CCCardiol CroatCardiologia CroaticaCardiol. Croat.1848-543X1848-5448Croatian Cardiac SocietyCC_11(8)_319-32910.15836/ccar2016.319Review ArticleDriving Ability in Patients with Cardiovascular DiseasesNikolićVjeran http://orcid.org/0000-0001-5332-391XHeitzlerSunce Clinic, Zagreb, CroatiaReceived: May 2, 2016 Updated: June 12, 2016 Accepted: June 28, 2016, Address for correspondence: Vjeran Nikolić Heitzler, Poliklinika Sunce, Trnjanska cesta 108, HR-10000 Zagreb, Croatia. / E-mail: vjeran.nikolic-heitzler@zg.t-com.hr0720161183193192016Croatian Cardiac SocietySummary
Issuing driving license to a person requires previous successful results on testing the person’s familiarity with traffic regulations, demonstrating practical driving skills, and the last but not the least, meeting the necessary health related criteria. Cardiovascular disorders can lead to sudden cerebral functional events, thus posing a risk for traffic safety. These disorders and diseases can be direct reasons for proclaiming temporary or permanent driving inability. The article describes the most common cardiovascular diseases that can influence driving ability in both private and commercial drivers.
Keywords: driving abilityprivate and commercial driverselderly driversdriving and heart diseasedifference in traffic regulationsIntroduction
Issuing driving license to a person requires previous satisfactory results on testing the person’s familiarity with traffic regulations, demonstrating practical driving skills, and the last but not the least, meeting the essential health related criteria. Cardiovascular disorders can lead to sudden cerebral functional events, thus posing a risk for traffic safety. These disorders and diseases can be right reasons for proclaiming temporary or permanent driving inability. The article describes the most common cardiovascular conditions that can influence driving ability in both private and commercial drivers (1). The importance of road traffic is best illustrated by the fact that 1 869 370 motor vehicles were registered in Croatia in 2013. Road traffic is one of the strong characteristics of modern civilization (2). Unfortunately, all the benefits of this phenomenon continues to be paid by the high price of human fatalities. Considering the potential traffic accidents, driving a motor vehicle is a dangerous activity associated with high morbidity and mortality (3). According to the World Health Organization report, 1.24 million individuals are killed in traffic accidents per year (4). Numerous factors contribute to road safety, including road network, vehicle quality, observing traffic regulations, and possibly the most important element of driving ability. Demographic surveys reveal a continuing trend of lifespan increase, in western countries in particular, which obviously leads to an ever greater proportion of elderly drivers. Advanced age ranks high on the list of cardiovascular risk factors.
Drivers
The European Society of Cardiology (ESC) (5) and current guidelines issued by the Canadian Cardiovascular Society (CCS) (3) and Cardiac Society of Australia and New Zealand (4) define two groups of drivers: private drivers (PD) and commercial drivers(CD). It is estimated that PDs spend 250 hours driving per year on average, depending on age and occupation. The figure is considerably greater in CDs. Driving a motor vehicle is a highly appreciated freedom in the modern world and for CDs a means to earn for living. Regulations on evaluating driving ability, with particular reference to health-related fitness, are in use all over the world. This means that drivers have to meet certain health standards to be sure that their medical condition will not impair driving safety. Among other diseases, the prevalence of cardiovascular diseases is very high in developed countries (5-8) It should be noted that there are considerable differences among countries in the mode of assessing driving ability, not only among European Union (EU) member countries but also between the USA and Canada. In some countries, evaluation of driving ability is performed at specialised centres or physician offices including specialists in occupational medicine. In others, like Canada, physicians are obliged to notify respective authorities on a driver being temporary or permanently unfit to drive (8). This obligation is also found in the Croatian legislative, but unfortunately, it is rarely applied (9, 10). Among other issues, a matter of dispute is the age to which people are allowed to drive motor vehicles. In most EU countries (1), driving is authorised to PD until the age of 70 (Denmark,Finland, Norway, England, Switzerland and The Netherlands), and then their driving license is renewed every third year, depending on the person’s positive health assessment. In Austria, Slovenia, Germany, France, and since recently Croatia, age is not a limiting factor for driving. What does it mean in Croatia? According to the Act on Amendments to the Traffic Safety Act from 2015, PDs are issued the 10-year driving license. On driving license renewal, “the driver need not undergo medical examination for drivers unless it is mandatory based on the health certificate upon which driving license has been Issued”. Unlike this regulation, CD is obliged to follow up medical examination every five years (11).
Presuming that a PD was issued a driving license at the age of 18, when he/she was healthy and free from any limitations, having thus met the requirements to be allowed to drive until he/she dies. Of course, we do agree that ageing is not a disease but this process is unavoidably accompanied by changes in the abilities that can influence driving safety. Some of these are easy to recognise (e.g., vision and hearing impairments, motor impairments, mental functions, etc.), whereas others like cardiovascular diseases require medical surveillance and appropriate treatment. It is also well known that 60% of individuals older than 60 have elevated values of arterial pressure and inappropriately controlled blood pressure can cause an array of undesired conditions, from arrhythmias to cardiovascular incidents (12-19). Unlike Croatia, in Italy, Spain and Ireland, medical examinations are performed every ten years, and every third year if necessary. In Hungary, drivers are obliged to present for follow-up medical examination after the age of 40 (1). Although Croatia has gradually reduced the number of roads traffic deaths since 2008, the figure still exceeds the average recorded in EU member countries. In 2013, there was 86 traffic deaths per million in Croatia, while the EU average is 52 deaths per million. However, disturbing is the fact that Croatia has lagged behind the EU average throughout the period of observation. The number of traffic deaths has been decreasing in Croatia at approximately the same rate as in the EU, suggesting that we have failed to use all the opportunities to improve the situation, i.e. to reduce the number of road traffic fatalities at a faster rate. As also indicated by statistical data, we are aware that young drivers account for the majority of traffic accidents (the causes are high speed, proneness to risk, and lack of driving experience); on the other hand, life expectancy is ever longer, resulting in an increased proportion of elderly drivers (17). This issue opens a very delicate debate. Is it allowable that PD health related driving ability is not tested ever since being granted a driving license, of course, in case there were no health-related limitations on initial examination? Considering age structure of the drivers killed in traffic accidents in Croatia in 2012, there were 30 deaths in the 18-24 age group, increasing significantly to 57 deaths in the 25-34 age group, and persisting at the figure of 39 deaths in the 55-64 and >65 age groups (2). In Austria, there were 92 deaths in traffic accidents per 580,000 drivers older than 75 versus an almost the identical figure of 88 deaths per 610,000 young drivers aged 20-24 during a two-year period (20). Numerous health problems influence is driving ability, causing permanent or temporary unfitness to drive. The Australian guidelines for driving ability assessment (4) provide a list of diseases and conditions that affect fitness to drive, as follows:
Blackouts:
vasovagal reaction in 50%
syncope of cardiovascular genesis (e.g., arrhythmia)
epileptic seizure in 10%
metabolic disorders (e.g., hypoglycemia)
effects of drugs
sleep disorders
Cardiovascular disease
Diabetes mellitus
Musculoskeletal disorders
Neurologic disorders (epilepsy, dementia, consciousness impairments of various genesis)
Psychiatric diseases
Sleep disorders
Vision impairments
Cardiovascular Disease
Individuals with cardiovascular diseases are at an increased risk of traffic accidents. Croatia as an EU member country has to follow European legislative on health-related driving ability.What are the conditions the presence of which can entail temporary or permanent driving license suspension according to the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates? (9)
CORONARY HEART DISEASE
The following conditions are associated with temporary or permanent unfitness to drive in both PD and CD:
1.1 Coronary disease with recurrent angina pectoris (AP) episodes until drugs achieve a stable state therapy or other treatment modalities, yielding the person fit to drive safely. This article in part corresponds to ESC (1) and CCS (3) guidelines; however, it does not include the possibility of percutaneous coronary intervention (PCI), after which resuming fitness for driving is possible in 7 days for PD and in 6 weeks for CD according to the ESC and CCS guidelines (Table 1).
Ischemic heart disease – Fitness to drive according to the European Society of Cardiology (ESC) (1) and the Canadian Cardiovascular Society (CCS) (3) Guidelines.
STEMI or NSTEMI with significant LV damageNSTEMI with minor LV damage
Driving allowed 1 month after dischargeDriving allowed after 48 h or 7 days whether 30 days whether PCI performed or not
Driving allowed 3 months after dischargeDriving allowed after 7 days or PCI performed or not
ESCCCS
PCIPCI
Driving allowed 1 week following PCIDriving allowed 48 hours post-PCI
Driving allowed 6 weeks post-PCIDriving allowed 7 days after PCI
ESCCCS
CABGCABG
Driving allowed 1 month following CABGDriving allowed 1 month after discharge
Driving allowed 6 weeks following CABGDriving allowed 3 months after discharge
CABG = coronary artery bypass grafting; LV = left ventricular; MI = myocardial infarction; NSTEMI = non-ST elevation myocardial infarction; PCI = percutaneous coronary intervention; STEMI = ST elevation myocardial infarction. NSTEMI with minor LV damage is classified as an MI defined only by elevated troponin with or without ECG changes in the absence of a new wall motion abnormality.
1.2 Myocardial infarction (MI):
1.2.1 This refers to PD (Regulations on Medical Examinations of Drivers and Driver Candidates (9)): fitness for driving is resumed after at least six months have elapsed since MI and successful rehabilitation, without AP and any sequels influencing driving safety. The possibility of PCI is not included. These regulations differ substantially from ESC guidelines (1), according to which driving is allowed in 4 weeks of acute MI for PD and in 6 weeks for CD. In case of urgent PCI for acute MI, driving fitness is resumed in 7 days of the intervention for PD and 6 weeks of the intervention for CD.
1.2.2 In case of urgent PCI for acute MI, driving fitness is resumed in 6 weeks of the intervention for CD, but they previously have to meet the following criteria: regular exercise test result, 90% of maximal values without ST-segment depression greater than 2 mm, no reversible kinetic events on stress echocardiography or no major perfusion events on radionuclide ventriculography. The left ventricular ejection fraction (LVEF) should be >40%. In the Croatian Regulations on CD, MI is not mentioned at all, stating other cardiovascular diseases and disorders that Driving Ability in Patients with Cardiovascular Diseases influence driving safety, which in fact eliminate the category of bus and truck is driving (Table 1).
1.3 According to the Croatian Regulations, CD is unfit or temporarily unfit for driving after cardiac surgery for coronary heart disease (coronary artery bypass graft, CABG) or dysrhythmia (pacemaker implantation) when these conditions influence driving safety, thus, as a rule, eliminating the category of bus and truck driving (9). This differs considerably from ESC (1) and CCS (3) guidelines, according to which at least 6 weeks should elapse from the operation to resume, fitness to drive unless there are some disqualifying states, while returning fitness to drive depends on the exercise test result. In the Croatian Regulations (9), the length of unfitness to drive after CABG and pacemaker implantation is not mentioned at all; instead, the need of regular pacemaker follow-ups to confirm normal cardiac function is stated. According to ESC (1) and CCS (3) guidelines, PDs having undergone CABG are not allowed to drive for 1 month and those with a permanent pacemaker for 1 week of discharge from the hospital; in case of CDs, they are not allowed to drive for 4 weeks of the procedure (Table 1).
ARTERIAL HYPERTENSION
According to the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates, PDs are evaluated as unfit or temporarily unfit for driving at arterial hypertension (AH) with systolic blood pressure greater than 160 mm Hg or diastolic blood pressure greater than 100 mm Hg. CDs are evaluated as unfit or temporarily unfit for driving at AH with complications and arterial pressure (AP) greater than 160/100 mm Hg, if influencing driving safety (9). This article in part corresponds to ESC guidelines where,interestingly, AH is not a disqualifying feature but CDs are proclaimed permanently unfit for driving in case of persistent AH values exceeding 180/100 mm Hg1. According to the recent Australian guidelines, PDs are considered temporarily unfit for driving in case of AH values persistently exceeding 200/110 mm Hg, treated or untreated. Their driving ability is resumed upon specific follow-up examinations at family physician office if AH is efficiently controlled by medication, there are no drug side effects and no organic lesions that may have the adverse impact on driving safety. In CDs, the AH value is decreased to 170/100 mm Hg. They will resume their driving fitness in 4 weeks if medicamentous therapy has been introduced or corrected and good therapeutic results have been recorded, there are no drug side effects and no organic lesions that may have an adverse impact on driving safety. In CDs, resuming fitness to drive is proclaimed upon having undergone mandatory regular annual follow-up examinations with close coordination between the family physician and the respective specialist (4).
CARDIAC INSUFFICIENCY
In the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates, cardiac insufficiency is included in the group of other cardiovascular diseases and disorders influencing driving safety for both PD and CD. In both PD and CD, this statement coincides with temporary or permanent unfitness to drive (9). According to ESC guidelines, PDs are unfit to drive while having symptoms of heart failure at rest. Fitness for driving is resumed if the symptoms fall on appropriate therapy. In CDs, the criteria are much more stringent. In this category, driving fitness is resumed when they become asymptomatic, along with LVEF >40%, no disqualifying arrhythmias, and normal exercise test results (1).
Australian guidelines are even more precise. PDs are supposed to undergo periodic follow-ups and are considered fit to drive if having minimal symptoms and a satisfactory therapeutic response. Permanent unfitness to drive is proclaimed in the case of symptoms at rest and resistance to therapy (NYHA IV). In CDs, obligatory annual cardiologic follow-up has been introduced. They are considered fit to drive in case of minimal symptoms, along with LVEF >40% and 90% maximum functional capacity tolerance on exercise test (4).
VALVULAR HEART DISEASE
According to the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates, both PD and CD are proclaimed permanently or temporarily unfit to drive if suffering from congenital or acquired heart diseases (involving cardiac valves and other heart structures) that may influence driving safety. In CD, no valvular heart disease is specified, instead the CD category is eliminated by this generalised statement (9). According to ESC guidelines, PDs with valvular heart disease including postoperative state following cardiac surgery are evaluated as fit to drive if asymptomatic. CDs are proclaimed unfit for driving if symptomatic, and resuming driving fitness depends on the possible presence of other disqualifying factors after cardiac surgery (e.g., cardiac insufficiency, ‘delayed’ surgery) or data on embolic events despite anticoagulant therapy (1). In English guidelines, approach to PDs is the same as in ESC guidelines, whereas CDs are proclaimed unfit to drive as long as their valvular heart disease is symptomatic. In case of cerebral embolism, they are evaluated as unfit to drive for 12 months, and then can be evaluated as fit to drive depending on specialist assessment, including postoperative state, provided there are no other disqualifying factors. Quite interesting is the approach to drivers with aortic stenosis. In case of symptomatic disease, both driver categories are evaluated as unfit to drive permanently. Although free of symptoms, CDs with severe aortic stenosis are obliged to undergo exercise test once a year. However, in this category permanent unfitness to drive is proclaimed (19) if:
cardiologist estimates that the driver cannot undergo exercise test due to disease severity,
symptoms, AH decrease and ECG changes occur during exercise testing, and
unable to undergo exercise test for some other reasons
Australian guidelines are even more specific. PDs with valvular heart disease are proclaimed unfit to drive if having symptoms at moderate exercise. They are not allowed to drive for at least 4 weeks following cardiac surgery. They are obliged to undergo regular periodic follow up examinations, where it is estimated whether a satisfactory therapeutic response has been achieved, whether there are minimal tolerance symptoms on driving (chest pain, palpitations, shortness of breath), and whether the residual postoperative musculoskeletal pain is acceptable and does not limit driving fitness. Commercial drivers are not allowed to drive for at least 4 weeks after valvular surgery and are obliged to undergo periodic follow-up examinations once a year. In case of symptomatic diseases irrespective of surgery, embolism, arrhythmia, cardiomegaly, pathologically altered ECG, elevated AH or permanent anticoagulant therapy, permanent unfitness for driving is proclaimed in CDs. Success of the procedure is assessed by ultrasonography 3 months of the surgery. If there are minimal symptoms (chest pain, palpitations, shortness of breath and musculoskeletal pain), patients are proclaimed fit to drive, however, with regular follow-up examinations. (4)
CARDIOMYOPATHIES
In the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates, cardiomyopathies are included in other cardiovascular diseases influencing driving ability for both PD and CD categories (9). According to ESC guidelines, PDs with cardiomyopathy are proclaimed unfit to drive in case of symptoms at rest. Once the symptoms have been properly controlled, PDs resume their driving ability, however, with mandatory regular follow-up examinations. CDs are allowed to drive if asymptomatic, free from embolic events and, of course, with regular periodic follow-up examinations. On recurrent embolism events in spite of oral anticoagulant therapy, this category is proclaimed permanently unfit to drive (1). Australian guidelines are considerably broader and more precise. In the case of dilated cardiomyopathy, PDs are obliged to present for periodic follow-up examinations, while CDs are forced to undergo follow-up medical examination once a year. In PDs, driving fitness depends on the symptoms, which should be minimal (chest pain, palpitations, and shortness of breath). No paroxysmal arrhythmia should be recorded. In CDs, besides minimal symptoms (chest pain, palpitations, and shortness of breath), driving fitness also requires the absence of arrhythmias and LVEF >40%. Periodic and annual follow-up examinations are needed in PDs and CDs with hypertrophic cardiomyopathy, respectively. Minimal symptoms (the same as those listed for dilated cardiomyopathy) are the main precondition for driving fitness in PD; however, the person should be free from paroxysmal arrhythmia and syncope. In CD, besides minimal symptoms, additional requirements for driving fitness include LVEF >40%, tolerating >90% maximal exercise test, no syncope and no ventricular arrhythmia on Holter ECG; severe left ventricular hypertrophy is also a factor for exclusion. The subject is asked about the family history of sudden death. If yes, a CD is proclaimed permanently unfit for driving (4).
VASCULAR DISEASES
In the Croatian Traffic Safety Act, vascular diseases are included in the group of other cardiovascular diseases influencing driving safety (9). According to Australian guidelines, PD is not allowed to drive if having an unoperated aortic, thoracic or an abdominal aneurysm. Upon aneurysm surgery, the person is not authorised to drive for 4 weeks postoperatively. PD is obliged to undergo periodic specialist examinations, while the acceptable aneurysm diameter is <5 cm. CDs are not allowed to drive for at least 3 months postoperatively, are obliged to undergo follow-up examinations once a year, and the acceptable aneurysm diameter is <5 cm (4). According to ESC guidelines, the allowable aortic aneurysm diameter is <5.5 cm (1). Anticoagulant therapy, provided it is within the recommended values, is not a contraindicationfor driving fitness for either PD or CD category (4).
ARRHYTHMIAS
According to the Croatian Traffic Safety Act, PD drivers and driver candidates are evaluated as unfit or temporarily unfit for driving if suffering from the following diseases or conditions: dysrhythmias and heart disease with consciousness disturbances that cannot be controlled by therapy, and complete heart block when influencing driving safety. Irrespective of the type of examination, CDs and CD candidates are proclaimed unfit or temporarily unfit for driving in the case of cardiac and cardiovascular diseases and conditions with impaired conduction, complete heart block, second-degree atrioventricular (AV) block, and left bundle branch block (LBBB) (9). This statement shows that arrhythmias are defined in general, i.e. not divided in line with the latest classifications into bradyarrhythmias (sinus node diseases and conduction disorders) and tachyarrhythmias (supraventricular and ventricular). Attention should, in particular, be paid to the possible history data on the previous syncope demonstrated to be of arrhythmic genesis. Symptomatic bradyarrhythmias are indications for permanent pacemaker implantation. If the person is asymptomatic, then there is no indication for permanent pacemaker implantation, and according to the European, Canadian and American recommendations these disorders do not preclude driving fitness as long as they are asymptomatic. LBBB and fascicular block are not indications for permanent pacemaker implantation but do require appropriate workup to rule out structural myocardial disease and potential progression of conduction impairment. There are no data suggesting that syncope during supraventricular tachycardia could lead to a traffic accident. Most likely, it happens very rarely. Persons with persistent and permanent atrial fibrillation or undulation can drive if appropriate rhythm control has been achieved. It is necessary to search for the cause of rhythm impairment, followed by appropriate treatment (5). Paroxysmal atrial fibrillation is by far more dangerous and can lead to short-term blackouts, in part due to embolic events. Patients with Wolff-Parkinson-White syndrome and other supraventricular tachycardias have a good prognosis, and these conditions do not lead to syncope. In these patients with manifest pre-excitation, catheter ablation is recommended; if successfully performed, the patients are then proclaimed fit for driving. Catheter ablation, i.e. pulmonary vein isolation has been ever more frequently suggested as an alternative treatment of atrial fibrillation. The majority of ventricular tachycardias (90%) occur consequentially to coronary ischemia, although only 20%-30% of these patients have a history of MI. When once present, ventricular tachyarrhythmia can recur. The only certain predictor is lowered ejection fraction (<35%) (5, 21). In such cases, current therapy is based on implantable cardioverter defibrillator (ICD). Individuals with this type of pacemaker are at a risk of symptomatic ventricular arrhythmia with syncope or impaired consciousness in spite of targeted electrical stimulation, thus posing a risk while driving not only for themselves but also for other traffic participants (22). Recent studies conducted in Canada showed that symptomatic arrhythmia occurred in only 5 per 100,000 patients with ICD per year. This finding has resulted in new guidelines for assessment of driving ability. In CDs, driving license is permanently suspended, whereas PDs are allowed to drive 3 months after ICD implantation in Europe and after 6 months in America. PDs with the congenital symptomatic long-QT syndrome, Brugada syndrome or other channelopathies with ventricular fibrillation paroxysms are not allowed to drive until ICD implantation (23).
Discussion and Conclusion
The most common cardiovascular diseases and conditions that can influence driving ability in both private and commercial drivers are described. It is a little bizarre that the Croatian Regulations on Medical Examinations of Drivers and Driver Candidates refer to some diseases which are extremely rare, such as constrictive pericarditis or chronic pulmonary heart with symptoms of decompensation, whereas other diseases and conditions which are exceptionally more common are not defined but are included in the group of other cardiovascular diseases and conditions were influencing driving safety (9). It should be noted that the ESC, CCS, English and Australian guidelines for assessment of driving fitness in cardiovascular patients are adjusted to the latest medical concepts, thus reducing the possibility of depriving commercial drivers of their economic status while being much more tolerant towards private drivers. In Croatia, cardiovascular diseases are the leading cause of mortality. According to the Croatian Central Bureau of Statistics, these diseases were the cause of 24,112 deaths or 47.43% of all-cause deaths in 2014 (19). Patients with cardiovascular disorders are at an increased risk of traffic accidents. A recent meta-analysis demonstrated the relative risk of being involved in traffic accidents to be by 23% higher in drivers with cardiovascular disorders as compared with those free from these disorders in EU (24).
In Spain, private drivers are obliged to present for follow-up examinations every tenth year. In a study including more than 5000 drivers, cardiovascular disorders that can influence driving ability was recorded in 11.6% of study subjects. Interestingly, the majority of these disorders resulted in temporary unfitness to drive, with restrictions and more frequent follow-up examinations, while only 1.6% of these drivers were proclaimed permanently unfit to drive (8, 17). In Croatia, the rate of traffic accidents is rather high. Noncompliance with traffic regulations, primarily high speed, is quite frequently identified as the main culprit. There are an ever growing proportion of elderly drivers. The incidence of traffic accidents is highest in ‘young’ age; however, it also rises significantly after the age of 70. Therefore, medical evaluation of drivers, both private and commercial, should be upgraded and coordinated with the standards valid in countries with the long tradition of road traffic, EU in particular, as Croatia is also part of this community.
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