Doctor, am I allowed to drive? A practical case-based guide on fitness to drive in cardiovascular diseases adapted from the Swiss model

	Group 1	Group 2
Vasovagal syncope 1×, not sitting/driving >1× OR while sitting/driving	✔	✔
	✔ 1-month waiting period	✔ >3-month waiting period and case-by-case assessment
Triggering and recoverable factor	✔	✔
Unclear syncope without prodrome	✔ 3-month waiting period	✔ If diagnosis and treatment; Otherwise, 12-month waiting period

Table 2

Fitness to drive with heart failure [6].

	Group 1	Group 2
NYHA I and II	✔	✔ If EF >35% and normal stress test
NYHA III	✔ If stable	✘
NYHA IV	✘	✘
LVAD	Case-by-case assessment	✘
After heart transplant	✔ After recovery	✔ NYHA I/II, EF >35% & normal stress test and 3-month waiting period

1 Abbreviations: NYHA = New York Heart Association; LAD = left arterial descending artery; LVAD = left ventricular assist device; EF = ejection fraction.

Table 3

Fitness to drive with coronary heart disease [6].

	Group 1	Group 2
ACS (conservative & PCI)	✔ 1 week waiting period & not angina CCS IV	✔ If asymptomatic, EF >35%, normal exercise test 6-week waiting period
Elective PCI	✔	✔
Bypass	✔ After recovery	✔ If NYHA I-II, EF >35%, normal exercise test 3-month waiting period
Stable coronary artery disease	✔ No resting angina	✔ If asymptomatic, EF >35%, normal stress test annually

1 Abbreviations: ACS = acute coronary syndrome; PCI = percutaneous coronary intervention; CCS = Canadian Cardiovascular Society; NYHA = New York Heart Association; EF = ejection fraction.

Table 4

Fitness to drive in the case of bradycardic arrhythmias [6].

	Group 1	Group 2
AV Block I and Wenkebach II	✔	✔
AV Block Mobitz II Paroxysmal in sleep While awake	✔	✔
AV Block Mobitz II Paroxysmal in sleep While awake	✔ After PM implantation	✔ After PM implantation
AV Block III born	✔ If asymptomatic	✔ After PM implantation
AV Block III acquired	✔ After PM implantation	✔ After PM implantation
RBBB or isolated hemiblock	✔	✔
LBBB	✔	✔ After echocardiography
Bifascicular block with normal PQ interval	✔	✔
Bifascicular blocked with prolonged PQ interval	✔ If asymptomatic	✔ If asymptomatic

1 Abbreviations: AV = atrioventricular; LBBB = left bundle branch block; RBBB = right bundle branch block.

Table 5

Fitness to drive with supraventricular arrhythmias [6]. Relevant symptoms = severe dizziness, presyncope, syncope. Regular: AVNRT, atrial flutter, atrial tachycardias. Effective therapy: medicinal, interventional, cardiac pacemaker.

	Group 1	Group 2
Regular SV tachycardia Without relevant symptoms With relevant symptoms	✔	✔
	✔ After ablation, 4 weeks of waiting and cardiological control	✔ After ablation, 4 weeks of waiting and cardiological control
WPW No history of tachycardia	✔	✔
Atrial fibrilation Without relevant symptoms With relevant symptoms	✔	✔
	✔ After therapy, 4 weeks of waiting and cardiological control	✔ After therapy, 4 weeks of waiting, and cardiological control

1 Abbreviations: SV = supraventricular; WPW = Wolf Parkinson White syndrome

Table 6

Ventricular arrhythmias: normal and structural heart disease [6]. Symptoms: severe vertigo, presyncope, syncope; therapy: drug or ablation or ICD.

Ventricular arrhythmias: no structural heart disease, no ion channel disease (typically from RVOT or LVOT)
	Group 1	Group 2
PVC	✔	✔
NSVT and VT without relevant symptoms with relevant symptoms	✔	Case-by-case assessment
	✔ After therapy, 4 weeks of waiting and cardiological control	✔ After therapy, 4 weeks of waiting and cardiological control
Idiopathic ventricular fibrillation	✔ After ICD	✘
Ventricular arrhythmias: structural heart disease (CAD, dilated cardiomyopathy)
PVC	✔	✔
NSVT Without relevant symptoms With relevant symptoms	✔	Case-by-case assessment
NSVT Without relevant symptoms With relevant symptoms	✔ After therapy, 3-month wait and cardiological control	✘
Sustained VT with/without symptoms	✔ After ICD	✘

1 Abbreviations: RVOT: right ventricular outflow tract; LVOT: left ventricular outflow tract; PVC: premature ventricular contraction; NSVT: nonsustained ventricular tachycardia; VT: ventricular tachycardia; ICD: implantable cardioverter-defibrillator; CAD: coronary artery disease;

Table 6

Devices: After PM/ICD implantation or replacement [6].

	Group 1	Group 2
PM: with history syncope	✔ 1 week waiting period	✔ 3-month waiting period and cardiological control Change: 2-week waiting period
PM: without history of syncope	✔ 1 week waiting period	✔ 4-week waiting period and cardiological control Change: 2-week waiting period
ICD	✔ With restrictions	✘
CRT-D in non-ischemic cardiomyopathy & for primary prevention	✔ 1 week waiting period	✔ If: >6 months sustained improvement to EF >50% and D function deactivated
After ICD activation
One-time, adequate shock	✔ 3 months waiting period
Inappropriate shock	✔ When cause resolved
Antitachycardic pacing of ventricular tachycardia with relevant symptoms without relevant symptoms	✔ 3-month waiting period
	✔

1 Abbreviations: PM, pacemaker; ICD, implantable cardioverter-defibrillator; CRT-D. resynchronisation therapy-defibrillator

Table 7

Valvular disease [6].

	Group 1	Group 2
Aortic Stenosis Asymptomatic Symptomatic After treatment	✔ ✘ ✔After convalescence	✔If not severe, annual reevaluation ✘ ✔3 month waiting period, NYHA I-II, EF >35%
Other valvulopathies Asymptomatic Symptomatic After treatment	✔ Depending on NYHA ✔After convalescence	✔EF >35% and no severe mitral stenosis ✔EF >35% and no severe mitral stenosis and NYHA I-II ✔EF >35% and NYHA I-II and waiting period of 3 months

1 Abbreviations: NYHA, New York Heart Association; EF, ejection fraction

Table 8

Congenital and hypertrophic diseases [6].

	Group 1	Group 2
Congenital diseases Asymptomatic Symptomatic	✔	✔
Congenital diseases Asymptomatic Symptomatic	Case-by-case assessment	Case-by-case assessment
Hypertrophic cardiomyopathies Asymptomatic Symptomatic	✔ Depending on NYHA and syncope anmanesis	✔ If no ICD indicated ✘

Table 9

Ion channel anomalies [6].

	Group 1	Group 2
Congenital long QT	✔ If ICD*	Case-by-case assessment ✘ If ICD is indicated
Brugada syndrome	✔ If ICD*	Case-by-case assessment ✘ If ICD is indicated

1 *If ICD indication according to the patient’s wishes (agree/disagree).

Table 10

Miscellaneous [6].

	Group 1	Group 2
Arterial hypertension	✔ Without cerebral symptoms or visual disturbances	✔ Without cerebral symptoms or visual disturbances BP <180 mmHg systolic / <110 mmHg diastolic
Pulmonary hypertension	✔ If NYHA I-III	✔ If NYHA I-II & no permanent O² need
Thoracic aortic aneurysm	✔ If <6.5 cm	✔ If <5.5cm