DALLAS, Feb. 7 -- People who receive implantable cardioverter defibrillators (ICD) as a preventative measure don't need the same driving restrictions as people who get an ICD after surviving a life-threatening heart rhythm disturbance, according to an updated scientific statement.
The statement, issued by the American Heart Association and the Heart Rhythm Society, is an addendum to "Personal and Public Safety Issues Related to Arrhythmias that May Affect Consciousness." It will be published online today in Circulation: Journal of the American Heart Association and on the Heart Rhythm Society's Web site. The original advisory was published in Circulation in 1996. The addendum addresses driving restrictions in patients who receive an ICD for primary prevention, meaning they have never had a life-threatening heart rhythm disturbance. The original advisory referred to prophylactic ICDs, which at the time were more commonly used for secondary prevention, meaning the recipient has survived at least one life-threatening arrhythmia.
"Because the majority of defibrillators being implanted now are for primary rather than secondary prevention, it seemed prudent to review the recommendations for driving," said Andrew E. Epstein, M.D., head of the statement writing committee and Professor of Medicine in the Division of Cardiovascular Disease at the University of Alabama at Birmingham.
"The update expands the discussion of driving restrictions that were only briefly touched upon in the 1996 document," Epstein said. "Since the original publication, multiple trials have been reported to establish the role of ICDs for the primary prevention of sudden cardiac death in at-risk people who have never had a sustained ventricular tachycardia or ventricular fibrillation. Based on the results of these trials, Medicare began covering ICDs for primary prevention in 2005, so we expect use of the devices for this purpose to increase."
"This is welcome news for patients," remarked Dwight W. Reynolds, M.D., F.H.R.S., President of the Heart Rhythm Society and Chief of the Cardiovascular Section at the University of Oklahoma College of Medicine. "Sudden cardiac arrest (SCA) continues to be a leading cause of death in the United States, and we know that ICD's are a proven therapy to prevent SCA. This updated joint AHA/HRS scientific statement will remove impediments to accessing this life-saving therapy for patients and families contemplating ICD therapy for primary prevention."
In preparing the new advisory, the writing committee reviewed research to determine the likelihood of an ICD discharge, the likelihood of automobile accidents, and the average driving habits of people who have ICDs.
The average person with an ICD drives eight to 20 miles a day for personal reasons, the writing committee said. This indicates that the typical private driver with an ICD spends about 30 minutes a day behind the wheel, which is about 2 percent of the day. When considered along with data from the SCD-HeFT, DEFINITE and MADIT II trials of ICDs for primary prevention, they determined the likelihood of an ICD discharge while driving may be about 0.15 percent a year in a person who has received the device for primary prevention.
"Even if each patient receives more than one shock in any given year, the chance of someone having an event while driving is less than 1 percent," the report said. However, the period immediately after ICD implantation may also be an unstable time for patients since complications, such as lead dislodgements and ICD shocks, can occur. The group said it's appropriate to restrict driving during this phase. In the absence of data regarding the optimal time for this restriction, at least one week is recommended.
The committee said the recommendations don't apply to people with a commercial license. Commercial licensing is subject to federal law, in which an ICD for any reason currently makes a person ineligible for certification.
"It's also important to note that many patients who receive an ICD for primary prevention often have other reasons for driving restrictions," Epstein said. "While they may not have had an arrhythmia yet, frequent angina, heart failure, or other conditions may indicate driving restrictions. Their healthcare providers should consider these factors when making recommendations to their patients."
Recommendations for patients with an ICD for primary prevention are:
- Patients receiving ICDs for primary prevention should be restricted from driving a private automobile for at least one week to allow them to recover from the implantation surgery. Thereafter, these driving privileges should not be restricted as long as there are no symptoms potentially related to an arrhythmia.
- Patients who receive an ICD for primary prevention but then receive appropriate therapy or shocks for ventricular fibrillation or ventricular tachycardia, especially with symptoms of cerebral hypoperfusion (decreased blood flow to the brain), should then be subject to the driving guidelines/restrictions for patients receiving an ICD for secondary prevention.
- Patients with ICDs for primary prevention must be instructed that impaired consciousness is a possibility if/when the ICD discharges a shock.
- These recommendations do not apply to the licensing of commercial drivers.
FOR RELEASE:
1 p.m. EST, Wednesday
Feb. 7, 2007
Other writing committee members are: Christina A. Baessler, R.N., M.S.N.; Anne B. Curtis, M.D.; N. A. Mark Estes III, M.D.; Blair Grubb, M.D.; Bernard J. Gersh, M.D., D. Phil.; and L. Brent Mitchell, M.D.
NR07 – 1114 (Circ/Epstein)