The privilege of driving is highly valued and often necessary for independent functioning in our society. However, society clearly restricts the privilege to those judged able to drive safely. Although sudden incapacitation due to medical illness is the cause of <1% of all accidents, these accidents are preventable by restricting driving in patients at high risk for such illnesses.

Patients with life-threatening ventricular arrhythmias are clearly at risk for sudden incapacitation and loss of consciousness. The implantable cardioverter-defibrillator (ICD) has been demonstrated to be the superior therapy for survival in patients with these arrhythmias. However, the ICD does not prevent these arrhythmias and may not prevent the associated loss of consciousness. As such, the resumption of driving in patients treated with an ICD may be problematic. Few states, and none in this region, have regulations for patients with arrhythmias or treated with an ICD. Consequently, the burden of decision falls on the physician.

The topic of driving in patients with life-threatening arrhythmias has been previously discussed in The Arrhythmia News (October, 1997). However, newly available data, published in the New England Journal of Medicine, and co-authored by Dr. Frederick Ehlert of the Arrhythmia Service, suggest value in revisiting the issue.

The evaluation of driving in patients with life-threatening arrhythmias was a substudy of the Antiarrhythmics Versus Implantable Defibrillator (AVID) Trial, a study which demonstrated the superiority of ICD therapy to antiarrhythmic drugs. The Arrhythmia Service was a leading enroller in this trial, which included 1016 patients from across North America. For the substudy, trial subjects were asked to complete anonymous questionnaires over the course of their participation in the AVID trial. 758 of 909 (83%) patients who were able completed questionnaires; 627 had actually been driving in the year prior to entry into the AVID trial and were the focus of the study. As would be expected, roughly half had received ICD therapy and half had received antiarrhythmic drugs. Their responses provide an interesting perspective on the driving patients actually do and the consequences of their driving.

Physician Proscription and Patient Compliance 

Interestingly, only 64% of patients reported that their physicians had even discussed driving with them. According to these patient reports, physician recommendations typically included a specific period during which driving was prohibited: <2 months in 25%, <12 months in an additional 45%. Of note, 10% of patients reported they were told they could resume driving immediately or at their own discretion and an additional 4% were told never to drive again. In spite of these physician recommendations, 57% of patients responding had resumed driving within 3 months, 78% within 6 months, and 88% within 12 months. Of those who had resumed driving, 63% reported driving the same amount as in the year prior to their life-threatening ventricular arrhythmia and subsequent entry into the AVID trial.

Symptom Recurrence and Accidents While Driving 

Amazingly, a significant number of events occurring during driving were reported by these patients. 22% of respondents reported episodes of dizziness or palpitations while driving, although the symptoms were not so severe as to necessitate them stopping the automobile. 11% of respondents reported dizziness or palpitations while driving severe enough to necessitate them stopping the automobile. 2% even reported having lost consciousness while driving.

Fifty of the 559 patients who responded to the questionnaire reported having at least 1 motor vehicle accident during a mean follow-up period of 35 months (1619 patient-months after the resumption of driving). These accidents were preceded by possible symptoms of an arrhythmia in 6 of these accidents; loss of consciousness in 3 and dizziness or palpitations in 3. No accident was preceded by a shock from an ICD. This translated to an annual accident risk of 3.4% in these patients and an annual risk of accidents presumed associated with arrhythmias of 0.4%. Of note, the annual accident risk of this population in the year prior to their entry in the study was 6.2%, or 1.8X higher.

Multivariate analysis demonstrated that the only independent predictor of motor vehicle accidents during follow-up was prior motor vehicle accident with a relative risk of 3.75. In addition, duration of abstinence from driving was not predictive of future motor vehicle accidents. Furthermore, the probability of having a motor vehicle accident remained constant over time and was not associated with the duration of abstinence from driving.

Clinical Implications and Recommendations for Physicians 

The data presented in this study is interesting and applicable to physicians treating patients with life-threatening arrhythmias. Clearly, symptoms associated with arrhythmias can and do result in motor vehicle accidents in these patients. However, the study suggests that the rates of these accidents are quite low and that prolonged prohibition of driving may not be indicated in these patients. While the study has the potential for bias, in that the sickest of patients, those at highest risk, are unlikely to participate, driving in patients with life-threatening arrhythmias can and should be reviewed on a case-by-case basis allowing most patients to achieve some degree of freedom and independence with minimal risk to themselves or others.

ARRHYTHMIA SERVICE OPENS OFFICE IN ORANGE COUNTY, NY 

In an effort to better serve its patient population and its referring physicians, the Arrhythmia Service has opened a new office in Orange County, New York. The office, located at 3302 Route 207 in Goshen, New York, will provide a full range of electrophysiology consultative services as well as pacemaker and defibrillator follow-up. Physicians and patients can contact the office at 845-373-7400.

Reproduced with permission. Published by the Arrhythmia Service of St. Luke's-Roosevelt Hospital Center, New York, New York.