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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Causes of death in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. J Am Coll Cardiol 1999; 34:1552.
- Grubman EM, Pavri BB, Shipman T, et al. Cardiac death and stored electrograms in patients with third-generation implantable cardioverter-defibrillators. J Am Coll Cardiol 1998; 32:1056.
- Mitchell LB, Pineda EA, Titus JL, et al. Sudden death in patients with implantable cardioverter defibrillators: the importance of post-shock electromechanical dissociation. J Am Coll Cardiol 2002; 39:1323.
- Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996; 335:1933.
- Kadish A, Dyer A, Daubert JP, et al. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N Engl J Med 2004; 350:2151.
- Hohnloser SH, Kuck KH, Dorian P, et al. Prophylactic use of an implantable cardioverter-defibrillator after acute myocardial infarction. N Engl J Med 2004; 351:2481.
- Bänsch D, Brunn J, Castrucci M, et al. Syncope in patients with an implantable cardioverter-defibrillator: incidence, prediction and implications for driving restrictions. J Am Coll Cardiol 1998; 31:608.
- Wood MA, Stambler BS, Damiano RJ, et al. Lessons learned from data logging in a multicenter clinical trial using a late-generation implantable cardioverter-defibrillator. The Guardian ATP 4210 Multicenter Investigators Group. J Am Coll Cardiol 1994; 24:1692.
- Klein RC, Raitt MH, Wilkoff BL, et al. Analysis of implantable cardioverter defibrillator therapy in the Antiarrhythmics Versus Implantable Defibrillators (AVID) Trial. J Cardiovasc Electrophysiol 2003; 14:940.
- Fogoros RN, Elson JJ, Bonnet CA. Actuarial incidence and pattern of occurrence of shocks following implantation of the automatic implantable cardioverter defibrillator. Pacing Clin Electrophysiol 1989; 12:1465.
- Bardy GH, Hofer B, Johnson G, et al. Implantable transvenous cardioverter-defibrillators. Circulation 1993; 87:1152.
- Freedberg NA, Hill JN, Fogel RI, et al. Recurrence of symptomatic ventricular arrhythmias in patients with implantable cardioverter defibrillator after the first device therapy: implications for antiarrhythmic therapy and driving restrictions. CARE Group. J Am Coll Cardiol 2001; 37:1910.
- Nunain SO, Roelke M, Trouton T, et al. Limitations and late complications of third-generation automatic cardioverter-defibrillators. Circulation 1995; 91:2204.
- Curtis JJ, Walls JT, Boley TM, et al. Time to first pulse after automatic implantable cardioverter defibrillator implantation. Ann Thorac Surg 1992; 53:984.
- Bigger JT Jr. Prophylactic use of implanted cardiac defibrillators in patients at high risk for ventricular arrhythmias after coronary-artery bypass graft surgery. Coronary Artery Bypass Graft (CABG) Patch Trial Investigators. N Engl J Med 1997; 337:1569.
- Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352:225.
- Moss AJ, Schuger C, Beck CA, et al. Reduction in inappropriate therapy and mortality through ICD programming. N Engl J Med 2012; 367:2275.
- Larsen GC, Stupey MR, Walance CG, et al. Recurrent cardiac events in survivors of ventricular fibrillation or tachycardia. Implications for driving restrictions. JAMA 1994; 271:1335.
- Levine JH, Mellits ED, Baumgardner RA, et al. Predictors of first discharge and subsequent survival in patients with automatic implantable cardioverter-defibrillators. Circulation 1991; 84:558.
- Whang W, Mittleman MA, Rich DQ, et al. Heart failure and the risk of shocks in patients with implantable cardioverter defibrillators: results from the Triggers Of Ventricular Arrhythmias (TOVA) study. Circulation 2004; 109:1386.
- Kou WH, Calkins H, Lewis RR, et al. Incidence of loss of consciousness during automatic implantable cardioverter-defibrillator shocks. Ann Intern Med 1991; 115:942.
- Strickberger SA, Cantillon CO, Friedman PL. When should patients with lethal ventricular arrhythmia resume driving? An analysis of state regulations and physician practices. Ann Intern Med 1991; 115:560.
- Abello M, Merino JL, Peinado R, et al. Syncope following cardioverter defibrillator implantation in patients with spontaneous syncopal monomorphic ventricular tachycardia. Eur Heart J 2006; 27:89.
- Rosenqvist M, Beyer T, Block M, et al. Adverse events with transvenous implantable cardioverter-defibrillators: a prospective multicenter study. European 7219 Jewel ICD investigators. Circulation 1998; 98:663.
- Grimm W, Flores BF, Marchlinski FE. Electrocardiographically documented unnecessary, spontaneous shocks in 241 patients with implantable cardioverter defibrillators. Pacing Clin Electrophysiol 1992; 15:1667.
- Albert CM, Rosenthal L, Calkins H, et al. Driving and implantable cardioverter-defibrillator shocks for ventricular arrhythmias: results from the TOVA study. J Am Coll Cardiol 2007; 50:2233.
- Assessment of the cardiac patient for fitness to drive. Can J Cardiol 1992; 8:406.
- Epstein AE, Miles WM, Benditt DG, et al. Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. A medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology. Circulation 1996; 94:1147.
- Merchant FM, Hoskins MH, Benser ME, et al. Time Course of Subsequent Shocks After Initial Implantable Cardioverter-Defibrillator Discharge and Implications for Driving Restrictions. JAMA Cardiol 2016; 1:181.
- Akiyama T, Powell JL, Mitchell LB, et al. Resumption of driving after life-threatening ventricular tachyarrhythmia. N Engl J Med 2001; 345:391.
- Trappe HJ, Wenzlaff P, Grellman G. Should patients with implantable cardioverter-defibrillators be allowed to drive? Observations in 291 patients from a single center over an 11-year period. J Interv Card Electrophysiol 1998; 2:193.
- Jung W, Anderson M, Camm AJ, et al. Recommendations for driving of patients with implantable cardioverter defibrillators. Study Group on 'ICD and Driving' of the Working Groups on Cardiac Pacing and Arrhythmias of the European Society of Cardiology. Eur Heart J 1997; 18:1210.
- Epstein AE, Baessler CA, Curtis AB, et al. Addendum to "Personal and public safety issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations: a medical/scientific statement from the American Heart Association and the North American Society of Pacing and Electrophysiology": public safety issues in patients with implantable defibrillators: a scientific statement from the American Heart Association and the Heart Rhythm Society. Circulation 2007; 115:1170.
- Bleakley JF, Akiyama T, Canadian Cardiovascular Society, et al. Driving and arrhythmias: implications of new data. Card Electrophysiol Rev 2003; 7:77.
- Kim SG, Hallstrom A, Love JC, et al. Comparison of clinical characteristics and frequency of implantable defibrillator use between randomized patients in the Antiarrhythmics Vs Implantable Defibrillators (AVID) trial and nonrandomized registry patients. Am J Cardiol 1997; 80:454.
- Task force members, Vijgen J, Botto G, et al. Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators. Europace 2009; 11:1097.
- http://ec.europa.eu/transport/road_safety/topics/behaviour/fitness_to_drive_en (Accessed on December 08, 2016).
- Mylotte D, Sheahan RG, Nolan PG, et al. The implantable defibrillator and return to operation of vehicles study. Europace 2013; 15:212.
- Curtis AB, Conti JB, Tucker KJ, et al. Motor vehicle accidents in patients with an implantable cardioverter-defibrillator. J Am Coll Cardiol 1995; 26:180.
- 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 GOVERNMENT 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
- Governmental laws
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS