiblocks | No restriction | No restriction |
| Alternating bundle branch block | Unfit to drive until treated effectively | Unfit to drive until treated effectively |
| Bifascicular block with syncope | Unfit to drive until treated effectively | Unfit to drive until treated effectively |
*Adapted from (14)
AV, atrioventricular; SA, sinoatrial; PM, pacemaker
Tachyarrhythmias and fitness to drive
Depending on heart rate and left ventricular function, tachyarrhythmias (ventricular rate >100/min) can lead to syncope. Patients with tachyarrhythmias should be referred to a cardiologist for better evaluation of the cardiac disease. The main question of interest is whether any cardiological disease is present in addition to the arrhythmia (structural heart disease, e.g. valve disease; hypertensive heart disease; cardiomyopathy) which might be important for the prognosis. Supraventricular tachycardia may be successfully treated by ablation or medication. In patients with ventricular tachycardia, although the most frequent cause is previous myocardial infarction with underlying coronary heart disease, the possibility of various forms of cardiomyopathy or ion channel disease must also be considered. The current BAST recommendations regarding fitness to drive of persons with various tachyarrhymias are shown in Table 6.
Table 6. Selected tachyarrhythmias and fitness to drive*.
|
Group 1 (private) drivers |
Group 2 (occupational) drivers |
|
|
AV nodal reentrant tachycardia /atrial ectopic tachycardia – Without syncope – With syncope |
No restriction Fit to drive after effective treatment |
No restriction Fit to drive 1 month after effective treatment, cardiological follow-up required |
|
WPW syndrome – Without atrial fibrillation, without syncope – With atrial fibrillation – With syncope |
No restriction No restriction Fit to drive after effective treatment |
No restriction After successful ablation Fit to drive 1 month after effective treatment, follow-up by specialist |
| Atrial fibrillation/flutter with syncope | Fit to drive after effective treatment | Fit to drive 1 month after effective treatment, cardiological follow-up |
|
Non-sustained ventricular tachycardia without syncope (NSVT), no structural heart disease |
No restriction | Case-by-case decision, usually fit to drive, cardiological examination required for polymorphous NSVT, Case-by-case decision, may be fit to drive |
|
Ventricular tachycardia with syncope, no structural heart disease |
Fit to drive after effective treatment | Fit to drive 1 month after effective treatment, cardiological follow-up |
|
Non-sustained ventricular tachycardia – Without syncope (NSVT), structural heart disease – With syncope |
Case-by-case decision, usually fit to drive Unfit to drive |
Case-by-case decision, cardiological examination Unfit to drive |
*Adapted from (14)
AV, atrioventricular; WPW, Wolff-Parkinson-White syndrome
'
Bradyarrhythmias.
The higher the estimated risk of syncope, the more likely it is that the individual is unfit to drive. If the individual fulfills the criteria for a cardiac pacemaker, it must be carefully considered whether he or she is fit to drive without a pacemaker.
FURTHER INFORMATION ON CME.
This article has been certified by the North Rhine Academy for Postgraduate and Continuing Medical Education. Deutsches Ärzteblatt provides certified continuing medical education (CME) in accordance with the requirements of the Medical Associations of the German federal states (Länder). CME points of the Medical Associations be acquired only through the Internet, not by mail or fax, by the use of the German version of the CME questionnaire. See the following website: cme.aerzteblatt.de.
Participants in the CME program can manage their CME points with their 15-digit “uniform CME number” (einheitliche Fortbildungsnummer, EFN). The EFN must be entered in the appropriate field in the cme.aerzteblatt.de website under “meine Daten” (“my data”), or upon registration. The EFN appears on each participant’s CME certificate.
This CME unit can be accessed until 7 January 2018, and earlier CME units until the dates indicated:.
„The Treatment of Illnesses Arising in Pregnancy“ (issue 37/17) until 10 December 2017.
„Cystic Fibrosis“ (issue 33–34/17) until 12 November 2017.
Please answer the following questions to participate in our certified Continuing Medical Education program. Only one answer is possible per question. Please select the answer that is most appropriate.
Question 1
A truck driver with stable angina pectoris on strenuous exertion has a coronary stent inserted. There are no complications. At the earliest, when is he or she likely to be fit to drive a truck again?
After 1 day
After 1 week
After 4 weeks
After 3 months
After 6 months
Question 2
A patient with coronary heart disease with left ventricular EF <35% (group 1 driver) refuses to undergo primary preventive implantation of an ICD. How should his fitness to drive be assessed?
Fit to drive after 6 months if no syncope occurs during that period.
Permanently unfit to drive because he lacks the protection provided by an ICD.
Fit only to drive routine local journeys.
Fit to drive up to a limit of 50 km/h.
Fit to drive (no restriction).
Question 3
A taxi driver (group 2 driver) is admitted to the hospital for recurrent syncope. Under what circumstances can the driver continue to be assessed as fit to drive?
The syncope episodes occur exclusively in situations that do not arise while driving (e.g., venipuncture, micturition syncope).
The patient has not yet sustained injury from the syncope episodes.
The syncope episodes are usually preceded by prodromal symptoms.
The syncope episodes started during adolescence.
The syncope is related to AV block III.
Question 4
When does an asymptomatic aortic aneurysm make a group 2 driver unfit to drive?
When it is located in the region of the thoracic aorta.
When it is 4 cm in diameter.
When it has been treated with a stent graft.
When its diameter exceeds 5.5 cm.
When physical effort leads to neurological deficit.
Question 5
Which of the following is used as a measure of heart failure in assessing fitness to drive?
pro-BNP
Left ventricular ejection fraction (EF)
Troponin I
Vital capacity
Peripheral oxygen saturation
Question 6
When can raised blood pressure be a threat to fitness to drive?
When it cannot rapidly be brought down to <140 mmHg (systolic).
When treatment requires five different drugs.
When it is associated with visual and/or cerebral symptoms.
When it is not checked three times a day.
When it does not show a normal nocturnal dip.
Question 7
How would you assess the fitness for occupational driving of Group 2 drivers who have undergone replacement of an implantable defibrillator (ICD) unit?
They are fit to drive 2 weeks after implantation.
They are fit to drive 3 months after implantation.
They are fit to drive 6 months after implantation.
They are fit to drive 12 months after implantation.
They are not fit for occupational driving.
Question 8
A bus driver is admitted to hospital with an acute myocardial infarction. On discharge, his left ventricular ejection fraction (EF) is 30%. What must the bus driver be told when he leaves hospital?
That he is not fit to drive group 2 vehicles because his EF is <35%.
That he may drive a bus again after he has been discharged from hospital.
That he may drive a bus again after rehabilitation treatment.
That he will be able to work as a bus driver again once he has had an ICD implanted.
That he may drive a bus for a maximum of 4 hours a day.
Question 9
How would you assess the fitness of a 75-year-old patient with acute myocardial infarction and pulmonary edema related to the myocardial infarction?
Permanent loss of fitness to drive must be assumed.
The patient may be fit to drive 4 weeks after the event.
The patient may be fit to drive 3 months after the event at the earliest.
The patient may be fit to drive 1 week after the event.
The patient is fit to drive immediately.
Question 10
Whom must the treating physician inform that a patient with cardiovascular disease is unfit to drive?
The police
The driving license authority
The patient
The health authority
The patient‘s next of kin
Footnotes
Conflict of interest statement
Professor Sechtem holds shares in Daimler, VW, General Motors, Ford, and BMW.
Professors Klein and Trappe declare that no conflict of interest exists.
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