Fitness to Drive in Cardiovascular Disease
Background: Medical students are taught little or nothing about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire competence in traffic medicine in order to be able to advise them about their fitness to drive.
Methods: We present the current governmental regulations and recommendations concerning fitness to drive in patients with cardiovascular disease. We also review pertinent publications that were retrieved by a selective search in PubMed with the search terms “cardiovascular disease and traffic accidents” and “cardiovascular disease and traffic deaths” for the decade 2007–2016, as well as further publications collected by us individually.
Results: Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, aneurysm rupture) and marked general weakness (e.g., after major surgery or in cardiac insufficiency).
Conclusion: Patients with cardiovascular disease should be advised by their physicians about their fitness to drive, and the discussion should be documented in writing. Because of the German law on the confidentiality of medical data, only the affected patient should receive this information, with very few exceptions.
With few exceptions, any person driving a motor vehicle on public roads must be in possession of a driving license. Individuals in possession of a driving license are regarded as fit to drive if they can meet the physical and mental demands of dealing with road traffic. If a person with a driving license has any physical or mental disability, § 2, paragraph 1 of the German Driving License Regulations (FeV, Fahrerlaubnisverordnung) provides that he or she may only drive if care is taken to ensure that other road users are not put at risk. This is a question that particularly affects patients with chronic diseases (1). Chronic diseases are covered in Appendix 4 of the German Driving License Regulations. They include visual and hearing impairments, impaired mobility, cardiovascular disease, diabetes mellitus, neurological disease, mental disorders, and drug and/or alcohol addiction. Appendix 4 of the German Driving License Regulations details the circumstances under which persons with any of these chronic conditions are fit to drive or have restrictions laid on their fitness to drive. Restricted fitness to drive usually involves regular testing, expert medical opinion, or restrictions on motor vehicle type or driving time, which are specified in reports from experts in traffic medicine. The term „fitness to drive“ (Fahreignung) refers to expected long-term capacity to drive, whereas the term „ability to drive“ (Fahrtüchtigkeit) refers to the driver‘s ability in their current state of health to control a vehicle over a long distance even in difficult traffic situations (1).
At medical school, medicine in relation to road safety is a subject that is barely touched upon, if at all (2). However, to be able to tell a patient with cardiovascular disease that he or she is not fit to drive, the treating physician must have acquired some knowledge of traffic medicine. Cardiovascular disease that can render a patient unfit to drive includes coronary heart disease, myocardial infarction, cardiac insufficiency of various etymologies, brady- or tachyarrhythmias with or without pacemaker/defibrillator implantation, and syncope. Assessment of fitness to drive is based on Appendix 4 of the German Driving License Regulations (FeV) and on the Assessment Guideline issued by the German Federal Highway Research Institute (BAST, Bundesanstalt für Straßenwesen), which implement European Union standards in Germany. The present article reproduces the contents of these documents in shortened form.
After reading this article, readers should
- know which legal provisions govern assessment of a patient‘s fitness to drive.
- be able to assess a patient‘s fitness to drive in accordance with current guidelines.
- know when it would be appropriate to consult a physician specializing in traffic medicine.
Road accidents following cardiovascular events
Cardiovascular disease can lead to accidents due to sudden loss of control by drivers. The most important pathophysiological mechanisms behind sudden loss of control of this kind are:
- cerebral perfusion disorders (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death in patients with ventricular fibrillation or asystole, stroke, aneurysm rupture) or
- pronounced general weakness (after major surgery or severe heart failure).
- Other diseases that can likewise lead to accidents include alcohol or drug consumption, epileptic seizures, hypoglycemia in patients with diabetes mellitus, daytime fatigue related to sleep apnea, cognitive disorders in persons suffering from psychosis, or disturbances of vision following a stroke.
Disease as a cause of road traffic accidents is not recorded in Germany, and only a very vague estimate of its incidence can be made. Old (1963) data from England suggest that about 1.5 out of every 1000 accidents are caused by sudden illness of the driver, and chronic illness may have been a factor in 5 out of 1000 accidents (3). A retrospective study of fatal road accidents in Finland and Switzerland concluded that about 2.5% of road deaths in Finland between 1984 and 1989 and 6.4% of road deaths in the Swiss canton of Waadt between 1986 and 1989 were related to a driver‘s sudden loss of consciousness at the wheel (4). According to a retrospective study in Germany, about 0.4% of road deaths are of persons who die a sudden natural death at the wheel. Among these, the main cause of death is coronary heart disease (5). In Japan, between 2004 and 2006, 211 cases of sudden incapacity to drive were notified to the Ministry of Transport; these were due to cerebrovascular disease (28.4%), cardiac and aortic disease (26.1%), syncope (8.5%), and gastrointestinal disease (8.1%). In 64.7% of these cases an accident occurred. Thirty-six percent of the drivers died immediately of their illness (6). According to other studies, disease-related road traffic accidents occur more often. A retrospective study in Finland estimates that in 20% to 30% of all fatal road accidents involving persons over 65 years of age, impaired concentration due to disease may have been involved, and in most cases (70%) the disease is cardiovascular (7). An autopsy study from Canada also suggests that coronary heart disease in drivers over the age of 60 plays an important role in road accidents. In this age group, 86% of drivers who died at the wheel had significant coronary heart disease. Of these, 40% had been driving erratically before the accident, and this was inferred to be due to loss of control caused by acute myocardial ischemia (8). In patients with acute myocardial ischemia, the main concerns are tachyarrhythmias such as ventricular tachycardia or ventricular fibrillation. In Ontario, Canada, patients who were regarded by their physician as unfit to drive were reported to the licensing authority. Loss of fitness to drive could result from diseases such as alcoholism, epilepsy, dementia, syncope, or cardiovascular disease. From April 2006 to December 2009, more than 100 000 patients received a warning from over 6000 physicians about their fitness to drive. Before receiving the warning, each year 0.476% of these drivers had been treated in an emergency department in Ontario because of a road accident in which they had been involved as a driver. After the warning, the annual rate of emergency department visits due to a road accident dropped to 0.273%, meaning that in this patient group this preventive measure reduced the accident rate by about 45%. Nevertheless, the accident rate was still higher than among the general population in Ontario (9). It may be assumed that disease plays a significant part in road accidents, and that cardiovascular disease as a cause of accidents increases with age (Box).
Confidentiality and the duty to inform
Treating physicians are under an obligation to tell their patients if they believe they are unfit to drive, and to record the fact that they have done so (10). This duty to inform, which previously was based on the medical treatment contract, has since February 2013 been formally laid down in the law governing patient rights as § 630 of the German Civil Code. Under this law, the physician is required to tell the patient all the important facts about his or her illness—and that includes the medical assessment of the patient‘s fitness or otherwise to drive. Withholding such information is held to be a medical treatment error (10).
Because of the confidentiality law in Germany, the only person informed by the physician about a loss of fitness to drive is the patient concerned. Informing the authorities (licensing authority, police) is not required and indeed is not permitted. The topic of patient confidentiality and fitness to drive was discussed extensively at the 50th Road Traffic Law Conference in Goslar in 2012 in Working Group III: Risk to Road Traffic from Disease-Related Impairments of Fitness to Drive and Driving Safety. This working group confirmed what had already been affirmed at the Road Traffic Law Conference in 2005—that in extreme cases the physician is not obligated to maintain confidentiality—and supported the view that in cases of extreme risk the physician has the right to report to the police a patient that the physician regards as medically unfit to drive but who does not agree with this view and is unwilling to cooperate (11). An example given was of a bus driver with acute myocardial infarction who refused admission to hospital for treatment, so that he could drive a class of schoolchildren in his bus. It was not concluded during this discussion that physicians are obligated to break patient confidentiality in cases where there is acute risk. If the patient asks the physician to produce a report on his or her fitness to drive, the obligation to maintain confidentiality is of course removed.
Concerning risk stratification, the Canadian Cardiovascular Society’s “risk of harm”-formula has become the gold standard for Germany and for the other countries in the European Union (12). This formula says that the probability that cardiac disease in the driver of a vehicle will lead to serious injury to another road user is directly proportional to:
- The time spent at the wheel
- The type of vehicle being driven (private car, truck)
- The annual probability of sudden loss of control („sudden cardiac incapacitation“, SCI).
Given normal hours per day at the wheel (8 hours for commercial drivers, 30 minutes for private drivers), unfitness to drive is assumed when the probability of sudden loss of control (syncope, sudden cardiac death, stroke) is >1% per year for an occupational driver and >22% per year for a private driver (12). The use of the „risk of harm“ formula is discussed in detail in the German Cardiac Society‘s position paper on fitness to drive in patients with cardiovascular disease (13). This formula served as the basis for assessment of fitness to drive of persons with cardiovascular disease both in the German Cardiac Society‘s position paper (13) and in the unpublished recommendations of the European Union, „New Standards for Driving and Cardiovascular Diseases,“ Brussels 2013, which for Germany are implemented in the current BAST recommendations regarding fitness to drive in patients with cardiovascular disease. However, the distinction made in the „risk of harm“ formula between bus drivers and taxi drivers in regard to fitness to drive was not adopted by the Brussels Expert Advisory Panel, and hence was not adopted by the BAST in Germany either. The Brussels Expert Advisory Panel agreed to treat all occupational drivers of passenger transport vehicles as the same, even though the general risk of bus drivers is estimated to be much higher than that of taxi drivers.
Requirements and recommendations for the assessment of fitness to drive
At present, the currently applicable requirements of Appendix 4 of the German Driving License Regulations (14) and the BAST recommendations (15) relating to cardiovascular disease must be adhered to. Both of these are currently available only on the Internet. All the tables displayed in the present article are drawn from the official requirements of the Driving License Regulations and the assessment guidelines of the BAST.
Compared with the BAST recommendations, Appendix 4 of the Driving License Regulations is couched in more general terms and goes into fewer diseases in detail. As a legal instrument, the requirements of this Appendix must be adhered to. Every assessment of fitness to drive must be undertaken on an individual basis. Factors that increase risk at the wheel—for example, several risk-promoting chronic diseases—or factors that reduce risk—for example, driving only rarely—must be included in the assessment. The position paper published by the German Cardiac Society on fitness to drive in patients with cardiovascular disease (13) helped to push forward a review of the official regulations and guidelines, and was used by the Expert Advisory Panel in Brussels as the basis for their recommendations. Today it has lost some of its importance since the revised official regulations reflect a more up-to-date state of scientific knowledge.
An abbreviated extract from the current regulations in Appendix 4 of the German Driving License Regulations relating to fitness to drive in patients with cardiovascular disease (16) is shown in Table 1. Follow-up assessments are not shown in Table 1. Where „Case-by-case decision“ is shown for patients with systolic blood pressure >180mmHg, the physician must consider carefully whether he or she believes the patient to be fit to drive. A value >180 mmHg could be 185 mmHg, which could be tolerated, or it could be 250 mmHg, which in an occupational driver would suggest unfitness to drive. To date there have been no scientific studies to establish a threshold value for blood pressure in relation to fitness to drive. The entry „May be fit to drive after 4 to 6 weeks“ means that the patient will be fit to drive after this time so long as no events occur during in the interim that would count against fitness to drive. An example of such an event might be symptomatic ventricular tachycardia.
The BAST guidelines on fitness to drive in persons with cardiovascular disease, which have applied since December 2016, go into some detail about patients with various arrhythmias, cardiac pacemakers and/or implanted defibrillators (ICDs), arterial hypertension, coronary heart disease including acute myocardial infarction, arterial occlusive disease, aortic aneurysm, heart valve disease, cardiomyopathies, rare ion channel diseases, heart failure, and syncope. Some of the most important of these disease entities are dealt with in more detail below.
Pacemakers and implanted defibrillators (ICDs)
and fitness to drive
The indications for ICD and pacemaker treatment are given in the current guidelines of the European Society of Cardiology and the German Cardiac Society (17, 18). The now-updated recommendations from BAST on fitness to drive differ considerably from the previous ones in regard to patients with pacemakers and ICDs. Group 2 drivers with a functioning cardiac pacemaker are now held to be fit to drive after 1 week. Group 2 drivers who experienced syncope before the pacemaker was implanted, or who are is dependent on the pacemaker, are not fit to drive until 4 weeks have elapsed. Patients with ICDs are usually unfit to be group 2 drivers. However, it is not the presence of the ICD but the heart condition that makes them unfit to drive. In some cases, the heart condition of a patient with an ICD may improve (e.g., healing of myocarditis), so that after a time the ICD is no longer indicated. In an individual case of this kind, even a patient with an ICD could be an occupational driver. Table 2 shows the BAST guidelines for patients with cardiac pacemakers and defibrillators. After an appropriate ICD shock in a patient with ventricular tachycardia or ventricular fibrillation, fitness to drive may be assumed in the absence of any new dangerous arrhythmic event that is treated with a shock within the subsequent three months. This recommendation is also supported by the findings of a large study of 2786 patients who had ICDs placed for primary or secondary prevention of sudden cardiac death (19). Even though the driving restrictions for patients with ICDs have been scientifically proven to be well founded, it has been found that 35% do not obey these restrictions (20). If the treating physician is in doubt about the fitness of a patient with a pacemaker or defibrillator to drive, he or she should contact physicians in the center in which the device was implanted.
Fitness to drive after syncope
Patients with syncope are a very heterogeneous group, with varying degrees of severity of disease (21). In all cases, an attempt should be made to identify the precise cause of the syncope, so that a mechanism-specific treatment can be implemented. Causes of loss of consciousness include the vasovagal, cardiac, orthostatic, and neurological syncope, as well as those not otherwise classified (22). It may be assumed that patients who experience syncope at the steering wheel have the same range of causes of syncope as those who experience syncope in other circumstances (21). About 87% of patients with syncope at the wheel experience prodromal symptoms, which if correctly interpreted can allow them to find a safe place to stop (23). Syncope patients should be informed about the possibility that their syncope may recur, so that if they experience prodromal symptoms they can stop their vehicle. A defensive driving style should always be recommended. According to a recent Danish study, it may be assumed that the accident risk of individuals with syncope is double that of the general population for at least the 2 years following hospital admission for syncope (24). Table 3 shows the current BAST guidelines on fitness to drive of patients with syncope. Individual assessment may result in a judgment that the patient may be fit to drive despite recurrent syncope, if the syncope is not associated with driving. This is the case, for example, for syncope associated with medical procedures (e.g. venipuncture) or after being on the toilet (micturition, defecation).
Acute coronary syndrome (ACS) and/or stable coronary heart disease (CHD) and fitness to drive
Table 4 shows the BAST guidelines on fitness to drive of persons with acute coronary syndrome and/or coronary heart disease. These recommendations also differ fundamentally from earlier BAST recommendations. Regarding myocardial infarction, no distinction is now made between a first myocardial infarction and a recurrence, nor between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI). The highest risk of dying of a myocardial infarction is during the first 10 days after the onset of the infarction (25). It may be assumed that about one-third of cardiovascular deaths after myocardial infarction are sudden cardiac deaths (26). In the BAST guidelines, the most important prognostic parameter in determining fitness to drive is now left ventricular ejection fraction (EF). Since many large studies have set the primary preventive indication for an ICD at EF <35%, this threshold value for restricted ventricular function after myocardial infarction has also been chosen by the European Union Expert Advisory Panel for unfitness to drive. Patients with group 2 driving licenses and an EF <35% are always unfit to be occupational drivers.
Bradyarrhythmias and fitness to drive
Patients with bradyarrhythmias (heart rate <50 to 60/min) are at risk of reduced cerebral perfusion leading to syncope. The higher the estimated risk of syncope, the more likely it is that the patient is unfit to drive. If a patient fulfills the criteria defined in the current guidelines of the German Cardiac Society for implantation of a cardiac pacemaker, it must be carefully considered whether that patient is fit to drive without a pacemaker. The current BAST recommendations regarding fitness to drive and bradyarrhythmias are summarized in Table 5.
Tachyarrhythmias and fitness to drive
Depending on heart rate and left ventricular function, tachyarrhythmias (ventricular rate >100/min) can lead to syncope. Patients with tachyarrhythmias should be referred to a cardiologist for better evaluation of the cardiac disease. The main question of interest is whether any cardiological disease is present in addition to the arrhythmia (structural heart disease, e.g. valve disease; hypertensive heart disease; cardiomyopathy) which might be important for the prognosis. Supraventricular tachycardia may be successfully treated by ablation or medication. In patients with ventricular tachycardia, although the most frequent cause is previous myocardial infarction with underlying coronary heart disease, the possibility of various forms of cardiomyopathy or ion channel disease must also be considered. The current BAST recommendations regarding fitness to drive of persons with various tachyarrhymias are shown in Table 6.
Conflict of interest statement
Professor Sechtem holds shares in Daimler, VW, General Motors, Ford, and BMW.
Professors Klein and Trappe declare that no conflict of interest exists.
Manuscript received on 22 February 2017, revised version accepted on
2 August 2017.
Prof. Dr. med. Hermann H. Klein
Langwiesen Str. 13,
55743 Idar-Oberstein, Germany
Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart:
Prof. Dr. med. Sechtem
Medical Clinic II—Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum
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