Risk factors

Cardiac devices have improved; so should driver risk assessment

Assessing the risk of driving in people with pacemakers and implanted cardioverter defibrillators (ICDs) should be more nuanced and incorporate the latest evidence on shock rates.

According to a review article in the Internal Medicine Journal, more individualisation of risk and recognition of improvements in device technology could perhaps even allow some commercial drivers safely back on the road.

“For patients, short periods of being unable to drive can be inconvenient but bearable, longer periods off the road and permanent bans in the case of commercial driving with ICDs can cause major social and financial distress,” the article said.

“The development of a complex risk calculator that thoroughly incorporates multiple facets of the patient’s cardiovascular disease along with their driving profile, should be developed.”

Many current driving recommendations for people with cardiac devices are based on older data, in patients with older generation devices and under differing models of medical care, the artcilke said.

“Contemporary studies suggest lower rates of shock frequency and resultant loss of consciousness in patients with ICDs than previously described,” the authors noted.

“This newer data should be incorporated into updated guidelines and consideration should be given to the creation of more detailed recommendations containing more specific situations that may allow some patients with an ICD to drive commercially.”

Lead author Dr Sam Lovibond, from the Heart Centre at the Alfred Hospital, told the limbic constructing a more complex risk assessment tool would first require a reassessment of – and consensus around – the evidence from sources including registry and RCT data.

“Individualised risk assessment is obviously a complex process and there are multiple variables that need to be taken into account for it. And so while I realise this is a large undertaking to construct a full risk assessment tool that could further categorise patients beyond what we already do, it would be of great benefit.”

He said that cardiac MRI could add value to the driving risk assessment by identifying and quantifying myocardial scar, which was linked with ventricular arrhythmias and sudden cardiac death.

The review also highlighted the need for recurrent driving risk assessment as variables such as LVEF and other indicators of risk of sudden cardiac death might change with therapy and over time.

ICD remote monitoring technology could also potentially play a role in driving advice.

The review advised it was reasonable that people receiving an inappropriate shock be allowed to resume non-commercial driving once their reprogramming had occurred, as is the case in Europe.

Currently they were more likely to receive the same guidance as people receiving an appropriate shock.

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