![]() (12) The estimated fatality rate of 7.5/100,000 patient-years in these ICD recipients was statistically lower than a similar fatality rate of 18.4/100,000 patient-years (p<0.05) for the general U.S population. physicians who follow patients post ICD implantation, 30 motor vehicle accidents related to ICD shocks were reported over a 12 year period. (3,4,10) Similarly, the risk for road accidents in patients with ICDs is reported to be low. The incidence of syncopal episodes with ICD discharges in this patient population was found to be 10-15%. (11) further reported that the highest incidence was in the first month after implantation, with a consequent reduction in months 2 to 7, followed by a further reduction after that. (4,8) The majority of these arrhythmias/ICD shocks, however, have been reported to occur in the first year following ICD implantation, after which the incidence decreases markedly. The risk of recurrence of a life threatening arrhythmia, as measured by ICD shocks over a 5-year follow up period, has been reported to be between 55% and 70%. The driving risk posed by patients with ICDs for secondary prophylaxis is based on several factors: the probability that these patients will have a recurrence of another life threatening arrhythmia, the probability that such a repeat incident will cause impaired consciousness, the probability that such an event will indeed lead to an accident, and finally, the probability that such an accident will lead to injury or death to self or others on the road. Risk Assessment in Patients With ICDs for Secondary Prophylaxis Of note, a goal of zero percent risk is not feasible, since both the young and the elderly pose a significant risk by themselves, and by permitting them to drive, society is already accepting a certain amount of risk. This mathematical expression has now become the basis for most recommendations on this issue, with an underlying assumption that an annual RH of 5 in 100,000 could be considered an acceptable risk for driving, a benchmark against which driving risks in patients with ICDs can be compared. (7) They estimated that the yearly RH would be proportional to: a) the average percentage of time spent driving (TD) b) type of vehicle driven (V) c) risk of sudden cardiac incapacitation (SCI) and d) the probability of such an event leading to an accident (Ac). The Canadian Cardiovascular Society at a consensus conference in 1992 developed a formula to estimate the risk of harm (RH) posed by a driver with cardiac disease (RH = TD × V × SCI × Ac). This mandate needs to be tightly balanced with the knowledge that driving restrictions could have a detrimental effect on patients’ quality of life (including loss of economic viability, independence and added emotional stress). Since patients with ICDs are potentially at a higher risk for incapacitation while driving, it becomes imperative to quantify the risk posed and then evaluate if their driving needs to be restricted. In any society, driving is restricted to members who do not pose an excessive threat to themselves or others. (5,6) There is also some risk of incapacitation secondary to the pain and surprise associated with an ICD shock. Since ICDs treat the arrhythmic manifestations of the underlying cardiac disease and not the disease substrate itself, these patients remain at risk for syncope secondary to VT or VF (despite early shock therapy from the ICD) (2-4) or sudden cardiac death (SCD) (since ICD implantation does not completely eliminate the risk for SCD). In some ways similar to patients with epilepsy, these patients are unique, since they appear fit to drive but could suddenly and unpredictably become unfit with potentially catastrophic consequences. (1) While ICDs have been consistently shown to improve survival, it has been recognized that these patients remain at ongoing risk of sudden incapacitation that could lead to harm to self or others on the road while driving a motor vehicle. ![]() Based on the results from multiple clinical trials, ICDs are now recommended both for secondary prophylaxis (following resuscitation from ventricular fibrillation (VF) or sustained ventricular tachycardia (VT)) as well as primary prophylaxis (selected high risk patients without prior cardiac arrest or sustained VT). The clinical indications for use of implantable cardioverter-defibrillators (ICDs) have evolved considerably over the last two decades.
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