Section 14
Cardiovascular diseases

Alert

Patients with unstable cardiac disease who require admission to hospital or intensified follow-up should cease driving immediately until they can be shown to be at an acceptably low risk.

14.1 Overview

These recommendations are based on the 2023 Canadian Cardiovascular Society (CCS) guideline on fitness to drive (Canadian Cardiovascular Society, 2023). They are intended to assist decision-makers in assessing the fitness of cardiac patients to drive and are not intended to diminish the role of the physician’s clinical judgment in individual cases.

Recommendations are presented in tabular form (Tables 4 to 10). Details regarding these and other recommendations can be found in the full report.*

The recommendations are based on expert opinion using the “risk of harm” formula developed by the CCS, as described in Appendix C. Application of the “risk of harm” formula throughout this section creates internal consistency among recommendations based on cardiovascular disorders, but does not imply consistency with recommendations based on other conditions or disorders, either in this guide or elsewhere.

For purposes of its medical fitness-to-drive standards, the CCS has adopted the New York Heart Association (NYHA) functional classification and the left ventricular ejection fraction (LVEF) as indicators of the severity of most cardiovascular disorders. These indicators are used throughout this section.

14.2 Coronary artery disease

Most patients with coronary artery disease (CAD) pose a low risk to other road users while driving. However, certain conditions require careful evaluation and judgment. It seems fair to conclude on both clinical and physiological grounds that the cardiovascular workload imposed by driving a vehicle is very light and that the risk that driving will provoke a recurrent acute coronary syndrome incident causing incapacitation is extremely small. Although a small percentage of acute coronary syndromes can present with sudden cardiac incapacitation, it is not possible with contemporary risk stratification to identify these patients in advance in a meaningful way.

*Guerra PG, Simpson CS, Van Spall HGC. 2023 Canadian Cardiovascular Society guidelines on the fitness to drive. Can J Cardiol 2023 Oct. 9 [online]. Available: https://onlinecjc.ca/article/S0828-282X(23)01755-5/fulltext. Used with permission.

TABLE 4: Recommendations for fitness to drive for patients with coronary artery disease
Condition	Non-commercial drivers	Commercial drivers
ACS: PCI performed
STEMI, LVEF ≤ 40%	May resume driving after 1 month	May resume driving after 3 months
STEMI, LVEF >40%	May resume driving after 2 weeks	May resume driving after 1 month
NSTEMI, LVEF ≤ 40%	May resume driving after 1 month	May resume driving after 3 months
NSTEMI, LVEF >40%	May resume driving after 2 weeks	May resume driving after 1 month
ACS without MI (unstable angina)	May resume driving after 48 hours	May resume driving after 7 days
ACS: PCI not performed
STEMI	May resume driving after 1 month	May resume driving after 3 months
NSTEMI	May resume driving after 1 month	May resume driving after 3 months
ACS without MI (unstable angina)	May resume driving after 7 days	May resume driving after 1 month
Chronic CAD
Stable angina or asymptomatic CAD*	No restriction	No restriction
PCI (in a non-ACS context)	May resume driving after 48 hours	May resume driving after 48 hours
Cardiac surgery
CABG surgery	May resume driving after 1 month	May resume driving after 3 months
Angiographic demonstration of 50% or greater reduction in diameter of the left main coronary artery should disqualify the patient from commercial driving, and 70% or greater reduction in the diameter of the left main coronary artery should disqualify the patient from non- commercial driving, unless treated with revascularization. Note:* ACS = acute coronary syndrome, CABG = coronary artery bypass graft, CAD = coronary artery disease, LVEF = left ventricular ejection fraction, MI = myocardial infarction, NSTEMI = non-ST-segment elevation myocardial infarction, PCI = percutaneous coronary intervention, STEMI = ST-segment elevation myocardial infarction.

Practical tips

For patients who have undergone coronary artery bypass graft (CABG) surgery or percutaneous cor- onary intervention (PCI), driving restrictions apply for the duration listed starting from the surgical/ procedural date. For patients who have been admitted to hospital but who have not undergone an intervention, driving restrictions apply for the duration listed following discharge from hospital.
For patients with an acute coronary syndrome (ACS) but with only non-obstructive coronary artery disease (CAD) found at coronary angiography, without additional data to guide decision-making, it is reasonable to manage care as if the patients were revascularized, letting left ventricular function guide further decision-making.

14.3 Valvular heart disease

Valvular heart disease can range from mild to severe. In general, the risk posed to the public by a driver with valvular heart disease depends largely on the following:

symptomatic status
echocardiography data that quantify both the valvular lesion and the left ventricular dimensions.

TABLE 5: Recommendations for fitness to drive for patients with valvular heart disease
Condition	Non-commercial drivers	Commercial drivers
Medically treated valvular heart disease
Aortic stenosis	No restriction if: NYHA Class I or II Disqualified if: NYHA Class III or IV	No restriction if: NYHA Class I, and no episodes of impaired level of consciousness, and LVEF ≥ 50% Otherwise disqualified
Aortic regurgitation	No restriction if: NYHA Class I–III Disqualified if: NYHA Class IV	No restriction if: NYHA Class I, and no episodes of impaired level of consciousness, and LVEF ≥ 50% Otherwise disqualified
Mitral regurgitation	No restriction if: NYHA Class I–III Disqualified if: NYHA Class IV	No restriction if: NYHA Class I, and no episodes of impaired level of consciousness, and LVEF ≥ 50%, and no history of pulmonary hypertension or systemic embolism Otherwise disqualified
Mitral stenosis	No restriction if: NYHA Class I–III Disqualified if: NYHA Class IV	No restriction if: NYHA Class I, and no episodes of impaired level of consciousness Otherwise disqualified
Tricuspid regurgitation	No restriction if: NYHA Class I–III Disqualified if: NYHA Class IV	No restriction if: NYHA Class I, and no episodes of right-sided HF or symptomatic sustained arrhythmia, and no right ventricular dysfunction, and LVEF ≥ 50% Otherwise disqualified
Valvular heart disease treated with transcatheter therapy*
Aortic stenosis, treated with TAVR	May resume driving 1 month after procedure if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I–III	May resume driving 3 months after procedure if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I Otherwise disqualified
Aortic regurgitation, treated with TAVR	May resume driving 1 month after procedure if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I–III	May resume driving 3 months after procedure if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Mitral regurgitation, treated with TEER†	May resume driving 48 hours after procedure if: NYHA Class I–III	May resume driving 1 month after procedure if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Mitral regurgitation, treated with TMVR	May resume driving 1 month after procedure if: NYHA Class I–III	May resume driving 3 months after procedure if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Mitral stenosis, treated with PBMV†	May resume driving 48 hours after procedure if: NYHA Class I–III	May resume driving 1 month after procedure if: NYHA Class I Otherwise disqualified
Tricuspid regurgitation, treated with TEER†	May resume driving 48 hours after procedure if: NYHA Class I–III	May resume driving 1 month after procedure if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Tricuspid regurgitation, treated with TTVR	May resume driving 1 month after procedure if: NYHA Class I–III	May resume driving 3 months after procedure if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Surgically treated valve disease
Aortic stenosis, treated with SAVR	May resume driving 1 month after surgery if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I–III Otherwise disqualified	May resume driving 3 months after surgery if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I Otherwise disqualified
Aortic regurgitation, treated with SAVR	May resume driving 6 weeks after surgery if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I–III Otherwise disqualified	May resume driving 3 months after surgery if: stable QRS duration‡ and no high-grade atrioventricular block§ in the absence of a permanent pacemaker, and NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Mitral stenosis, treated with SMVR	May resume driving 6 weeks after surgery if: NYHA Class I–III Otherwise disqualified	May resume driving 3 months after surgery if: NYHA Class I Otherwise disqualified
Mitral regurgitation, treated with SMVR or repair	May resume driving 6 weeks after surgery if: NYHA Class I–III Otherwise disqualified	May resume driving 3 months after surgery if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
Tricuspid regurgitation, treated with STVR	May resume driving 6 weeks after surgery if: NYHA Class I–III Otherwise disqualified	May resume driving 3 months after surgery if: NYHA Class I, and LVEF ≥ 50% Otherwise disqualified
These recommendations pertain to post-procedural driving status; for patients with persistent advanced HF, refer to section 14.4. †Although few data exist on sudden cardiac incapacitation following these procedures, the consensus opinion is that caution is warranted to allow for appropriate recovery after hospitalization, immobilization, sedation, and vascular instrumentation. ‡Stable QRS duration defined as no new bundle branch block and stability of QRS duration (within 10%) for 24 hours after TAVR or AVR. §High-grade atrioventricular block defined as second-degree type II or third-degree atrioventricular block. Note:* AVR = aortic valve replacement, HF = heart failure, LVEF = left ventricular ejection fraction, NYHA = New York Heart Association, PBMV = percutaneous balloon mitral valvuloplasty, SAVR = surgical aortic valve replacement, SMVR = surgical mitral valve replacement, STVR = surgical tricuspid valve replacement, TAVR = transcatheter aortic valve replacement, TEER = transcatheter edge-to-edge repair (mitral valve), TMVR = transcatheter mitral valve replacement, TTVR = transcatheter tricuspid valve replacement.

Practical tips

Patients with untreated severe symptomatic aortic valve stenosis and regurgitation (New York Heart Association [NYHA] Class IV) are disqualified from non-commercial driving. For commercial driving, untreated aortic stenosis must be completely asymptomatic (NYHA Class I).
Patients with untreated severe symptomatic mitral valve stenosis and regurgitation and those with tricuspid valve regurgitation (NYHA Class IV) are disqualified from both non-commercial and com- mercial driving.
Patients undergoing transcatheter aortic valve replacement (TAVR) with a stable QRS duration and no high-grade atrioventricular block may resume non-commercial driving 1 month after the implant date and commercial driving 3 months after the implant date.
Unless they remain within NYHA Class IV, patients who have undergone mitral valve or tricuspid valve transcatheter edge-to-edge repair (TEER) may resume non-commercial driving 48 hours after the procedure.

14.4 Congestive heart failure, left ventricular dysfunction, cardiomyopathy, and transplantation

Patients with cardiomyopathy, with or without a history of heart failure, potentially pose a risk on the roads. Functional status is a major determinant of fitness, as is the LVEF. Because sudden death is so common in this group, physicians are encouraged to cross-reference this section with section 14.6, Rhythm and devices. In the event of a conflict, the more restrictive recommendation applies.

TABLE 6: Recommendations for fitness to drive for patients with heart failure, LVAD, or heart transplant
Condition	Non-commercial drivers	Commercial drivers
Heart failure
NYHA Class I	No restriction	No restriction if EF ≥ 30%
NYHA Class II	No restriction	Disqualified if EF < 30%
NYHA Class III	No restriction	Disqualified
NYHA Class IV	Disqualified	Disqualified
Receiving intermittent outpatient or home inotrope therapy	Disqualified	Disqualified
LVAD	May resume driving if: at least 2 months after implant, and NYHA Class I or II Otherwise disqualified	Disqualified
Heart transplant	May resume driving if: at least 6 weeks after discharge, and NYHA Class I or II, and on stable immunosuppression therapy, and undergoing annual reassessment Otherwise disqualified	May resume driving if: at least 6 months after discharge, and NYHA Class I, and EF ≥ 50%, and undergoing annual reassessment that includes testing to rule out active ischemia Otherwise disqualified
Note: EF = ejection fraction, LVAD = left ventricular assist device, NYHA = New York Heart Association.

Practical tips

Among patients with heart failure with reduced ejection fraction, commercial driving is restricted to those with left ventricular ejection fraction ≥ 30% and New York Heart Association (NYHA) Class I or II symptoms.
Non-commercial drivers with heart failure and NYHA Class IV symptoms are disqualified from driving.

14.5 Inherited arrhythmia syndromes and cardiomyopathies

Patients with inherited arrhythmia syndromes and cardiomyopathies are increasingly recognized in clinical practice. The risk posed when these patients get behind the wheel is determined predominantly by the risk of sudden death or non-fatal (but temporarily incapacitating) ventricular arrhythmias. The magnitude of the risk depends on symptom status, adherence to therapy, and stability over time.

TABLE 7: Recommendations for fitness to drive for patients with inherited arrhythmia syndromes and cardiomyopathies
Condition	Non-commercial drivers	Commercial drivers
Brugada syndrome
Spontaneous type 1, asymptomatic	No restriction	No restriction (after expert evaluation)
Provoked type 1, asymptomatic	No restriction	No restriction
Symptomatic, prior syncope*	No restriction	Disqualified (consider resumption of driving at ≥ 3 years, with expert evaluation§)
Symptomatic, prior cardiac arrest	May resume driving after 3 months	Disqualified
Long QT syndrome
Asymptomatic, QTc <500 ms	No restriction	No restriction if adherent to recommended β-blocker therapy
Asymptomatic, high-risk features (QTc >500 ms with long QT syndrome type 2 or 3), receiving recommended β -blockers	No restriction¶	Disqualified, but may be considered for resumption of driving (with expert opinion) after 6 months if adherent to recommended β -blocker therapy
Prior syncope,* receiving β -blockers†	May resume driving after 3 months	Disqualified, but may be considered for resumption of driving after 12 months if adherent to recommended β -blocker therapy
Prior cardiac arrest, receiving β -blockers†	May resume driving after 3 months	Disqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
Arrhythmogenic right ventricular cardiomyopathy
Definitive diagnosis‡ and no prior syncope*	No restriction¶	Disqualified (unless condition is stable and expert evaluation determines otherwise§)
Prior syncope* and stable on appropriate therapy	May resume driving after 3 months¶	Disqualified (consider resumption of driving at ≥ 3 years, with expert evaluation§)
Prior sustained ventricular arrhythmia event and stable on appropriate therapy	May resume driving after 3 months	Disqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
No definitive diagnosis: variant carriers, family members with no definite arrhythmogenic right ventricular cardiomyopathy, possible or borderline diagnosis	No restriction	No restriction
Lamin cardiomyopathy
Prior sustained ventricular arrhythmia, stable on appropriate therapy	May resume driving after 3 months	Disqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
No high-risk features	No restriction	No restriction
High-risk features (two or more of LVEF <45%, male sex, NSVT, and non-missense variants)	No restriction¶	Disqualified
Other arrhythmogenic cardiomyopathies
Prior sustained ventricular arrhythmia event, stable on appropriate therapy	May resume driving after 3 months	Disqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
Low risk of ventricular arrhythmia (<1% annually), according to expert opinion	No restriction	No restriction
Higher risk of ventricular arrhythmia event, according to expert opinion	No restriction if annual risk of ventricular arrhythmia <22% Driving prohibited if annual risk of ventricular arrhythmia ≥ 22%	Driving prohibited if annual risk of ventricular arrhythmia ≥ 1%
Hypertrophic cardiomyopathy
Prior sustained ventricular arrhythmia event	May resume driving after 3 months	Disqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
No high-risk features	No restriction	No restriction
High risk features: any of wall thickness ≥ 30 mm, syncope,* otherwise unexplained systolic dysfunction (LVEF <50%), and presence of an apical aneurysm or a calculated risk of ventricular arrhythmia above 6% over 5 years	If syncope is present, may resume driving after 3 months; if asymptomatic, no restriction¶	Disqualified (consider resumption of driving at ≥ 3 years, with expert evaluation,§ and after age 60 years)
Syncope presumed to be arrhythmic. †If β -blockers are recommended. Exceptions may apply for patients with prior left cardiac sympathetic denervation. ‡If a patient with a borderline diagnosis has a syncopal or sustained ventricular arrhythmia event that is deemed, after expert evaluation, to have been caused by arrhythmogenic right ventricular cardiomyopathy, the recommendation for patients with a definitive diagnosis should be followed. §If risk of impairment of consciousness is considered less than 1% annually, based on expert opinion. ¶If an implantable cardioverter defibrillator has been implanted, refer to section 14.6, Rhythm and devices. Note:* LVEF = left ventricular ejection fraction, NSVT = non-sustained ventricular tachycardia.

Practical tips

Commercial driving in patients with heart failure with reduced ejection fraction is restricted to those with left ventricular ejection fraction ≥ 30% and with New York Heart Association (NYHA) Class I or II symptoms.
Non-commercial drivers with heart failure and NYHA Class IV symptoms are disqualified from driving.

14.6 Rhythm and devices: cardiac implantable electronic devices, bradyarrhythmias, and tachyarrhythmias

The general trend away from risk stratification guided by electrophysiology studies and toward risk stratification based on left ventricular function is reflected in the 2023 CCS guideline and in medical standards for fitness to drive, given that most trials of implantable cardioverter defibrillators have identified left ventricular function as one of the most important determinants of risk.

TABLE 8a: Recommendations for fitness to drive for patients with pacemakers
Condition	Non-commercial and commercial drivers
Permanent pacemaker
Transvenous and leadless pacemakers, with prior impaired consciousness or high-grade atrioventricular block	Disqualified for 1 week after implantation, after which patient may resume driving
Transvenous and leadless pacemakers, without impaired consciousness or high-grade atrioventricular block	No restriction*
Generator change	No restriction*
Upgrade/lead revision	If there is a prior history of impaired level of consciousness or high-grade atrioventricular block, patient is disqualified for 1 week, after which patient may resume driving Otherwise no restriction*
*All procedures (including those marked as “No restriction”) are subject to driving restrictions relating to appropriate recovery from hospitalization, site of intervention, vascular access, and the anesthesia provided (i.e., general anesthesia or sedatives).

TABLE 8b: Recommendations for fitness to drive for patients with ICDs*†
Condition	Non-commercial drivers	Commercial drivers‡
Transvenous ICD
Primary prophylaxis	May resume driving 1 week after implant	Disqualified
Secondary prophylaxis for VF or VT with impaired level of consciousness	May resume driving 3 months after implant	Disqualified
Secondary prophylaxis for sustained VT without impaired consciousness	May resume driving 1 week after implant	Disqualified
Subcutaneous ICD	Same recommendations as for primary and secondary prophylaxis with transvenous devices	Disqualified
Generator change	No restriction§	Disqualified
Upgrade/lead revision	May resume driving 1 week after procedure	Disqualified
ICD delivery of therapy
Appropriate ICD shock or any ICD therapy with impaired level of consciousness or otherwise disabling	May resume driving 3 months after event	Disqualified
Non-shock ICD therapy (i.e., anti-tachycardia pacing) without impaired level of consciousness and not otherwise disabling	May resume driving 1 week after event	Disqualified
Inappropriate ICD therapies	No restriction	Disqualified
Electrical storm (≥ three VT or VF events in 24 hours)	Disqualified for 3–6 months after event, dependent on severity of electrical storm and clinical management; expert evaluation required to determine eligibility to return to driving	Disqualified
All recommendations are subject to physician judgment, incorporating patient-specific considerations and risk factors for arrhythmias and syncope. Furthermore, all recommendations are based on devices with satisfactory operational parameters (i.e., normal functionality). In cases of suboptimal capture thresholds and sensing, unusual programming, or compromised device functionality, restrictions should be at the discretion of the treating physician. †Remote monitoring should ideally be provided for all patients receiving ICDs, to ensure that generator and lead malfunctions can be identified early, both to prevent malfunction of the device system and to mitigate the risk of adverse events while driving. ‡Drivers with ICDs are disqualified from commercial driving on the basis of their underlying condition (e.g., ventricular dysfunction, history of ventricular arrhythmia) rather than the ICD itself. §All procedures (including those marked as “No restriction”) are subject to driving restrictions relating to appropriate recovery from hospitalization, site of intervention, vascular access, and the anesthesia provided (i.e., general anesthesia or sedatives). Note:* ICD = implantable cardioverter defibrillator, VF = ventricular fibrillation, VT = ventricular tachycardia.

Practical tip

Patients with electrical storm caused by ventricular arrhythmia may require more aggressive driving restrictions (relative to the standard 3-month restriction), depending on the severity of the electrical storm and clinical management (ablation and/or antiarrhythmic therapy). Those with clustered arrhythmias, implantable cardioverter defibrillator shocks, and a greater number of arrhythmias per cluster (or shorter cluster length) may require prolonged driving restrictions, at the discretion of the treating physician.

TABLE 8c: Recommendations for fitness to drive for patients with bradyarrhythmias
Condition	Non-commercial and commercial drivers*
Sinus node dysfunction
Sinus node dysfunction without impaired level of consciousness	No restriction
Sinus node dysfunction with impaired level of consciousness (sick sinus syndrome)	Disqualified until appropriate pacemaker therapy is in place
Atrial fibrillation with conversion pauses (≥ 5 seconds) or conversion pauses with impaired level of consciousness	Disqualified until appropriate pacemaker therapy is in place
AV and fascicular block†
Isolated first-degree AV block	No restriction if no impaired level of consciousness‡
Isolated RBBB, left anterior fascicular block, or left posterior fascicular block	No restriction if no impaired level of consciousness‡
LBBB	No restriction if no impaired level of consciousness‡
Bifascicular block	No restriction if no impaired level of consciousness‡
Second-degree AV block (Mobitz I)	No restriction if no impaired level of consciousness‡
First-degree AV block + bifascicular block	No restriction if no impaired level of consciousness‡
Second-degree AV block (Mobitz II)	Disqualified until appropriate pacemaker therapy is in place
Alternating LBBB and RBBB	Disqualified until appropriate pacemaker therapy is in place
Acquired third-degree AV block	Disqualified until appropriate pacemaker therapy or successful resolution in the case of a reversible cause (e.g., inferior STEMI or Lyme carditis)
Congenital third-degree AV block	No restriction if no impaired level of consciousness†
For commercial drivers, at least annual follow-up with the treating physician is recommended for evaluation of symptoms and possible progression of conduction abnormalities. †There are special considerations when conduction disease is present in patients with certain cardiomyopathies (e.g., sarcoidosis) and various inherited conditions (laminopathies, muscular dystrophies). In these patients, driving restriction is at the discretion of the treating physician. ‡For patients with first-degree AV block, isolated RBBB, left anterior fascicular block, left posterior fascicular block, LBBB, bifascicular block, second-degree AV block (Mobitz I), first-degree AV block + bifascicular block, and congenital third-degree AV block, no restrictions are required if there is no history of impaired level of consciousness. If there is a history of impaired level of consciousness, driving is disqualified until appropriate therapy with a cardiac implantable electronic device is in place. Note:* AV = atrioventricular, LBBB = left bundle branch block, RBBB = right bundle branch block, STEMI = ST-segment elevation myocardial infarction.

Practical tip

Patients with congenital third-degree atrioventricular block may require a driving restriction if they are symptomatic or have evidence of marked bradycardia (junctional pauses >3 seconds). Decisions related to therapy with a cardiac implantable electronic device and driving restrictions should be made at the discretion of the treating physician with expertise in congenital heart disease.

TABLE 8d: Recommendations for fitness to drive for patients with tachyarrhythmias
Condition	Non-commercial drivers	Commercial drivers
Ventricular arrhythmias*
VF (no reversible cause)	May resume driving 3 months after index event	Disqualified
VT/VF due to a reversible cause†	Disqualified until/unless successful treatment of underlying condition
Hemodynamically unstable VT or VT with impaired level of consciousness	May resume driving 3 months after event	Disqualified
Sustained VT with structural heart disease without impaired level of consciousness (in patients without ICD)‡	May resume driving 3 months after event	Disqualified
Sustained VT§ with structurally normal heart (i.e., idiopathic VT) without impaired level of consciousness	May resume driving 1 week after event, provided there is satisfactory control	Disqualified
Supraventricular tachycardia, atrial fibrillation, atrial flutter
With impaired level of consciousness	Disqualified until satisfactory control
Without impaired level of consciousness	No restriction
Following electrophysiology study or catheter ablation procedure	May resume driving 48 hours after procedure if no new conduction disturbance, dysrhythmias, or exacerbation of underlying condition¶
All patients should receive an ICD wherever indicated (i.e., VT/VF with no reversible cause, hemodynamically unstable VT, or VT with impaired consciousness). †Examples of reversible causes of VT/VF include, but are not limited to, VF within 24 hours of myocardial infarction, VF during coronary angiography, VF with electrocution, and VF secondary to drug toxicity. Reversible-cause VF recommendations overrule the VF (no reversible cause) recommendations if the reversible cause is treated successfully and the VF does not recur. ‡In patients with an ICD present, refer to ICD recommendations (Table 8b). §Sustained VT is VT that lasts for more than 30 seconds and/or results in hemodynamic compromise within 30 seconds. ¶All procedures (including those marked as “No restriction”) are subject to driving restrictions relating to appropriate recovery from hospitalization, site of intervention, vascular access, and the anesthesia provided (i.e., general anesthesia or sedatives). Note:* ICD = implantable cardioverter defibrillator, VF = ventricular fibrillation, VT = ventricular tachycardia.

Practical tips

Patients with supraventricular tachycardia, atrial fibrillation, or atrial flutter with impaired level of consciousness may drive following satisfactory clinical control of their arrhythmia, at the discretion of the treating physician.
Women may experience symptoms associated with supraventricular tachycardia more frequently than men.

14.7 Syncope

Most episodes of syncope have a vasovagal mechanism, which can usually be diagnosed from the history, and do not warrant further investigation. When syncope is not clearly vasovagal, further testing is necessary to reach the diagnosis and direct possible therapy.

A patient with structural heart disease (e.g., reduced ejection fraction, significant valvular disease, previous myocardial infarction, or significant congenital heart disease) is potentially at high risk and should be subject to driving restrictions, pending clarification of the underlying heart disease and the cause of syncope.

TABLE 9: Recommendations for fitness to drive for patients who experience syncope
Condition	Non-commercial drivers	Commercial drivers
Single episode of typical vasovagal syncope	No restriction
Recurrent (within 12 months) vasovagal syncope	No restriction
Syncope with a reversible cause or syncope that has been treated (e.g., orthostatic, hemorrhage, dehydration)	May resume driving after 1 week	May resume driving after 1 month
Situational syncope with avoidable trigger (e.g., micturition syncope, defecation syncope)	May resume driving after 1 week	May resume driving after 1 month
Single episode of unexplained syncope	May resume driving after 1 week	May resume driving after 12 months
Recurrent episode of unexplained syncope (within 12 months)	May resume driving after 3 months	May resume driving after 12 months
Syncope due to documented tachyarrhythmia or inducible tachyarrhythmia at electrophysiology study	Refer to section 14.6, Rhythm and devices
Syncope with diagnosed and treated cause (e.g., permanent pacemaker for bradycardia)	Refer to section 14.6, Rhythm and devices

Practical tips

Syncope as a symptom can result from a wide range of underlying cardiovascular pathologies, associated with a wide spectrum of risk for recurrent episodes. This highlights the importance of appropriately investigating patients with syncope, to determine the underlying cause.
Patients with vasovagal syncope, even those with recurrent episodes, have a very low risk of experiencing an episode while driving, which negates the need for driving restrictions.

14.8 Congenital heart disease and cyanotic heart disease

Patients with congenital heart disease, including cyanotic heart disease, may pose a risk of sudden cardiac incapacitation ranging from trivial to substantial and may require specialized evaluation by experts. Guidance from other sections can be applied as appropriate for many specific conditions; however, it is often the case that individual risk assessments are required according to the unique set of structural lesions and their severity, taking into consideration their capacity to produce sudden incapacitation.

TABLE 10: Recommendations for fitness to drive for patients with cyanotic heart disease / Eisenmenger syndrome
Condition	Non-commercial and commercial drivers
Cyanotic heart disease / Eisenmenger syndrome	No restrictions unless other limiting conditions are present Expert individual risk assessment is recommended

Practical tips

Patients with complex (corrected or uncorrected) congenital heart disease should discuss their fitness to drive with a practitioner who has expertise in the field.
Patients with supplemental oxygen requirements should be carefully assessed, possibly with the help of respiratory medicine specialists, with regard to their fitness to drive. If applicable, local restrictions concerning the use of in-vehicle oxygen delivery systems should be followed.

14.9 Abnormal blood pressure

14.9.1 Hypertension

Hypertension, other than uncontrolled malignant hypertension, is not itself a contraindication to the operation of any class of motor vehicle, although the complications that can arise from increased blood pressure, such as cardiac, ocular, or renal damage, may well preclude safe driving. Sustained hypertension above 170/110 mm Hg is, however, often accompanied by complications that make driving dangerous, and patients with this level of hypertension must be evaluated carefully.

Higher standards are required of commercial drivers. If a commercial driver is found to have blood pressure of 170/110 mm Hg or higher, the patient should be referred to an internist or other appropriate specialist for an opinion. The long-term risks associated with sustained hypertension (over 170/110 mm Hg) are such that patients who are unable to reduce their blood pressure to a level below this figure should not be recommended for licensing as commercial drivers.

14.9.2 Hypotension

Hypotension is not a contraindication to the operation of any type of motor vehicle unless it has caused episodes of syncope (refer to section 14.7, Syncope).

14.10 Anticoagulants

Although the use of anticoagulant drugs is not itself a contraindication to driving any class of motor vehicle, the underlying condition that led to prescribing the anticoagulant may be incompatible with safe driving.

References

Guerra PG, Simpson CS, Van Spall HGC. 2023 Canadian Cardiovascular Society guidelines on the fitness to drive. Can J Cardiol 2023 Oct. 9 [online]. Available: https://onlinecjc.ca/article/S0828-282X(23)01755-5/fulltext. Used with permission.

Other resources

Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2018;72(14):e91-e220.

Baskett R, Crowell R, Freed D, et al. Canadian Cardiovascular Society focused position statement update on assessment of the cardiac patient for fitness to drive: fitness following left ventricular assist device implantation. Can J Cardiol. 2012;28(2):137-40.

Bozkurt B, Coats JS, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail. 2021;27(4):387-413.

Folino AF, Migliore F, Porta A, et al. Syncope while driving: pathophysiological features and long-term follow-up. Auton Neurosci. 2012;166(1-2):60-5.

Koepsell TD, Wolf ME, McCloskey L, et al. Medical conditions and motor vehicle collision injuries in older adults. J Am Geriatr Soc. 1994;42(7):695-700.

Maas R, Ventura R, Kretzschmar C, et al. Syncope, driving recommendations, and clinical reality: survey of patients. BMJ. 2003;326(7379):21.

Numé AK, Gislason G, Christiansen CB, et al. Syncope and motor vehicle crash risk: a Danish nationwide study. JAMA Intern Med. 2016;176(4):503-10.

O’Connor C, Fiuzat M, Mulder H, et al. Clinical factors related to morbidity and mortality in high risk heart failure patients: the GUIDE-IT predictive model and risk score. Eur J Heart Fail. 2019;21(6):770-8.

O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439-50.

Priori SG, Blomström-Lundqvist C, Mazzanti A, et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2015;36(41):2793-867.

Sheldon R, Koshman ML. Can patients with neuromediated syncope safely drive motor vehicles? Am J Cardiol. 1995;75(14):955-6.

Steinberg C, Cheung CC, Wan D, et al. Driving Restrictions and Early Arrhythmias in Patients Receiving a Primary-Prevention Implantable Cardioverter-Defibrillator (DREAM-ICD) study. Can J Cardiol. 2020;36(8):1269-77.

Steinberg C, Dognin N, Sodhi A, et al. DREAM-ICD-II study [Driving restrictions and early arrhythmias in patients receiving a secondary prevention implantable cardioverter-defibrillator]. Circulation. 2022;145(10):742-53.

Tan VH, Ritchie D, Maxey C, et al. Prospective assessment of the risk of vasovagal syncope during driving. JACC Clin Electrophysiol. 2016;2(2):203-8.

Thijssen J, Borleffs CJW, van Rees JB, et al. Driving restrictions after implantable cardioverter defibrillator implantation: an evidence-based approach. Eur Heart J. 2011;32(21):2678-87.

Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 2022;43(40):3997-4126.

Cardiovascular diseases

Section 14 Cardiovascular diseases

Alert

14.1 Overview

14.2 Coronary artery disease

Practical tips

14.3 Valvular heart disease

Practical tips

14.4 Congestive heart failure, left ventricular dysfunction, cardiomyopathy, and transplantation

Practical tips

14.5 Inherited arrhythmia syndromes and cardiomyopathies

Practical tips

14.6 Rhythm and devices: cardiac implantable electronic devices, bradyarrhythmias, and tachyarrhythmias

Practical tip

Practical tip

Practical tips

14.7 Syncope

Practical tips

14.8 Congenital heart disease and cyanotic heart disease

Practical tips

14.9 Abnormal blood pressure

14.9.1 Hypertension

14.9.2 Hypotension

14.10 Anticoagulants

References

Other resources

Section 14
Cardiovascular diseases