DRIVING ISSUES RELATED TO ARRHYTHMIC SYNCOPE

Patients with arrhythmias may experience complete or partial loss of consciousness, and questions about activities that are safe for them arise commonly. The most common question concerns the advisability of driving because the safety of both patients and others may be threatened when potentially hazardous activities are performed by persons with arrhythmias that may impair consciousness. Although ventricular arrhythmias are the most common cause of sudden cardiac death, both bradyarrhythmias and the usually more benign supraventricular arrhythmias can lead to syncope or sudden death. Some arrhythmias can be cured, and others can only be palliated. Thus, the efficacy of treatment and the implications of arrhythmia recurrence are especially important, regardless of the treatment approach (i.e., drug, device, surgery, or ablation). The major questions that need to be addressed before allowing a patient with an arrhythmia to drive are: What would be the risk of harm to other road users (and to the patient) if a patient with a given cardiac condition were permitted to drive? What level of risk is acceptable to society? More specific questions include: What is the rhythm diagnosis? Does the arrhythmia actually correlate with the symptoms? Can the arrhythmia be treated effectively? What is the probability of recurrence of arrhythmia? In the event of recurrence, what is the chance for syncope, incapacity, or accident? What is the risk over time? How can patients at risk for arrhythmia recurrence be identified prospectively? The goal of zero risk is unobtainable. Society defines what constitutes an acceptable risk and already accepts certain degrees of risk by allowing higher-risk groups such as the young and elderly to drive.35,49 Attempts have been made to quantify the risks society has deemed acceptable (for example, in patients post–myocardial infarction), and similar logic can be extended to patients with arrhythmias using mathematical models10; this is described in more detail later. The rights of individuals, including acceptance of personal risk, compete with society's right to legislate the level of risk it considers acceptable for performance of certain activities by people who may cause harm to others. Any such policy must be fair to all persons, recognizing that restrictions may limit personal freedom, job security, productivity, and feelings of well-being. There are significant limitations in the available data with which to make recommendations for driving in patients with arrhythmias. There is often uncertainty as to whether a medical problem actually contributed to an accident. For example, since the advent of implantable cardioverter-defibrillators (ICDs), one must recognize that an accident involving a patient with such a device is not necessarily a result of the device or a ventricular tachyarrhythmia; however, there has been a tendency to use implantation of an ICD as a marker to identify patients for whom driving should be limited, when in reality the crux of the problem is whether the patient is likely to have impaired consciousness no matter what therapeutic option to deal with the arrhythmia was chosen.