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
ConditionNon-commercial driversCommercial drivers
ACS: PCI performed
STEMI, LVEF ≤ 40%May resume driving after 1 monthMay resume driving after 3 months
STEMI, LVEF >40%May resume driving after 2 weeksMay resume driving after 1 month
NSTEMI, LVEF ≤ 40%May resume driving after 1 monthMay resume driving after 3 months
NSTEMI, LVEF >40%May resume driving after 2 weeksMay resume driving after 1 month
ACS without MI (unstable angina)May resume driving after 48 hoursMay resume driving after 7 days
ACS: PCI not performed
STEMIMay resume driving after 1 monthMay resume driving after 3 months
NSTEMIMay resume driving after 1 monthMay resume driving after 3 months
ACS without MI (unstable angina)May resume driving after 7 daysMay resume driving after 1 month
Chronic CAD
Stable angina or asymptomatic CAD*No restrictionNo restriction
PCI (in a non-ACS context)May resume driving after 48 hoursMay resume driving after 48 hours
Cardiac surgery
CABG surgeryMay resume driving after 1 monthMay 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
ConditionNon-commercial driversCommercial 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
  • LVEF ≥ 30%

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 ≥ 30%

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 ≥ 30%

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 ≥ 30%

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 ≥ 30%

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 ≥ 30%

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
  • LVEF > 30%

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 ≥ 30%

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 ≥ 30%

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 ≥ 30%

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
ConditionNon-commercial driversCommercial drivers
Heart failure
NYHA Class INo restrictionNo restriction if EF < 30%
NYHA Class IINo restrictionDisqualified if EF < 30%
NYHA Class IIINo restrictionDisqualified
NYHA Class IVDisqualifiedDisqualified
Receiving intermittent outpatient or home inotrope therapyDisqualifiedDisqualified
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
ConditionNon-commercial driversCommercial drivers
Brugada syndrome
Spontaneous type 1, asymptomaticNo restrictionNo restriction (after expert evaluation)
Provoked type 1, asymptomaticNo restrictionNo restriction
Symptomatic, prior syncope*No restrictionDisqualified (consider resumption of driving at ≥ 3 years, with expert evaluation§)
Symptomatic, prior cardiac arrestMay resume driving after 3 monthsDisqualified
Long QT syndrome
Asymptomatic, QTc <500 msNo 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 -blockersNo 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 monthsDisqualified, 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 monthsDisqualified (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 therapyMay 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 therapyMay resume driving after 3 monthsDisqualified (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 diagnosisNo restrictionNo restriction
Lamin cardiomyopathy
Prior sustained ventricular arrhythmia, stable on appropriate therapyMay resume driving after 3 monthsDisqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
No high-risk featuresNo restrictionNo 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 therapyMay resume driving after 3 monthsDisqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
Low risk of ventricular arrhythmia (<1% annually), according to expert opinionNo restrictionNo 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 eventMay resume driving after 3 monthsDisqualified (consider resumption of driving at ≥ 5 years, with expert evaluation§)
No high-risk featuresNo restrictionNo 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
ConditionNon-commercial and commercial drivers
Permanent pacemaker
Transvenous and leadless pacemakers, with prior impaired consciousness or high-grade atrioventricular blockDisqualified for 1 week after implantation, after which patient may resume driving
Transvenous and leadless pacemakers, without impaired consciousness or high-grade atrioventricular blockNo restriction*
Generator changeNo 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*†
ConditionNon-commercial driversCommercial drivers‡
Transvenous ICD
Primary prophylaxisMay resume driving 1 week after implantDisqualified
Secondary prophylaxis for VF or VT with impaired level of consciousnessMay resume driving 3 months after implantDisqualified
Secondary prophylaxis for sustained VT without impaired consciousnessMay resume driving 1 week after implantDisqualified
Subcutaneous ICDSame recommendations as for primary and secondary prophylaxis with transvenous devicesDisqualified
Generator changeNo restriction§Disqualified
Upgrade/lead revisionMay resume driving 1 week after procedureDisqualified
ICD delivery of therapy
Appropriate ICD shock or any ICD therapy with impaired level of consciousness or otherwise disablingMay resume driving 3 months after eventDisqualified

Non-shock ICD therapy (i.e., anti-tachycardia pacing) without

impaired level of consciousness and not otherwise disabling

May resume driving 1 week after eventDisqualified
Inappropriate ICD therapiesNo restrictionDisqualified
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 drivingDisqualified

*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
ConditionNon-commercial and commercial drivers*
Sinus node dysfunction
Sinus node dysfunction without impaired level of consciousnessNo 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 consciousnessDisqualified until appropriate pacemaker therapy is in place
AV and fascicular block†
Isolated first-degree AV blockNo restriction if no impaired level of consciousness‡
Isolated RBBB, left anterior fascicular block, or left posterior fascicular blockNo restriction if no impaired level of consciousness‡
LBBBNo restriction if no impaired level of consciousness‡
Bifascicular blockNo 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 blockNo restriction if no impaired level of consciousness‡
Second-degree AV block (Mobitz II)Disqualified until appropriate pacemaker therapy is in place
Alternating LBBB and RBBBDisqualified until appropriate pacemaker therapy is in place
Acquired third-degree AV blockDisqualified 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 blockNo 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
ConditionNon-commercial driversCommercial drivers
Ventricular arrhythmias*
VF (no reversible cause)May resume driving 3 months after index eventDisqualified
VT/VF due to a reversible cause†Disqualified until/unless successful treatment of underlying condition
Hemodynamically unstable VT or VT with impaired level of consciousnessMay resume driving 3 months after eventDisqualified
Sustained VT with structural heart disease without impaired level of consciousness (in patients without ICD)‡May resume driving 3 months after eventDisqualified
Sustained VT§ with structurally normal heart (i.e., idiopathic VT) without impaired level of consciousnessMay resume driving 1 week after event, provided there is satisfactory controlDisqualified
Supraventricular tachycardia, atrial fibrillation, atrial flutter
With impaired level of consciousnessDisqualified until satisfactory control 
Without impaired level of consciousnessNo restriction 
Following electrophysiology study or catheter ablation procedureMay 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
ConditionNon-commercial driversCommercial drivers
Single episode of typical vasovagal syncopeNo restriction
Recurrent (within 12 months) vasovagal syncopeNo restriction
Syncope with a reversible cause or syncope that has been treated (e.g., orthostatic, hemorrhage, dehydration)May resume driving after 1 weekMay resume driving after 1 month
Situational syncope with avoidable trigger (e.g., micturition syncope, defecation syncope)May resume driving after 1 weekMay resume driving after 1 month
Single episode of unexplained syncopeMay resume driving after 1 weekMay resume driving after 12 months
Recurrent episode of unexplained syncope (within 12 months)May resume driving after 3 monthsMay resume driving after 12 months
Syncope due to documented tachyarrhythmia or inducible tachyarrhythmia at electrophysiology studyRefer 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
ConditionNon-commercial and commercial drivers
Cyanotic heart disease / Eisenmenger syndromeNo 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.


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