Dallas, TX and Washington, DC - Patients with primary-prevention implantable cardioverter-defibrillators (ICDs) have a low enough risk of receiving a shock or pacing therapy while behind the wheel that they needn't be restricted from driving, according to a joint statement from two cardiology societies [1] that update their recommendations from a decade ago [2].

The document from the American Heart Association and Heart Rhythm Society (HRS) is consistent with but expands on the brief mention of primary-prevention ICDs in the earlier report and should help clear up any misconceptions based on the wisdom of a bygone era, when ICDs were implanted overwhelmingly for secondary prevention, according to Dr Andrew E Epstein (University of Alabama at Birmingham), who led the update's writing committee.

Today, as before, the recommendation is that patients with secondary-prevention devices shouldn't drive, Epstein observed for heartwire. But the restriction isn't appropriate for the rapidly growing new generation of patients with primary-prevention ICDs, who, as the report states, based on published clinical-trial data, have a predicted 0.15% average annual risk of experiencing a shock while driving.

The updated recommendations were published online February 7, 2007 by Circulation and are scheduled for its March 6, 2007 issue as well as the March 2007 issue of the HRS flagship journal Heart Rhythm. They do not apply to the licensing of commercial drivers, who, the document notes, are subject to more comprehensive federal restrictions.

The update says that patients implanted with primary-prevention devices should avoid driving for at least week after surgery, a time of increased risk of inappropriate shocks, to allow adequate healing. But even in this group, the delivery of device therapy, whether shocks or antitachycardia pacing, "warrants transitioning from rules of primary prevention to those of secondary prevention, ie, restriction from driving." Their future clinical course is unpredictable, it states. "Because the risk to patients and others is significant if there is an important chance for syncope, it appears inappropriate to support driving in such patients."

In fact, concern over "the risk to others" presented by ICD patients who drive is thoroughly discussed in the document. Epstein said he believes its substantive passages on ethics and social responsibility "are absolutely essential" if the recommendations are to be meaningful.

Ethics compels physicians to balance "the rights of the individual and the good of the society" when counseling their patients with ICDs and to be consistent about driving restrictions, according to the document. Being unable to drive can be an immense burden to a patient, but others have "the right to protect themselves against the harm caused by individuals who are unable to operate a motor vehicle in a safe and prudent manner. In a just and open society, all individuals are treated equally. Therefore, restrictions on the driving ability of patients with arrhythmias must be clearly elaborated and applied uniformly to all."