Motor vehicle crash risk after cardioverter-defibrillator implantation: a population-based cohort study

BACKGROUND

Limited empirical evidence informs driving restrictions after implantable cardioverter-defibrillator (ICD) implantation. We sought to evaluate real-world motor vehicle crash risks after ICD implantation.

METHODS

We performed a retrospective cohort study using 22 years of population-based health and driving data from British Columbia, Canada (2019 population: 5 million). Individuals with a first ICD implantation between 1997 and 2019 were age and sex matched to three controls. The primary outcome was involvement as a driver in a crash that was attended by police or that resulted in an insurance claim. We used survival analysis to compare crash risk in the first 6 months after ICD implantation to crash risk during a corresponding 6-month interval among controls.

RESULTS

A crash occurred prior to a censoring event for 296 of 9373 individuals with ICDs and for 1077 of 28 119 controls, suggesting ICD implantation was associated with a reduced risk of subsequent crash (crude incidence rate, 8.5 vs 10.5 crashes per 100 person-years; adjusted HR (aHR), 0.71; 95% CI 0.61 to 0.83; p<0.001). Results were similar after stratification by primary versus secondary prevention ICD. Relative to controls, ICD patients had more traffic contraventions in the 3 years prior to ICD implantation but fewer contraventions in the 6 months after implantation, suggesting individuals reduced their road exposure (hours or miles driven per week) or drove more conservatively after ICD implantation.

CONCLUSIONS

Crash risk is lower in the 6 months after ICD implantation than among matched controls, likely because individuals reduced their road exposure in order to comply with contemporary postimplantation driving restrictions. Policymakers might consider liberalisation of postimplantation driving restrictions while monitoring crash rates.

Stress Level Detection Based on the Capacitive Electrocardiogram Signals of Driving Subjects

The automotive industry and scientific community are making efforts to develop innovative solutions that would increase successful driver performance in preventing crashes caused by drivers' health and concentration. High stress is one of the causes of impaired driver performance. This study investigates the ability to classify different stress levels based on capacitive electrocardiogram (cECG) recorded during driving by unobtrusive acquisition systems with different hardware implementations. The proposed machine-learning model extracted only four features, based on the detection of the R peak, which is the most reliably detected characteristic point even in inferior quality cECG. Another criterion for selecting the features is their low computational complexity, which enables real-time application. The proposed method was validated on three open data sets recorded during driving: electrocardiogram (ECG) recorded by electrodes with direct skin contact (high quality); cECG recorded without direct skin contact through clothes by electrodes built into a portable multi-modal cushion (middle quality); and cECG recorded through the clothes without direct skin contact by electrodes built into a car seat (lowest quality). The proposed model achieved a high accuracy of 100% for high-quality ECG, 96.67% for middle-quality cECG, and 98.08% for the lower-quality cECG.

Age-Related Diseases and Driving Safety

Due to demographic changes, the number of older drivers is steadily increasing. Mobility is highly relevant for leading an independent life in the elderly. It largely depends on car driving, which is a complex task requiring a multitude of cognitive and motor skills vulnerable to age- related functional deterioration. The almost inevitable effects of senescence may be potentiated by age-related diseases, such as stroke or diabetes mellitus. Respective pharmacological treatment may cause side effects, additionally affecting driving safety. The present article reviews the impact of age-related diseases and drug treatment of these conditions on driving fitness in elderly drivers. In essence, we focus on diseases of the visual and auditory systems, diseases of the central nervous system (i.e., stroke, depression, dementia and mild cognitive disorder, and Parkinson's disease), sleep disorders, as well as cardiovascular diseases, diabetes mellitus, musculoskeletal disorders, and frailty. We will outline the role of functional tests and the assessment of driving behavior (by a driving simulator or in real traffic), as well as the clinical interview including questions about frequency of (near) accidents, etc. in the evaluation of driving fitness of the elderly. We also address the impact of polypharmacy on driving fitness and end up with recommendations for physicians caring for older patients.

Awareness of fitness to drive among cardiologists in Saudi Arabia

OBJECTIVES

To assess the perception and awareness of cardiologists in Saudi Arabia about medical fitness to drive in different cardiovascular diseases. Methods: The study is a cross-sectional survey-based study between June 2018 and July 2018. Cardiologists were asked to complete a self-administered questionnaire inquiring about awareness of driving fitness and educating patients regarding driving risks in specific cardiovascular conditions. Results: A total of 194 cardiologists completed the study survey; there were 30.4% consultants, 59.3% specialists, and 10.3% residents. Out of 195, 72% were aware of the existence of particular international driving regulations for cardiovascular diseases, whereas 28% were not aware. Although, no Saudi guidelines assessing fitness-to-drive are available, 11% of the participants claimed awareness of such regulations. Interestingly, we found that cardiologists had never or rarely educated their patients regarding the potential risks of driving: 49% in symptomatic angina, 47% when ejection fraction is ≤35%, 39% in symptomatic valvular diseases, 26% after cardioverter defibrillators implantation, and 23% after non-elective percutaneous coronary interventions. Conclusion: There is a lack of awareness among cardiologists in Saudi Arabia about international guidelines regarding medical driving fitness. This study highlights the necessity of formulating appropriate national driving regulations for cardiovascular diseases.

Inappropriate implantable cardioverter defibrillator shocks-incidence, effect, and implications for driver licensing

Purpose

Patients with implantable cardioverter defibrillators (ICDs) have an ongoing risk of sudden incapacitation that may cause traffic accidents. However, there are limited data on the magnitude of this risk after inappropriate ICD therapies. We studied the rate of syncope associated with inappropriate ICD therapies to provide a scientific basis for formulating driving restrictions.

Methods

Inappropriate ICD therapy event data between 1997 and 2014 from 50 Japanese institutions were analyzed retrospectively. The annual risk of harm (RH) to others posed by a driver with an ICD was calculated for private driving habits. We used a commonly employed annual RH to others of 5 in 100,000 (0.005%) as an acceptable risk threshold.

Results

Of the 4089 patients, 772 inappropriate ICD therapies occurred in 417 patients (age 61 ± 15 years, 74% male, and 65% secondary prevention). Patients experiencing inappropriate therapies had a mean number of 1.8 ± 1.5 therapy episodes during a median follow-up period of 3.9 years. No significant differences were found in the age, sex, or number of inappropriate therapies between patients receiving ICDs for primary or secondary prevention. Only three patients (0.7%) experienced syncope associated with inappropriate therapies. The maximum annual RH to others after the first therapy in primary and secondary prevention patients was calculated to be 0.11 in 100,000 and 0.12 in 100,000, respectively.

Conclusions

We found that the annual RH from driving was far below the commonly cited acceptable risk threshold. Our data provide useful information to supplement current recommendations on driving restrictions in ICD patients with private driving habits.

Electronic supplementary material

The online version of this article (doi:10.1007/s10840-017-0272-4) contains supplementary material, which is available to authorized users.

Driving restrictions in patients with implantable cardioverter defibrillators and pacemakers

Implantable cardioverter-defibrillators (ICDs) improve the survival in patients at risk of sudden cardiac death. However, these patients have an ongoing risk of sudden incapacitation that may cause harm to individuals and others when driving. Considerable disagreement exists about whether and when these patients should be allowed to resume driving after ICD therapies. This information is critical for the management decisions to avoid future potentially lethal incidents and unnecessary restrictions for ICD patients. The cardiac implantable device committee of the Japanese Heart Rhythm Society reassessed the risk of driving for ICD patients based on the literature and domestic data. We reviewed the driving restrictions of ICD patients in various regions and here present updated Japanese driving restrictions.