Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators

Cardioverter-Defibrillator Implantation as a Risk Factor For Motor Vehicle Crash

BACKGROUND

Limited empirical evidence informs fitness-to-drive recommendations after implantable cardioverter-defibrillator (ICD) implantation. Cohort designs can be deceptive because ICD recipients differ from control individuals and may temporarily cease driving after implantation.

OBJECTIVES

This study sought to generate evidence to inform medical driving restrictions after ICD implantation.

METHODS

We used population-based data to identify all drivers involved in a serious motor vehicle crash in British Columbia, Canada, from 1997 to 2019. Exposure was defined as ICD implantation in the 6 months before a crash. One analysis used a case-crossover design to control for relatively fixed individual characteristics like driving experience. Another analysis used a responsibility design to account for road exposure (miles of driving per week). Both analyses used logistic regression with adjustment for potential confounders.

RESULTS

In the case-crossover analysis of crash-involved ICD recipients, ICD implantation occurred in 212 of 3,299 precrash intervals and in 485 of 6,598 control intervals, suggesting no temporal association between ICD implantation and subsequent crash (6.4% vs 7.4%; adjusted OR [aOR]: 0.86; 95% CI: 0.71-1.03; P = 0.11). In the analysis of all crash-involved drivers with determinate crash responsibility, 14 of 22 drivers with recent ICD implantation and 532,741 of 1,035,433 drivers without recent ICD implantation were deemed responsible for their crash, suggesting no association between ICD implantation and crash responsibility (crude proportion responsible, 64% vs 51%; aOR: 2.20; 95% CI: 0.94-5.30; P = 0.08).

CONCLUSIONS

The 6-month interval after ICD implantation is not associated with increased odds of crash nor with increased likelihood of crash responsibility. Contemporary driving restrictions in the first weeks after ICD implantation appear to adequately mitigate the potential increase in crash risk.

Incidence of ventricular arrhythmias after implantable cardioverter-defibrillator implantation or replacement, and driving restriction consequences

BACKGROUND

Following implantation/replacement of an implantable cardioverter-defibrillator, patients are legally subjected to variable lengths of driving restrictions based on the indication (1 and 3 months after primary and secondary prevention, respectively; 1 week after device replacement).

AIM

To assess the incidence of ventricular arrhythmia during the theoretical driving restriction period in a large cohort of patients.

METHODS

Patients who underwent implantable cardioverter-defibrillator implantation for primary or secondary prevention or device replacement between 2015 and 2021 were included retrospectively. The primary endpoint was the occurrence of ventricular arrhythmia during the theoretical driving restriction period, as defined by guidelines.

RESULTS

A total of 914 patients were analysed, including 654 first implantations (438 and 216 for primary and secondary prevention, respectively) and 260 device replacements. The primary outcome occurred in 2/438 patients (0.004%) during the 1-month period following device implantation for primary prevention and in 25/216 patients (11.5%) during the 3-month period following device implantation for secondary prevention; it did not occur in the 1-week period following device replacement. The monthly calculated risk of harm remained below the accepted threshold of 0.005% for each group.

CONCLUSIONS

Primary prevention patients, such as those who have undergone device replacement, have a low risk of ventricular arrhythmia, which could lead to a reduction in their driving restriction period. Secondary prevention patients experienced a higher risk of recurrent ventricular arrhythmia, supporting the 3-month driving restriction period.

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.

DREAM-ICD-II Study

BACKGROUND

Regulatory authorities of most industrialized countries recommend 6 months of private driving restriction after implantation of a secondary prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. This study aimed to assess the incidence rate of appropriate device therapies in contemporary recipients of a secondary prevention ICD.

METHODS

This retrospective study at 3 Canadian tertiary care centers enrolled consecutive patients with new secondary prevention ICD implants between 2016 and 2020.

RESULTS

For a median of 760 days (324, 1190 days), 721 patients were followed up. The risk of recurrent ventricular arrhythmia was highest during the first 3 months after device insertion (34.4%) and decreased over time (10.6% between 3 and 6 months, 11.7% between 6 and 12 months). The corresponding incidence rate per 100 patient-days was 0.48 (95% CI, 0.35-0.64) at 90 days, 0.28 (95% CI, 0.17-0.45) at 180 days, and 0.21 (95% CI, 0.13-0.33) between 181 and 365 days after ICD insertion (P<0.001). The cumulative incidence of arrhythmic syncope resulting in sudden cardiac incapacitation was 1.8% within the first 90 days and subsequently dropped to 0.4% between 91 and 180 days (P<0.001) after ICD insertion.

CONCLUSIONS

The incidence rate of appropriate therapies resulting in sudden cardiac incapacitation in contemporary recipients of a secondary prevention ICD is much lower than previously reported and declines significantly after the first 3 months. Lowering driving restrictions to 3 months after the index cardiac event seems safe, and revision of existing guidelines should be considered in countries still adhering to a 6-month period. Existing restrictions for private driving after implantation of a secondary prevention ICD should be reconsidered.

Heinzel F, Davos CH, Kudaiberdieva G, Frederix I, Svendsen JH, Hansen D. Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Driving following defibrillator implantation: a nationwide register-linked survey study

AIMS

Patients are restricted from driving following implantable cardioverter defibrillator (ICD) implantation or shock. We sought to investigate how many patients are aware of, and adhere to, the driving restrictions, and what proportion experience an ICD shock or other cardiac symptoms while driving.

METHODS AND RESULTS

We performed a nationwide survey of all living Danish residents 18 years or older who received a first-time ICD between 2013 and 2016 (n = 3913) and linked their responses with nationwide registers. Of 2741 respondents (47% primary prevention, 83% male, median age 67 years), 2513 (92%) held a valid driver's license at ICD implantation, 175 (7%) of whom had a license for professional driving. Many drivers were unaware of driving restrictions: primary prevention 58%; secondary prevention 36%; post-appropriate shock 28%; professional drivers 55%. Almost all (94%) resumed non-professional driving after ICD implantation, more than one-third during the restricted period; 35% resumed professional driving. During a median follow-up of 2.3 years, 5 (0.2%) reported receiving an ICD shock while driving, one of which resulted in a traffic accident. The estimated risk of harm was 0.0002% per person-year.

CONCLUSION

In this nationwide study, many ICD patients were unaware of driving restrictions, and more than one third resumed driving during a driving restriction period. However, the rate of reported ICD shocks while driving was very low.

Comprehensive multicomponent cardiac rehabilitation in cardiac implantable electronic devices recipients: a consensus document from the European Association of Preventive Cardiology (EAPC; Secondary prevention and rehabilitation section) and European Heart Rhythm Association (EHRA)

Cardiac rehabilitation (CR) is a multidisciplinary intervention including patient assessment and medical actions to promote stabilization, management of cardiovascular risk factors, vocational support, psychosocial management, physical activity counselling, and prescription of exercise training. Millions of people with cardiac implantable electronic devices live in Europe and their numbers are progressively increasing, therefore, large subsets of patients admitted in CR facilities have a cardiac implantable electronic device. Patients who are cardiac implantable electronic devices recipients are considered eligible for a CR programme. This is not only related to the underlying heart disease but also to specific issues, such as psychological adaptation to living with an implanted device and, in implantable cardioverter-defibrillator patients, the risk of arrhythmia, syncope, and sudden cardiac death. Therefore, these patients should receive special attention, as their needs may differ from other patients participating in CR. As evidence from studies of CR in patients with cardiac implantable electronic devices is sparse, detailed clinical practice guidelines are lacking. Here, we aim to provide practical recommendations for CR in cardiac implantable electronic devices recipients in order to increase CR implementation, efficacy, and safety in this subset of patients.

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) Study

BACKGROUND

Current guidelines recommend 4 weeks of private driving restriction after implantation of a primary-prevention implantable cardioverter-defibrillator (ICD). These driving restrictions result in significant inconvenience and social implications. Advances in medical treatment and ICD programming have lowered the overall rate of device therapies. The objective of this study was to assess the incidence of ICD therapies at 30, 60, and 180 days after implantation.

METHODS

Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) was a retrospective cohort study conducted at 2 Canadian university centres enrolling patients with new implantation of a primary-prevention ICD. Device programming was standardised according to current guidelines. A total of 803 patients were enrolled.

RESULTS

The cumulative rates of appropriate ICD therapies at 30, 60, and 180 days were 0.12%, 0.50%, and 0.75%, respectively. There was no syncope during the first 6 months. The median duration to the first appropriate ICD therapy was 208 (range 23-1109) days after implantation. The rate of inappropriate ICD therapies at 30 days was only 0.2%. Overall, < 13.6% of all appropriate ICD therapies occurred within the first 6 months after implantation.

CONCLUSIONS

The rate of appropriate ICD therapies within the first 30 days after device insertion is extremely low in contemporary primary prevention cohorts with guideline-concordant device programming. There was no increased risk for ventricular arrhythmia early after ICD insertion. The results of DREAM-ICD suggest the need for a revision of the existing driving restrictions for primary-prevention ICD recipients.

Driving with cardiac devices in Australia. Does a review of recent evidence prompt a change in guidelines?

Australian Driving Guidelines for patients with pacemakers and implanted cardioverter defibrillators are in line with many around the world, with some minor differences. Some aspects of these guidelines lack contemporary evidence in key decision-making areas and make broad recommendations regarding groups with heterogeneous populations. In addition, more recent studies suggest lower rates of adverse events in some patients with these devices than previously thought. Through a systematic literature review, along with discussion of current guidelines, we combine new evidence with well established risk assessment tools to ask the following questions: (i) Given the heterogeneity of patient risk within the defibrillator population, should guidelines allow for further individualisation of risk and subsequent licensing restrictions?; and (ii) Could some patients with primary prevention automated cardioverter defibrillators be able to hold a commercial driving licence?

A Review of Driving Restrictions in Patients at Risk of Syncope and Cardiac Arrhythmias Associated with Sudden Incapacity: Differing Global Approaches to Regulation and Risk

The ability to drive is a highly valued freedom in the developed world. Sudden incapacitation while driving can result in injury or death for the driver and passengers or bystanders. Cardiovascular conditions are a primary cause for sudden incapacitation and regulations have long existed to restrict driving for patients with cardiac conditions at high risk of sudden incapacitation. Significant variation occurs between these rules in different countries and legislatures. Quantification of the potential risk of harm associated with various categories of drivers has attempted to make these regulations more objective. The assumptions on which these calculations are based are now old and less likely to reflect the reality of modern driving. Ultimately, a more individual assessment of risk with a combined assessment of the medical condition and the patient's driving behaviour may be appropriate. The development of driverless technologies may also have an impact on decision making in this field.

Seat belts-related behaviors in car drivers with cardiac implantable electronic devices

BACKGROUND

Seat belt use is the single most effective means of reducing fatal injuries in road traffic accidents. The presence of a cardiac implantable electronic device (CIED) might influence seat belt-related behaviors due to the physical proximity of the seat belt and left subclavian area in which the device is usually implanted. Understanding the underlying mechanisms of improper seat belt use may improve safety of these patients.

METHODS

We performed a prospective study using a structured questionnaire with 120 CIED recipients (age, 63.9 ± 10.9 years) attending a pacing outpatient clinic. All study participants were active drivers and predominantly male. The majority of patients (79%) had undergone high-energy device implantation.

RESULTS

We found that 18% of study participants do not fasten seat belts on a regular basis or use the seat belt in an atypical fashion (such as under the armpit). Moderate or high level of discomfort from the interaction between seat belt and CIED was present in 27%, while more than half (51%) were afraid of seat belt-induced CIED damage. In multifactorial analysis, we found the following independent predictors of improper seat belt use: (1) at least moderate level of discomfort at the CIED site (P = 0.02); (2) fear of CIED damage (P = 0.009); and (3) irregular seat belt use prior to CIED implantation (P = 0.037).

CONCLUSIONS

Improper seat belt-related behaviors are common in CIED recipients. They arise from previous habits and from CIED-related physical and psychological factors. Patients' education regarding the importance and safety of proper seat belt use is a priority.

Driving following defibrillator implantation: development and pilot results from a nationwide questionnaire

BACKGROUND

Implantable cardioverter defibrillator (ICD) implantation is associated with driving restrictions which may have profound effects on the patient's life. However, there is limited patient-reported data on the information given about driving restrictions, the adherence to the restrictions, the incidence of arrhythmic symptoms while driving, and the driving restrictions' effect on ICD patients' daily life and quality of life factors. A specific questionnaire was designed to investigate these objectives, intended for use in a nationwide ICD cohort.

METHODS

The conceptual framework based on literature review and expert opinion was refined in qualitative semi-structured focus group interviews with ten ICD patients. Content validity was pursued through pre-testing, including expert review and 28 cognitive interviews with patients at all ICD implanting centres in Denmark. Finally, the Danish Pacemaker and ICD registry was used to randomly select 50 ICD patients with a first-time implantation between January 1, 2013 and November 30, 2016 for pilot testing, followed by a test-retest on 25 respondents. Test-retest agreement was assessed using kappa statistics or intraclass correlation coefficients.

RESULTS

The pilot test achieved a response rate of 78%, whereof the majority were web-based (69%). Only 49% stated they had been informed about any driving restrictions after ICD implantation, whereas the number was 75% after appropriate ICD shock. Among respondents, 95% had resumed private driving, ranging from 1 to 90 days after ICD implantation. In those informed of a significant (≥ 1 month) driving ban, 55% stated the driving restrictions had impeded with daily life, especially due to limitations in maintaining employment or getting to/from work and 25% admitted they had knowingly been driving during the restricted period. There were six episodes of dizziness or palpitations not necessitating stopping the vehicle. Test-retest demonstrated good agreement of questionnaire items, with 69% of Kappa coefficients above 0.60.

CONCLUSIONS

We have developed a comprehensive questionnaire on ICD patients' perspective on driving. Pre-testing and pilot testing demonstrated good content validity, feasible data collection methods, and a robust response rate. Thus, we believe the final questionnaire, distributed to almost 4000 ICD patients, will capture essential evidence to help inform driving guidelines in this population.

How Do Patients Understand Safety for Cardiac Implantable Devices? Importance of Postintervention Education

Aim

This study was designed to assess the effect of patient education on the knowledge of safety and awareness about living with cardiac implantable electronic devices (CIEDs) within the context of phase I cardiac rehabilitation.

Methods

The study was conducted with 28 newly implanted CIED patients who were included in “education group (EG)”. Patients were questioned with a survey about living with CIEDs and electromagnetic interference (EMI) before and 1 month after an extensive constructed interview. Ninety-three patients who had been living with CIEDs were included in the “without education group (woEG)”.

Results

Patients in EG had improved awareness on topics related to physical and daily life activities including work, driving, sports and sexual activities, EMI of household items, harmful equipment, and some of the medical devices in the hospital setting (p<0.05). Patients in EG gave significantly different percent of correct answers for doing exercise or sports, using the arm on the side of CIEDs, EMI of some of the household appliances, medical devices, and all of the harmful equipment compared to woEG (p<0.05).

Conclusion

It was demonstrated that a constructed education interview on safety of CIEDs and living with these devices within the context of phase I cardiac rehabilitation is important for improving the awareness of patients significantly. Thus, patients might achieve a faster adaptation to daily life and decrease disinformation and misperceptions and thus promote the quality of life after the device implantation.

Physicians' knowledge of implantable defibrillator treatment: are we good enough?

Aims

When admitted to hospitals, patients with an implantable cardioverter defibrillator (ICD) are treated in a variety of departments. Physicians need to have basic ICD knowledge in order to provide the best possible care from implantation to the end of life. The aim of this study was to assess the levels of knowledge concerning ICD treatment among physicians active in Cardiology, Internal Medicine, and Geriatrics.

Methods and results

This cross-sectional comparative study, after stratified sampling, distributed 432 surveys in 18 hospitals with a response rate of 99.5%. As many as 349 (83%) physicians had experience with ICD patients; 288 (68%) rated their ICD knowledge to be low. According to predefined criteria, 175 (41%) physicians' scores reflected sufficient knowledge. There was a significant difference in the level of knowledge between specialities. Sufficient knowledge was reached by 56 (30%) of the physicians in Internal Medicine and 20 (19%) of them in Geriatrics, whereas in Cardiology 99 (71%) reached sufficient knowledge.

Conclusion

There is lack of basic knowledge in ICD treatment and clinical management among physicians. The majority of the respondents had prior experience in treating ICD patients. Over two-thirds of the physicians rated their knowledge to be low, while test scores revealed sufficient knowledge in only 41% of the physicians surveyed. The lack of ICD knowledge is most prominent in Internal Medicine and Geriatrics, but it also extends to physicians in Cardiology departments. With an increasing number of ICD patients, it is of great importance to fill this knowledge gap as soon as possible.

Driving restrictions for Dutch patients with an implantable cardioverter defibrillator : Compliance and associated factors

Background

Dutch patients with an implantable cardioverter defibrillator (ICD) are restricted from driving for two months after implantation or shocks. This requires significant lifestyle adjustments and is one of the primary concerns of ICD patients. Previous studies indicated that compliance with the driving restrictions is poor, but insight in socio-demographic, clinical and psychological factors associated with compliance is limited. Hence, this study aimed to explore compliance with the driving restrictions and associated factors in a large sample of Dutch ICD patients.

Method

Dutch ICD patients (N = 313) completed an elaborative set of questionnaires at time of implantation and at four months after implantation, assessing socio-demographic, psychological and driving-related characteristics. Clinical data were collected from the patients’ medical records.

Results

A substantial subgroup (28%) of the patient sample (median age 64 (interquartile range = 55–71), 81% male) reported to have been noncompliant with the driving restrictions. Univariate analysis indicated that noncompliant patients more often considered refusing the ICD due to the restrictions, compared to compliant patients (19% versus 10%, p = 0.02). Multivariate analysis showed that the feeling of understanding the reason behind the driving restrictions was associated with better compliance (odds ratio = 2.16, 95% confidence interval 1.02–4.56, p = 0.04). No other socio-demographic, clinical, psychological or driving-related factors were associated with compliance.

Conclusion

A large number of ICD patients does not comply with the driving restrictions after implantation. This study emphasised the importance of the patient’s feeling of understanding the reason behind the restrictions.

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.

Patient-centred care of patients with ventricular arrhythmias and risk of sudden cardiac death: What do the 2015 European Society of Cardiology guidelines add?

Nurses and allied professionals are at the forefront of care delivery in patients with arrythmogenic risk and have a responsibility to deliver care that is focused on their individual needs. The 2015 European Society of Cardiology guideline on prevention of ventricular arrhythmia and sudden cardiac death heralds a step-change in patient and family focus and interdisciplinary involvement. This development reflects a recognition within the European Society of Cardiology that chronic care of patients with cardiovascular conditions can be improved by involving all stakeholders, making use of multidisciplinary interventions, and placing the patient at the centre of the care process. In this article, taskforce contributors discuss the latest evidence and highlight some of the most pertinent issues for nurses involved in patient-centred care of patients and families with ventricular arrhythmias and/or risk of sudden death.

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.

Sports and Driving With an Implantable Cardioverter-Defibrillator

Many patients with implantable cardioverter-defibrillators (ICD) want to participate in sports and many need or wish to operate a personal motor vehicle. Healthcare providers need to advise patients regarding restrictions related to these activities in the context of the clinical indication for the ICD. Ethical considerations need to be considered when advising ICD patients of restrictions to reduce risk of injury to themselves and to others when participating in either sports or driving. Shared decision-making is necessary to have ICD patients understand and comply with recommended restrictions. Guidelines have been developed based on available studies; however, studies assessing the need for ICD patients to restrict these activities are observational and often out of date. More recent studies challenge driving and sports restrictions that are recommended by the guidelines. Recommendations to ICD patients must be individualized yet be compliant with the guidelines, and need to adapt to changes in a patients' condition.

Efficacy and Limitations of Tachycardia Detection Interval Guided Reprogramming for Reduction of Inappropriate Shock in Implantable Cardioverter-Defibrillator Patients

The avoidance of inappropriate shock therapy is an important clinical issue in implantable cardioverter-defibrillator (ICD) patients. We retrospectively analyzed therapeutic events in ICD patients, and the effect of tachycardia detection interval (TDI) and tachycardia cycle length (TCL) guided reprograming on the reduction of inappropriate ICD therapy. The clinical determinants of after reprogramming were also evaluated.A total of 254 consecutive ICD patients were included in the study, and the incidence of antitachycardia therapy was evaluated during the follow-up period of 27.3 ± 18.7 months. When inappropriate antitachycardia therapy appeared, TDI was reprogrammed not to exceed the detected TCL and the patients continued to be followed-up. Various clinical parameters were compared between patients with and without inappropriate ICD therapy. During the initial follow-up period of 18.6 ± 15.6 months, ICD therapy occurred in 127/254 patients (50%) including inappropriate antitachycardia pacing (ATP) (12.9%) and shock (44.35%). Determinants of initial inappropriate therapy were dilated cardiomyopathy (DCM), history of therapeutic hypothermia, and QRS duration. Of the 61 patients with inappropriate therapy, 24 received TCL guided reprogramming. During the additional observation period of 17.0 ± 16.8 months, inappropriate therapy recurred in 5/24 patients (2 ATP, 3 shocks). The determinant of these inappropriate therapy events after reprogramming was the presence of supraventricular tachycardia.By applying simple TCL and TDI guided reprogramming, inappropriate therapy was reduced by 79%. The determinant of inappropriate therapy after reprogramming was the presence of supraventricular tachycardia.

Predictors and Proarrhythmic Consequences of Inappropriate Implantable Cardioverter-Defibrillator Therapy

BACKGROUND

Despite the benefits of implantable cardioverter-defibrillator (ICD) therapy, inappropriate shocks can lead to multiple adverse effects. The aim of this study was to clarify the predictors of inappropriate ICD shocks and their proarrhythmic consequences.

METHODS AND RESULTS

We retrospectively studied 316 consecutive patients who underwent ICD implantation from December 2000 to December 2011. Of them, 70 (22%) experienced inappropriate ICD shocks without proarrhythmia requiring some intervention; 2 patients (0.6%) had proarrhythmic inappropriate ICD therapy by antitachycardia pacing (ATP), thereby calculated to be 0.18% of patients per year. However, they did not have syncope from this inappropriate ATP. Multivariate analysis identified younger age (≤56 years: hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.02-2.77, P=0.043), paroxysmal atrial fibrillation (HR 3.00, 95% CI 1.64-5.31, P=0.0002), stroke (HR 2.23, 95% CI 1.11-4.47, P=0.024), and no diuretic use (HR 1.72, 95% CI 1.03-2.93, P=0.039) as independent predictors of the occurrence of inappropriate ICD shocks.

CONCLUSIONS

Young age, paroxysmal atrial fibrillation, stroke, and no use of diuretics were independently associated with inappropriate ICD shocks. Proarrhythmic inappropriate ICD therapy was observed with an annual incidence of 0.18% by ATP.

Phone-delivered mindfulness training for patients with implantable cardioverter defibrillators: results of a pilot randomized controlled trial

BACKGROUND

The reduction in adrenergic activity and anxiety associated with meditation may be beneficial for patients with implantable cardioverter defibrillators.

PURPOSE

This study aims to determine the feasibility of a phone-delivered mindfulness intervention in patients with defibrillators and to obtain preliminary indications of efficacy on mindfulness and anxiety.

METHODS

Clinically stable outpatients were randomized to a mindfulness intervention (eight weekly individual phone sessions) or to a scripted follow-up phone call. We used the Hospital Anxiety and Depression Scale and the Five Facets of Mindfulness to measure anxiety and mindfulness, and multivariate linear regression to estimate the intervention effect on pre-post-intervention changes in these variables.

RESULTS

We enrolled 45 patients (23 mindfulness and 22 control; age, 43-83; 30 % women). Retention was 93 %; attendance was 94 %. Mindfulness (beta = 3.31; p = 0.04) and anxiety (beta = -1.15; p = 0.059) improved in the mindfulness group.

CONCLUSIONS

Mindfulness training can be effectively phone-delivered and may improve mindfulness and anxiety in cardiac defibrillator outpatients.

Appropriate duration of driving restrictions after inappropriate therapy from implantable cardiac shock devices-interim analysis of the Nippon Storm Study

BACKGROUND

Little is known regarding the appropriate duration for driving restrictions after inappropriate implantable cardiac shock device (ICSD) therapy.

METHODS AND RESULTS

We evaluated the Nippon Storm Study data, and found that inappropriate ICSD therapy occurred in 114 (7.6%) patients during a median follow-up of 464 days. Among those patients, 25 experienced further inappropriate ICSD therapy during a subsequent median follow-up of 380 days. Time-dependent recurrence of inappropriate ICSD therapy occurred in 19 (76%) patients within 180 days.

CONCLUSIONS

The interval for driving restrictions after inappropriate ICSD therapy can be reduced.

Inappropriate ICD shocks caused by T-wave oversensing due to acute alcohol intoxication

T-wave oversensing can be a serious problem that often results in inappropriate device therapy. We report here a patient with binge alcohol use who received multiple, inappropriate ICD shocks due to T-wave oversensing from repolarization changes induced by acute alcohol intoxication and no other relevant metabolic derangements. Following recovery from his alcohol intoxication a few days later, the T-wave amplitude decreased so the device no longer inappropriately sensed or delivered therapies. This case represents an uncommon, but reversible, cause of T-wave oversensing that should be considered before more aggressive measures are taken to correct the abnormality.

Cardiac Resynchronization Therapy With and Without Defibrillator in a Commercial Truck Driver with Ischemic Cardiomyopathy and New York Heart Association Class III Heart Failure

Commercial drivers warrant tighter restrictions to their driving privileges than private drivers. Patients with cardiac disease who are at risk of consciousness-impairing arrhythmias are not allowed to drive commercially. Patients with left ventricular systolic dysfunction and/or heart failure symptoms are permanently disqualified from commercial driving. A biventricular pacemaker without defibrillator can improve symptoms and mortality in selected patients with heart failure. Biventricular pacing may have antiarrhythmic effects that may reduce the added benefit of a defibrillator. Motor vehicle collisions resulting from arrhythmic events are infrequent. The interests of public safety must outweigh individual liberties when driving safety is in question.

Driving restrictions after implantable cardioverter defibrillator implantation: an evidence-based approach

Aims

Little evidence is available regarding restrictions from driving following implantable cardioverter defibrillator (ICD) implantation or following first appropriate or inappropriate shock. The purpose of the current analysis was to provide evidence for driving restrictions based on real-world incidences of shocks (appropriate and inappropriate).

Methods and results

A total of 2786 primary and secondary prevention ICD patients were included. The occurrence of shocks was noted during a median follow-up of 996 days (inter-quartile range, 428–1833 days). With the risk of harm (RH) formula, using the incidence of sudden cardiac incapacitation, the annual RH to others posed by a driver with an ICD was calculated. Based on Canadian data, the annual RH to others of 5 in 100 000 (0.005%) was used as a cut-off value. In both primary and secondary prevention ICD patients with private driving habits, no restrictions to drive directly following implantation, or an inappropriate shock are warranted. However, following an appropriate shock, these patients are at an increased risk to cause harm to other road users and therefore should be restricted to drive for a period of 2 and 4 months, respectively. In addition, all ICD patients with professional driving habits have a substantial elevated risk to cause harm to other road users during the complete follow-up after both implantation and shock and should therefore be restricted to drive permanently.

Conclusion

The current analysis provides a clinically applicable tool for guideline committees to establish evidence-based driving restrictions.

[Cardiac syncope : diagnosis and therapy]

The second most frequent category of syncope is cardiac syncope. In contrast to syncope of noncardiac causes, the 1-year mortality of patients presenting with cardiac syncope without treatment is as high as 33%. Therefore, immediate diagnosis and treatment are necessary. Bradyarrhythmias or tachyarrhythmias are the most common causes of cardiac syncope. In many cases, an initial evaluation including history, physical examination, and electrocardiogram identifies the cause of syncope, so that specific treatment can be initiated immediately. In the remainder of cases, implantable loop recorders are useful to identify arrhythmias, while the presence or absence of structural cardiac disease is diagnosed by echocardiography. Syncope due to arrhythmias is typically treated with implantation of a pacemaker or an implantable cardioverter-defibrillator; treatment of syncope of other cardiac causes requires therapy of the underlying heart disease.

Approach to patients with implanted pacemaker and scheduled surgical or diagnostic procedure

Application of cardiac electrostimulation in strictly defined indications has been on the increase over the last few decades. Frequent use of this therapy as well as the fact that it is applied predominantly in patients in the seventh decade of life, implies possible signifficant comorbidities and need for various diagnostic and surgical procedures. These are the reasons we decided to point out certain specific features in approaching this patient group in preparation and implementation of these procedures. Preoperative approach starts with usual patient history, with additional information on the type of pacemaker, last pacemaker check and electrocardiogram. This general approach is not substantialy different for pacemaker or ICD patients. What is specific is the possible interferrence caused by devices used in diagnostic or therapeutic procedures (diathermy, lithotripsy). Complications that may arise are usually related to the underlying disease rather than the pacemaker malfunction, but still, careful approach and pacemaker check are warranted, especially in the group marked as "pacemaker dependent". Adequate preoperative assessment, only slightly different from the usual, represents a sufficient guarantee for safe procedures diagnostic, therapeutic or surgical.