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To Drive or Not Following ICD Implantations?

June 18, 2014Joshua M. Cooper, MD

 

Driving is a privilege shared by approximately 200 million Americans. Drivers not only enjoy the independence that comes with having a license, but also the ability to complete daily tasks such as going to work, the grocery store, the doctor and the pharmacy.

During a recent staged debate at the American College of Cardiology 2014 Scientific Sessions, Joshua M. Cooper, MD, Director of Cardiac Electrophysiology at Temple University Hospital and Professor of Medicine at Temple University School of Medicine, defended the notion that patients with implantable cardioverter defibrillators (ICD) are safe to drive if the device has not delivered a treatment shock in three months. ICDs use automatic electrical pulses, or shocks, to restore a normal heartbeat when a potentially dangerous fast heart rhythm occurs. Taking the opposing view at the debate was Steven Markowitz, MD, from New York-Presbyterian/Weill Cornell Medical College.

"We take it for granted when we can drive, but the moment it's taken away, people suffer – economically because they can no longer work, socially, [and] they can't drive to get food," said Dr. Cooper.

Dr. Cooper pointed out the psychological impact of restricting patients from driving. In one analysis of driving bans for various medical reasons, there was a 27% jump in emergency room visits for depression, 29% visited their doctor less often, and 10% stopped seeing their doctor altogether.

At issue during the debate was a theoretical patient with an ICD who received a shock three months earlier, and now wishes to resume driving.

"In order for somebody to have an accident, they need to have an arrhythmia that occurs while they're driving. The arrhythmia would have to be fast enough to cause them to lose control of the vehicle, crash the vehicle, and sustain injury or death. And this almost never happens," Dr. Cooper said.

Citing published studies that looked at drivers who are suddenly incapacitated for medical reasons, Dr. Cooper pointed out that while more than 300 patients lost the ability to control their vehicles, less than half actually had accidents and of those that did, there were only six injuries and one death.

Further supporting his point, Dr. Cooper used a timeline graph showing that recurrent arrhythmia following a shock is most likely to occur in the first month or two after the ICD is implanted. After that, the risk of recurrent problems decreases.

In the end, both Dr. Cooper and Dr. Markowitz agreed that driving instructions to ICD patients should be made on a case-by-case basis.

"Perhaps we should resist the urge to fall back on arbitrary recommendations, a 'one-size-fits-all' guideline," said Dr. Markowitz. "Maybe we should think about how often a patient drives and how high a risk that patient has.