Driving restrictions in patients with an implantable cardioverter-defibrillator
- Ann C Garlitski, MD, FACC, FHRS
Ann C Garlitski, MD, FACC, FHRS
- Assistant Professor of Medicine
- Hofstra North Shore-LIJ School of Medicine
- Hofstra University
The implantable cardioverter-defibrillator (ICD) improves survival in patients who have been resuscitated from ventricular fibrillation or unstable ventricular tachycardia (ie, secondary prevention of sudden cardiac death). Compelling data indicate that the ICD is also effective in the primary prevention of sudden cardiac death (SCD) in select high risk patients. (See "Secondary prevention of sudden cardiac death in heart failure and cardiomyopathy" and "Overview of sudden cardiac arrest and sudden cardiac death".)
Most ICD candidates are ambulatory and appear well enough to drive an automobile. However, due to the risks of ventricular arrhythmias and ICD shocks, there are concerns about the risks associated with driving in this population. This topic will review issues related to driving in patients with an ICD.
CONCERNS WITH DRIVING
Concerns about driving center on the risk of symptomatic ventricular tachyarrhythmias and/or ICD discharge. More specifically, the risks associated with driving are based upon the likelihood that such events could impair consciousness and the patient's ability to control the vehicle. Driving, therefore, carries risk for the patient, other occupants of the vehicle, and persons outside of the vehicle. The extension of risk to others makes this issue a public health concern. Data regarding the risks associated with driving with an ICD are primarily retrospective, with no prospective trials that have randomized patients to driving with or without restrictions, and recommendations are based primarily on expert opinion and public policy.
Mechanisms of risk — Both ventricular arrhythmias and the actions of the ICD itself can potentially interfere with driving by several mechanisms:
●Sudden cardiac death – Although ICDs improve survival, they do not entirely eliminate the risk of sudden cardiac death (SCD). Data from major trials indicate that the rate of SCD among patients who receive an ICD for secondary prevention is one to two percent per year [1-3]. Similar or slightly lower SCD rates have been reported in major primary prevention trials [4-6].
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- CONCERNS WITH DRIVING
- Mechanisms of risk
- Overall incidence of ventricular arrhythmias and ICD shocks
- - In patients treated for secondary prevention
- - In patients treated for primary prevention
- - Predictors of events
- - Risk factors for syncope
- - Potential benefit of antiarrhythmic drugs
- Inappropriate ICD shocks
- INCIDENCE OF ICD SHOCKS WHILE DRIVING AND ACCIDENTS
- ICD shocks while driving
- RECOMMENDATIONS OF OTHERS AND STATE LAWS
- Patients with an ICD placed for secondary prevention
- Patients with an ICD placed for primary prevention
- Patients with nonsustained arrhythmias but without an ICD
- State laws
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS