Table 2: Recommendations of Driving Restrictions.
| Cardiovascular condition | Driving licence group | Europe | US | Canada | Australia | Japan | |||
|---|---|---|---|---|---|---|---|---|---|
| EHRA (professional guideline) | EC recommendations 2013 (proposal to update Directive 2006/126/EC) | UK | Germany | ||||||
| Guideline | Proposal to update legal document | Legal document | Legal document | Guideline | Legal document | Guideline | Legal document | ||
| Syncope | Group 1 | - | 1. Single syncope or recurrent syncopal episodes occurring in known low-risk circumstances – no restrictions. 2. All other cases of recurrent syncopal episodes – no driving for 6 months. |
1. Isolated 1.1. typical vasovagal: a) if standing – no restriction b) if sitting – may drive only if risk of recurrence is <20%/year 1.2. unexplained: no driving for 6 months if no cause identified. 2. Recurrent 2.1. typical vasovagal, with prodrome a) while standing – no restrictions b) while sitting: may drive if risk of recurrence is <20%/year. 2.2. vasovagal without prodrome /unexplained: no driving for 12 months. |
1. Isolated – no restrictions. 2. Recurrent – no driving for >6 months, pending additional investigations. |
1. Mild – no restrictions. 2. Severe, treated – no driving for 3 months. 3. Severe, untreated – no driving until effective treatment established. |
1. Typical vasovagal - isolated – no restrictions - recurrent within 12 months – no driving for 1 week. 2. Unexplained - isolated – no driving for 1 week - recurrent within 12 months – no driving for 3 months. |
1. Typical vasovagal with cause unlikely to occur while driving – no restrictions. 2. Cardiovascular syncope – no driving for 4 weeks. 3. Isolated unexplained blackout – no driving for 6 months, then to annual review. 4. Recurrent unexplained blackouts – no driving for 12 months, then to annual review. |
1. Isolated – no restrictions. 2. Recurrent / severe – no driving until symptom control. 3. Unexplained – no restrictions, unless severe structural heart disease, no prodrome, or occurring while driving (no driving until treatment established). |
| Group 2 | - | 1.Single syncope or recurrent syncopal episodes occurring in known low-risk circumstances – no restrictions. 2. All other cases of recurrent syncopal episodes – permanent ban. |
1. Isolated 1.1. typical vasovagal: a) if standing – no driving b) if sitting – no driving for >3 months, requires investigations 1.2. unexplained: no driving for 12 months if no cause identified. 2. Recurrent 2.1. typical vasovagal, with prodrome a) while standing – no driving b) while sitting: no driving, can resume driving only if risk of recurrence is <2%/year 2.2. vasovagal without prodrome / unexplained: no driving for 10 years. |
1. Isolated - no restrictions, in the absence of any indication of a high risk of recurrence. 2. Recurrent – no driving until effective treatment established. |
1. Mild – no driving for 1 month. 2. Severe, treated – no driving for 6 months. 3. Severe, untreated – no driving until effective treatment established. |
1. Typical vasovagal 1.1. isolated – no restrictions 1.2. recurrent within 12 months – no driving for 1 year. 2. Unexplained 2.1. isolated – no driving for 1 year 2.2. recurrent within 12 months – no driving for 1 year. |
1. Typical vasovagal with cause unlikely to occur while driving – no restrictions. 2. Cardiovascular syncope – no driving for 6 months. 3. Isolated unexplained blackout – no driving for 5 years, then to annual review. 4. Recurrent unexplained blackouts – no driving for 10 years, then to annual review. |
1. Isolated – no restriction unless driving with a high-risk activity. 2. Recurrent / severe / unexplained – no driving until effective treatment. |
|
| Supraventricular arrhythmias | Group 1 | - | If history of syncope: no driving until the condition has been satisfactorily controlled /treated. | No driving if arrhythmia caused / is likely to cause incapacity. Resume driving only if cause identified and arrhythmia controlled for at least 4 weeks. |
1. No syncope – no restrictions. 2. Syncope – no driving until effective treatment established. |
1. No / minimal symptoms – no restrictions. 2. Symptoms – no driving until symptoms controlled. |
1. No impaired consciousness – no restrictions. 2. Impaired consciousness – no driving until symptoms controlled, as follows: a) medical therapy – no driving for 3 months b) successful ablation – no restrictions. |
Recurrent arrhythmias causing syncope / presyncope – no driving until definite treatment or according to pacemaker / ICD guidelines. | - |
| Group 2 | - | If history of syncope: no driving until the condition has been satisfactorily controlled /treated and risk of recurrence is low. In case of pre-excitation, driving may only be allowed after specialist assessment. | No driving if arrhythmia caused / is likely to cause incapacity Resume driving only if: underlying cause has been identified; arrhythmia has been controlled for at least 3 months; LV ejection fraction is at least 40%. |
1. No syncope – no restrictions 2. With syncope – no driving for 1 month, need cardiology follow-up |
1. No / minimal symptoms – no restrictions 2. Symptoms – no driving until symptoms controlled |
As per Group 1 | Recurrent arrhythmias causing syncope / presyncope – no driving until definite treatment or according to pacemaker / ICD guidelines | - | |
| Ablation | Group 1 | - | - | Resume driving after 2 days. | - | After recovery from the procedure. | No driving for 2 days after discharge. | No driving for 2 days. | - |
| Group 2 | - | - | 1. arrhythmia not causing incapacity: no driving for 2 weeks. 2. arrhythmia causing incapacity: no driving for 6 weeks. |
- | After recovery from the procedure. | No driving for 1 week after discharge. | No driving for 4 weeks. | - | |
| Pacemaker | Group 1 | - | Driving allowed after adequate function and wound healing (no time limit). | No driving for 1 week. | Can drive anytime. | Can drive anytime (but no driving for 1 week if pacemaker dependant). | No driving for 1 week, and correct pacemaker function. | No driving for 2 weeks. | No driving for 1 week. |
| Group 2 | - | Driving allowed after adequate function and wound healing (at least 2 weeks). | No driving for 6 weeks. | No driving for 1 week (4 weeks if dependant or history of syncope). | Can drive anytime (but no driving for 4 weeks if pacemaker dependant). | No driving for 1 month, and correct pacemaker function. | No driving for 4 weeks. | No driving until pacemaker integrity confirmed. | |
| ICD – secondary prevention | Group 1 | Post-implant: No driving for 3 months. ICD therapies: - |
1. Post-implant: No driving for 3 months. 2. ICD therapies: 2.1. appropriate: no driving for 3 months; 2.2. inappropriate: no driving until measures are taken to prevent inappropriate therapies. |
No driving for: 1. After implant – 6 months. 2. Lead revision – 1 month. 3. Box change – 1 week. 4. Appropriate ATP or shock, associated with symptoms, but NO incapacity – 6 months. 5. ANY therapy with incapacity (ATP/shock; appropriate/inappropriate) – 2 years, except: a) inappropriate shocks because of AF / programing issues – 1 month b) appropriate ATP/shocks for VT/VF but steps to control arrhythmia were taken (antiarrhythmics, ablation) and no recurrence – 6 months. |
No driving for: 1. After implant – 3 months. 2. Lead revision – 1–2 weeks. 3. Box change – 1 week. 4. ICD therapies: 4.1. appropriate ATP/shock – 3 months 4.2. inappropriate shock – can drive once cause removed. |
No driving for 6 months. | No driving for: 1. After implant – 1 week, plus post-VT/VF banning period: a) 3 months after last sustained VT episode without impaired consciousness b) 6 months after syncopal VT/VF. 2. Post-therapies associated with impaired consciousness or disabling symptoms – 6 months. |
No driving for: 1. After implant – 6 months after cardiac arrest (or 2 weeks after implant, whichever the longest). 2. Post-therapies associated with symptoms of haemodynamic compromise – 4 weeks. 3. Generator change – 2 weeks. |
No driving for: 1. After implant: 6 months. 2. Post-therapies: 2.1. appropriate, no driving for 3 months 2.2. inappropriate: a) no symptoms – no restrictions b) syncope – 3 months. 3. Generator change – 1 week. |
| Group 2 | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | |
| ICD – primary prevention | Group 1 | No driving for 4 weeks. ICD therapies: - |
No driving for: 1. Post-implant – 2 weeks. 2. ICD therapies: 2.1. appropriate – no driving for 3 months 2.2. inappropriate – no driving until measures are taken to prevent inappropriate therapies. |
No driving for: 1. Post-implant – 1 month. 2. All others as per secondary prevention. |
Post-implant: No driving for 1–2 weeks. | Post-implant: No driving for 1 week | No driving for: 1. After implant – 4 weeks. 2. Post-therapies associated with impaired consciousness or disabling symptoms – 6 months. |
No driving for: 1. After implant – 2 weeks. 2. Post-therapies associated with symptoms of haemodynamic compromise – 4 weeks. 3. Generator change – 2 weeks |
No driving for: 1. Post-implant – 1 week. 2. Post-therapies: 2.1. appropriate, no driving for 3 months 2.2. inappropriate: a) no symptoms – no restrictions b) syncope – 3 months. 2. Generator change – 1 week. |
| Group 2 | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban. | Permanent ban but may drive if risk of events is <1%/year. | Permanent ban. | Permanent ban. |
Recommendations of driving restrictions in patients at risk of syncope and cardiac arrhythmias associated with sudden incapacity, in different countries. The type of document (legal or guidelines only) is also displayed. Adapted from: Watanabe E et al.[10]; DVLA 2018[33]; Task Force members 2009[34]; Epstein et al. 1996[35]; Epstein et al. 2007[36]; Klein et al.[37]; EUR-Lex Directive 2006/126/EC[39]; The Expert Group on Driving and Cardiovascular Disease[40]; Lococo et al.[42]; Canadian Council of Motor Transport Administration[43]; Austroads[44; Oginosawa et al.[45]; Sumiyoshi.[46] AF = atrial fibrillation; ATP = antitachycardia pacing; EC = European Commission; EHRA = European Heart Rhythm Association; VT = ventricular tachycardia