- Email: [email protected]
Resumption of motor vehicle operation in vasovagal fainters
abnormalities. Our findings underscore the need for long-term studies to determine whether the benefit of RV pacing can be sustained. Furthermore, the general recommendations to program the AV delay of a dual-chamber pacemaker to permit spontaneous conduction for better LV function may be inappropriate in patients with LBBB.3,16,17 1. Askenazi J, Alexander JH, Koenigsberg DI, Belic N, Lesch M. Alteration of left ventricular performance by left bundle branch block simulated with atrioventricular sequential pacing. Am J Cardiol 1984;53:99 –104. 2. Burkhoff D, Oikawa RY, Sagawa K. Influence of pacing site on canine left ventricular contraction. Am J Physiol 1986;251:H428 –H435. 3. Rosenqvist M, Isaaz K, Botvinick E, Dae MW, Cockrell J, Abbott JA, Schiller NB, Griffin JC. Relative importance of activation sequence compared to AV synchrony in left ventricular function. Am J Cardiol 1991;67:148 –156. 4. Schneider JF, Thomas HE Jr, McNamara PM, Kannel WB. Clinical-electrocardiographic correlates of newly acquired left bundle branch block: the Framingham Study. Am J Cardiol 1985;55:1332–1338. 5. Katritis D, Camm AJ. Chronotropic incompetence: a proposal for definition and diagnosis. Br Heart J 1993;70:400 – 402. 6. Grines CD, Bashore TM, Boudoulas H, Olson S, Shafer P, Wooley CF. Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony. Circulation 1989;79:845– 853. 7. Xiao HB, Brecker SJD, Gibson DG. Differing effects of right ventricular pacing and left bundle branch block on left ventricular function. Br Heart J 1993;69:166 –173.
8. Ormerod OJM, Barber RW, Wraight EP. The reliability of first harmonic
Fourier analysis fitting to simulated time activity curve. Nucl Med Commun 1986;7:157–163. 9. Santomauro M, Fazio S, Ferraro S, Maddalena G, Papaccioli G, Pappone C, Betocchi S, Chiarello M. Fourier analysis in patients with different pacing modes. PACE 1991;14:1351–1358. 10. Ormerod OJM, Barber RW, Wraight EP. The accuracy of functional parameters extracted from left ventricular time activity curves by multiple Fourier harmonic fitting: a simulation study. Nucl Med Commun 1986;7:91–103. 11. Links JM, Raichlen JS, Wagner HN Jr, Reid PR. Assessment of the site of ventricular activation by Fourier analysis of gated blood-pool studies. J Nucl Med 1985;26:27–32. 12. Brecker SJ, Gibson DG. What is the role of pacing in dilated cardiomyopathy? Eur Heart J 1996;17:819 – 824. 13. Glickson M, Hayes DL, Nishimura RA. Newer clinical applications of pacing. J Cardiovasc Electrophysiol 1997;8:1190 –1203. 14. Cazeau S, Ritter P, Lazarus A, Gras D, Backdach H, Mundler O, Mugica J. Multisite pacing for end-stage heart failure: early experience. PACE 1996;19(part II):1748 –1757. 15. Blanc JJ, Etienne Y, Gilard M, Mansourati J, Munier S, Boschat J, Benditt DG, Lurie KG. Evaluation of different ventricular pacing sites in patients with severe heart failure. Results of an acute hemodynamic study. Circulation 1997; 96:3273–3277. 16. Leclercq C, Gras D, Le Holloco A, Nicol L, Daubert C. Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing. Am Heart J 1995;129:1133–1141. 17. Vardas PE, Simantirakis EN, Parthenakis FI, Chrysostomakis SI, Skalidis EI, Zuridakis EG. AAIR versus DDDR pacing in patients with impaired sinus node chronotropy: an echocardiographic and cardiopulmonary study. PACE 1997;20: 1762–1768.
Resumption of Motor Vehicle Operation in Vasovagal Fainters Keith G. Lurie,
MD,
Demosthenes Iskos, MD, Scott Sakaguchi, and David G. Benditt, MD
asovagal syncope is the most common cause of fainting. Consequently, physicians often are V faced with making a decision regarding resumption of motor vehicle operation in this subset of fainters. Although a relatively recent set of published recommendations may guide physicians in their decision process,1 the actual status of clinical practice is unknown. This study evaluates current medical practice with regard to the method by which physicians specializing in the treatment of cardiac rhythm disturbances arrived at recommendations regarding resumption of driving for patients with vasovagal syncope. To this end, we conducted an international survey on the topic of driving and vasovagal syncope. •••
Physicians in 9 countries who specialize in the care of patients with cardiac arrhythmias were queried regarding their approach to the evaluation and treatment of vasovagal syncope. By way of example, the following are representative of the 12 questions posed to each physician: From the Cardiac Arrhythmia Center and the Syncope Center, Department of Medicine, Cardiovascular Division, University of Minnesota School of Medicine, Minneapolis, Minnesota. Dr. Benditt’s address is: Cardiovascular Division, University of Minnesota School of Medicine, Box 508 UMHC, Minneapolis, Minnesota 55455. Manuscript received June 16, 1998; revised manuscript received and accepted September 1, 1998.
604
©1999 by Excerpta Medica, Inc. All rights reserved.
MD,
Gerard J. Fahy,
MB,
1. How many patients with vasovagal syncope have you treated? 2. Do you use tilt table testing to (1) diagnose patients with vasovagal syncope, and (2) guide drug therapy during follow-up? 3. How long before you let the patient drive again if (1) he/she was initially tilt positive but became tilt negative with treatment, or (2) he/she continued to be tilt positive despite treatment? 4. Does the fact that the patient develops syncope only when standing, but not while sitting, influence your decision to permit driving? 5. Do you differentiate between driving a commercial vehicle and driving a private car when restricting driving in patients with vasovagal syncope? In addition, physicians were asked to report any motor vehicle accident that may have occurred as a result of a vasovagal syncopal event, both before and after treatment was initiated. Data are expressed as mean 6 SEM. Sixty-six physicians responded to the survey (65% response rate). Fifty-one respondents practiced in 22 states in the United States, and 15 practiced in 8 other countries (Spain, United Kingdom, France, Italy, Germany, Canada, Taiwan, and Hong Kong). They reported having treated .11,500 patients with vasovagal syncope. Routine use of upright tilt-table testing to substantiate a diagnosis of vasovagal syncope was 0002-9149/99/$–see front matter PII S0002-9149(98)00924-2
indicated by 98% of respondents. Thereafter, 77% of physicians used follow-up tilt-table testing to assess treatment efficacy. In patients with syncope and an initial positive tilt-table study who were rendered tilt negative on treatment, physician recommendations regarding driving ranged from immediate resumption of driving to as long as 1 year of abstinence (Figure 1). The mean recommended period without driving was 54 6 10 days (range 0 to 365, median 7). Beta-adrenergic blockers were used by 92% of respondents as first- or second-line treatment and were the most commonly used agents for treatment of vasovagal syncope. Disopyramide was the second most frequent choice, with 54% of physicians using it as second-line therapy after failure of b blockers. Additional therapies included patient reassurance, fludrocortisone, sertraline, scopolamine patch, and ergot alkaloids. Pacemakers were rarely used, and midodrine was not generally available at the time. When results of follow-up tilt testing suggested that an “effective” treatment had not been established, recommendations related to driving varied markedly among physician-respondents. Most (82%) believed that they would ultimately allow driving, but the duration of time without driving privileges would need to be decided on a case-by-case basis. Approximately 20% specifically indicated that a 6- to 12-month event-free period would be required before they would advise resumption of driving. Ten percent indicated they would not recommend return to driving, whereas 8% did not respond to the question. Sixty percent of respondents believed that syncope that occurred while the patient was in a sitting position should be taken more seriously than syncope that occurred only when the individual was standing; a longer period without driving was recommended in the former circumstance. There was an even greater consensus related to the presence or absence of premonitory symptoms before syncope; 88% of respondents stated that the consistent occurrence of “warning” symptoms before the development of frank loss of consciousness would influence them to allow driving at an earlier time. Finally, 74% of respondents tended to be more cautious about recommending driving resumption for commercial drivers. However, there was no consensus regarding the duration of the driving-free period. Several physicians indicated that they had cared for patients involved in motor vehicle accidents as a result of presumed vasovagal syncope, before initiation of treatment. However, it was not possible to determine the prevalence precisely. A more accurate estimate could be made of the number of patients involved in motor vehicle accidents after treatment. Nine of the respondents followed at least 1 patient who sustained $1 motor vehicle accident due to syncope recurrence after evaluation had begun. In only 17 instances were motor vehicle accidents due to syncope noted after starting therapy in the 11,500 patients reported by respondents (approximate prevalence among treated patients of 0.1% to 0.2%).
•••
This study examined current practice patterns with respect to the manner by which cardiac arrhythmia specialists advise patients with vasovagal syncope regarding resumption of motor vehicle operation. Despite diverse cultural and educational backgrounds among physician-respondents, we observed important similarities in their practice. Nearly all used tilt-table testing to confirm the diagnosis of vasovagal syncope. Seventy-seven percent used follow-up tilt-table testing to guide therapy and to provide a measure of susceptibility to recurrent faints. Finally, there was a remarkable consensus related to pharmacologic treatment of vasovagal syncope, with .90% of respondents using b-blocker therapy as first- or second-line options. In this study, when effective treatment appeared to have been found based upon head-up tilt-table testing, the average time recommended before resumption of driving was approximately 2 months; however, responses varied. More than half of the respondents permitted patients to drive within 1 week of a negative follow-up tilt-table study on drug therapy. In contrast, 1 clinician recommended waiting a full year. This variability in response may partly reflect continuing uncertainty regarding the use of upright tilt testing for predicting subsequent treatment efficacy.2–7 Given this circumstance, the even greater divergence of physician opinion with regard to driving for patients in whom an apparent effective therapy was not found (i.e., subjects who remain tilt positive despite treatment) is not surprising; in these cases, decisions were apparently tailored to the individual patient, although the specifics of the decision process are unknown. Nonetheless, some “objective” criteria, such as fainting while sitting, absence of premonitory symptoms, and driving a commercial vehicle, appeared to impact these difficult “judgment” calls. Other potential contributing factors, such as ease of patient access to public transportation or urban versus rural residence, were not assessed. In any event, with application of these “community standards,” the risk of subsequent motor vehicle accident was low (in 0.1% to 0.2% of treated patients). When asked to offer “expert advice” about driving to patients with vasovagal syncope, the physician is faced with several difficulties.1, 8 –11 These include the uncertain natural history of the disorder, lack of a uniformly efficacious treatment, limitations of current tools in predicting long-term treatment efficacy, and the potential for serious injury for both the fainter and others in case of symptom recurrence during driving. Further, although there are rules and statutory regulations about driving after seizures,12 significant ventricular arrhythmias,12,13 or implantation of pacemakers and cardioverter-defibrillators,14,15 few guidelines are available regarding resumption of driving in patients with vasovagal syncope.1 In some cases, national or state laws or regulations dictate actions. For example, physicians in California are required to report any patient who has had loss of consciousness of any etiology; that subject is restricted from driving for 1 BRIEF REPORTS
605
FIGURE 1. Bar graph illustrating the durations of recommended abstinence from driving for patients with vasovagal syncope who were rendered tilt negative while receiving pharmacologic treatment. The ordinate indicates the number of physicians, and the abscissa the duration of recommended abstinence. Almost half (24 of 54) of the physicians responding to this question indicated that they would allow patients to drive immediately (0 days) after a negative repeat upright tilt.
year. On the other hand, Minnesota physicians are under no legal obligation to report fainters. The current American Heart Association/North American Society of Pacing and Electrophysiology driving recommendations for persons with vasovagal syncope range from grade “A” (no driving restrictions) to “C” (driving completely prohibited). These recommendations are based on symptom severity (“mild” vs “severe”) and whether the patient operates a private versus a commercial vehicle.1 The role of tilt-table testing in decision making was deemphasized. Nevertheless, our survey indicates that many clinicians were more likely to permit driving if “effective” therapy, as assessed by tilt testing, appeared to have been found. Thus, even though the predictive value of a negative repeat tilt-table study remains uncertain, physicians often sought its “reassurance.” In summary, findings in this study indicate that tilt table testing is commonly used by arrhythmia specialists to guide drug therapy and to help formulate recommendations regarding the driving status of patients with vasovagal syncope. Once an effective treatment appears to have been found based on serial tilt-table testing, a mean 6- to 7-week symptom-free waiting period before resumption of driving is the predominant practice. Acknowledgment: We express our appreciation to Barry L.S. Detloff and Wendy Markuson for assistance with preparation of the manuscript.
1. Epstein AE, Miles WM, Benditt DG, Camm AJ, Darling EJ, Friedman PL,
Garson A, Harvey JC, Kidwell GA, Klein GJ, et al. Personal and public safety
606 THE AMERICAN JOURNAL OF CARDIOLOGYT
VOL. 83
issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. Circulation 1996;94:1147– 1166. 2. Natale A, Sra J, Dhala A, Wase A, Jazayeri M, Deshpande S, Blanck Z, Akhtar M. Efficacy of different treatment strategies for neurocardiogenic syncope. PACE 1995;18:655– 662. 3. Milstein S, Buetikofer J, Dunnigan A, Benditt DG, Gornick C, Reyes WJ. Usefulness of disopyramide for prevention of upright tilt-induced hypotensionbradycardia. Am J Cardiol 1990;65:1339 –1344. 4. Morillo CA, Leitch JW, Yee R, Klein GJ. A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally mediated syncope induced by head-up tilt. J Am Coll Cardiol 1993;22:1843–1848. 5. Grubb BP, Wolfe DA, Samoil D, Temesy-Armos P, Hahn H, Elliott L. Usefulness of fluoxetine hydrochloride for prevention of resistant upright tilt induced syncope. PACE 1993;16:458 – 464. 6. Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D. A controlled trial of acute and long-term medical therapy in tilt-induced neurally mediated syncope. Am J Cardiol 1992;70:339 –342. 7. Moya A, Permanyer-Miralda G, Sagrista-Sauleda J, Carne X, Rius T, Mont L, Soler-Soler J. Limitations of head-up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: results of a controlled study of etilefrine versus placebo. J Am Coll Cardiol 1995;25:65– 69. 8. Anonymous. Assessment of the cardiac patient for fitness to drive: 1996 update. Can J Cardiol 1996;12:1164 –1170,1175–1182. 9. Grattan E, Jeffcoate GO. Medical factors and road accidents. BMJ 1968;1:75– 79. 10. Epstein SE, Quyyumi AA, Bonow RO. Sounding board. Sudden cardiac death without warning: possible mechanisms and implications for screening asymptomatic populations. N Engl J Med 1989;321:320 –324. 11. Hossack DW. Death at the wheel: a consideration of cardiovascular disease as a contributory factor to road accidents. Med J Aust 1974;1:164 –166. 12. Strickberger SA, Cantillon CO, Friedman PL. When should patients with lethal ventricular arrhythmia resume driving? An analysis of state regulations and physician practices. Ann Intern Med 1991;115:560 –563. 13. Larsen GC, Stupey MR, Walance CG, Griffith KK, Cutler JE, Kron J, McAnuty JH. Recurrent cardiac events in survivors of ventricular fibrillation or tachycardia: implications for driving restrictions. JAMA 1994;271:1335–1339. 14. Cambre S, Silverman ME. Is it safe to drive with an automatic implantable cardioverter-defibrillator or a history of recurrent symptomatic ventricular arrhythmias? Heart Dis Stroke 1993;2:179 –181. 15. Kou WH, Calkins H, Lewis RR, Bolling SF, Kirsch MM, Langberg JJ, de Buitleir M, Sousa J, El-Atassi R, Morady F. Incidence of loss of consciousness during automatic implantable cardioverter-defibrillator shocks. Ann Intern Med 1991;115:942–945.
FEBRUARY 15, 1999
8. Ormerod OJM, Barber RW, Wraight EP. The reliability of first harmonic
Fourier analysis fitting to simulated time activity curve. Nucl Med Commun 1986;7:157–163. 9. Santomauro M, Fazio S, Ferraro S, Maddalena G, Papaccioli G, Pappone C, Betocchi S, Chiarello M. Fourier analysis in patients with different pacing modes. PACE 1991;14:1351–1358. 10. Ormerod OJM, Barber RW, Wraight EP. The accuracy of functional parameters extracted from left ventricular time activity curves by multiple Fourier harmonic fitting: a simulation study. Nucl Med Commun 1986;7:91–103. 11. Links JM, Raichlen JS, Wagner HN Jr, Reid PR. Assessment of the site of ventricular activation by Fourier analysis of gated blood-pool studies. J Nucl Med 1985;26:27–32. 12. Brecker SJ, Gibson DG. What is the role of pacing in dilated cardiomyopathy? Eur Heart J 1996;17:819 – 824. 13. Glickson M, Hayes DL, Nishimura RA. Newer clinical applications of pacing. J Cardiovasc Electrophysiol 1997;8:1190 –1203. 14. Cazeau S, Ritter P, Lazarus A, Gras D, Backdach H, Mundler O, Mugica J. Multisite pacing for end-stage heart failure: early experience. PACE 1996;19(part II):1748 –1757. 15. Blanc JJ, Etienne Y, Gilard M, Mansourati J, Munier S, Boschat J, Benditt DG, Lurie KG. Evaluation of different ventricular pacing sites in patients with severe heart failure. Results of an acute hemodynamic study. Circulation 1997; 96:3273–3277. 16. Leclercq C, Gras D, Le Holloco A, Nicol L, Daubert C. Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing. Am Heart J 1995;129:1133–1141. 17. Vardas PE, Simantirakis EN, Parthenakis FI, Chrysostomakis SI, Skalidis EI, Zuridakis EG. AAIR versus DDDR pacing in patients with impaired sinus node chronotropy: an echocardiographic and cardiopulmonary study. PACE 1997;20: 1762–1768.
Resumption of Motor Vehicle Operation in Vasovagal Fainters Keith G. Lurie,
MD,
Demosthenes Iskos, MD, Scott Sakaguchi, and David G. Benditt, MD
asovagal syncope is the most common cause of fainting. Consequently, physicians often are V faced with making a decision regarding resumption of motor vehicle operation in this subset of fainters. Although a relatively recent set of published recommendations may guide physicians in their decision process,1 the actual status of clinical practice is unknown. This study evaluates current medical practice with regard to the method by which physicians specializing in the treatment of cardiac rhythm disturbances arrived at recommendations regarding resumption of driving for patients with vasovagal syncope. To this end, we conducted an international survey on the topic of driving and vasovagal syncope. •••
Physicians in 9 countries who specialize in the care of patients with cardiac arrhythmias were queried regarding their approach to the evaluation and treatment of vasovagal syncope. By way of example, the following are representative of the 12 questions posed to each physician: From the Cardiac Arrhythmia Center and the Syncope Center, Department of Medicine, Cardiovascular Division, University of Minnesota School of Medicine, Minneapolis, Minnesota. Dr. Benditt’s address is: Cardiovascular Division, University of Minnesota School of Medicine, Box 508 UMHC, Minneapolis, Minnesota 55455. Manuscript received June 16, 1998; revised manuscript received and accepted September 1, 1998.
604
©1999 by Excerpta Medica, Inc. All rights reserved.
MD,
Gerard J. Fahy,
MB,
1. How many patients with vasovagal syncope have you treated? 2. Do you use tilt table testing to (1) diagnose patients with vasovagal syncope, and (2) guide drug therapy during follow-up? 3. How long before you let the patient drive again if (1) he/she was initially tilt positive but became tilt negative with treatment, or (2) he/she continued to be tilt positive despite treatment? 4. Does the fact that the patient develops syncope only when standing, but not while sitting, influence your decision to permit driving? 5. Do you differentiate between driving a commercial vehicle and driving a private car when restricting driving in patients with vasovagal syncope? In addition, physicians were asked to report any motor vehicle accident that may have occurred as a result of a vasovagal syncopal event, both before and after treatment was initiated. Data are expressed as mean 6 SEM. Sixty-six physicians responded to the survey (65% response rate). Fifty-one respondents practiced in 22 states in the United States, and 15 practiced in 8 other countries (Spain, United Kingdom, France, Italy, Germany, Canada, Taiwan, and Hong Kong). They reported having treated .11,500 patients with vasovagal syncope. Routine use of upright tilt-table testing to substantiate a diagnosis of vasovagal syncope was 0002-9149/99/$–see front matter PII S0002-9149(98)00924-2
indicated by 98% of respondents. Thereafter, 77% of physicians used follow-up tilt-table testing to assess treatment efficacy. In patients with syncope and an initial positive tilt-table study who were rendered tilt negative on treatment, physician recommendations regarding driving ranged from immediate resumption of driving to as long as 1 year of abstinence (Figure 1). The mean recommended period without driving was 54 6 10 days (range 0 to 365, median 7). Beta-adrenergic blockers were used by 92% of respondents as first- or second-line treatment and were the most commonly used agents for treatment of vasovagal syncope. Disopyramide was the second most frequent choice, with 54% of physicians using it as second-line therapy after failure of b blockers. Additional therapies included patient reassurance, fludrocortisone, sertraline, scopolamine patch, and ergot alkaloids. Pacemakers were rarely used, and midodrine was not generally available at the time. When results of follow-up tilt testing suggested that an “effective” treatment had not been established, recommendations related to driving varied markedly among physician-respondents. Most (82%) believed that they would ultimately allow driving, but the duration of time without driving privileges would need to be decided on a case-by-case basis. Approximately 20% specifically indicated that a 6- to 12-month event-free period would be required before they would advise resumption of driving. Ten percent indicated they would not recommend return to driving, whereas 8% did not respond to the question. Sixty percent of respondents believed that syncope that occurred while the patient was in a sitting position should be taken more seriously than syncope that occurred only when the individual was standing; a longer period without driving was recommended in the former circumstance. There was an even greater consensus related to the presence or absence of premonitory symptoms before syncope; 88% of respondents stated that the consistent occurrence of “warning” symptoms before the development of frank loss of consciousness would influence them to allow driving at an earlier time. Finally, 74% of respondents tended to be more cautious about recommending driving resumption for commercial drivers. However, there was no consensus regarding the duration of the driving-free period. Several physicians indicated that they had cared for patients involved in motor vehicle accidents as a result of presumed vasovagal syncope, before initiation of treatment. However, it was not possible to determine the prevalence precisely. A more accurate estimate could be made of the number of patients involved in motor vehicle accidents after treatment. Nine of the respondents followed at least 1 patient who sustained $1 motor vehicle accident due to syncope recurrence after evaluation had begun. In only 17 instances were motor vehicle accidents due to syncope noted after starting therapy in the 11,500 patients reported by respondents (approximate prevalence among treated patients of 0.1% to 0.2%).
•••
This study examined current practice patterns with respect to the manner by which cardiac arrhythmia specialists advise patients with vasovagal syncope regarding resumption of motor vehicle operation. Despite diverse cultural and educational backgrounds among physician-respondents, we observed important similarities in their practice. Nearly all used tilt-table testing to confirm the diagnosis of vasovagal syncope. Seventy-seven percent used follow-up tilt-table testing to guide therapy and to provide a measure of susceptibility to recurrent faints. Finally, there was a remarkable consensus related to pharmacologic treatment of vasovagal syncope, with .90% of respondents using b-blocker therapy as first- or second-line options. In this study, when effective treatment appeared to have been found based upon head-up tilt-table testing, the average time recommended before resumption of driving was approximately 2 months; however, responses varied. More than half of the respondents permitted patients to drive within 1 week of a negative follow-up tilt-table study on drug therapy. In contrast, 1 clinician recommended waiting a full year. This variability in response may partly reflect continuing uncertainty regarding the use of upright tilt testing for predicting subsequent treatment efficacy.2–7 Given this circumstance, the even greater divergence of physician opinion with regard to driving for patients in whom an apparent effective therapy was not found (i.e., subjects who remain tilt positive despite treatment) is not surprising; in these cases, decisions were apparently tailored to the individual patient, although the specifics of the decision process are unknown. Nonetheless, some “objective” criteria, such as fainting while sitting, absence of premonitory symptoms, and driving a commercial vehicle, appeared to impact these difficult “judgment” calls. Other potential contributing factors, such as ease of patient access to public transportation or urban versus rural residence, were not assessed. In any event, with application of these “community standards,” the risk of subsequent motor vehicle accident was low (in 0.1% to 0.2% of treated patients). When asked to offer “expert advice” about driving to patients with vasovagal syncope, the physician is faced with several difficulties.1, 8 –11 These include the uncertain natural history of the disorder, lack of a uniformly efficacious treatment, limitations of current tools in predicting long-term treatment efficacy, and the potential for serious injury for both the fainter and others in case of symptom recurrence during driving. Further, although there are rules and statutory regulations about driving after seizures,12 significant ventricular arrhythmias,12,13 or implantation of pacemakers and cardioverter-defibrillators,14,15 few guidelines are available regarding resumption of driving in patients with vasovagal syncope.1 In some cases, national or state laws or regulations dictate actions. For example, physicians in California are required to report any patient who has had loss of consciousness of any etiology; that subject is restricted from driving for 1 BRIEF REPORTS
605
FIGURE 1. Bar graph illustrating the durations of recommended abstinence from driving for patients with vasovagal syncope who were rendered tilt negative while receiving pharmacologic treatment. The ordinate indicates the number of physicians, and the abscissa the duration of recommended abstinence. Almost half (24 of 54) of the physicians responding to this question indicated that they would allow patients to drive immediately (0 days) after a negative repeat upright tilt.
year. On the other hand, Minnesota physicians are under no legal obligation to report fainters. The current American Heart Association/North American Society of Pacing and Electrophysiology driving recommendations for persons with vasovagal syncope range from grade “A” (no driving restrictions) to “C” (driving completely prohibited). These recommendations are based on symptom severity (“mild” vs “severe”) and whether the patient operates a private versus a commercial vehicle.1 The role of tilt-table testing in decision making was deemphasized. Nevertheless, our survey indicates that many clinicians were more likely to permit driving if “effective” therapy, as assessed by tilt testing, appeared to have been found. Thus, even though the predictive value of a negative repeat tilt-table study remains uncertain, physicians often sought its “reassurance.” In summary, findings in this study indicate that tilt table testing is commonly used by arrhythmia specialists to guide drug therapy and to help formulate recommendations regarding the driving status of patients with vasovagal syncope. Once an effective treatment appears to have been found based on serial tilt-table testing, a mean 6- to 7-week symptom-free waiting period before resumption of driving is the predominant practice. Acknowledgment: We express our appreciation to Barry L.S. Detloff and Wendy Markuson for assistance with preparation of the manuscript.
1. Epstein AE, Miles WM, Benditt DG, Camm AJ, Darling EJ, Friedman PL,
Garson A, Harvey JC, Kidwell GA, Klein GJ, et al. Personal and public safety
606 THE AMERICAN JOURNAL OF CARDIOLOGYT
VOL. 83
issues related to arrhythmias that may affect consciousness: implications for regulation and physician recommendations. Circulation 1996;94:1147– 1166. 2. Natale A, Sra J, Dhala A, Wase A, Jazayeri M, Deshpande S, Blanck Z, Akhtar M. Efficacy of different treatment strategies for neurocardiogenic syncope. PACE 1995;18:655– 662. 3. Milstein S, Buetikofer J, Dunnigan A, Benditt DG, Gornick C, Reyes WJ. Usefulness of disopyramide for prevention of upright tilt-induced hypotensionbradycardia. Am J Cardiol 1990;65:1339 –1344. 4. Morillo CA, Leitch JW, Yee R, Klein GJ. A placebo-controlled trial of intravenous and oral disopyramide for prevention of neurally mediated syncope induced by head-up tilt. J Am Coll Cardiol 1993;22:1843–1848. 5. Grubb BP, Wolfe DA, Samoil D, Temesy-Armos P, Hahn H, Elliott L. Usefulness of fluoxetine hydrochloride for prevention of resistant upright tilt induced syncope. PACE 1993;16:458 – 464. 6. Brignole M, Menozzi C, Gianfranchi L, Lolli G, Bottoni N, Oddone D. A controlled trial of acute and long-term medical therapy in tilt-induced neurally mediated syncope. Am J Cardiol 1992;70:339 –342. 7. Moya A, Permanyer-Miralda G, Sagrista-Sauleda J, Carne X, Rius T, Mont L, Soler-Soler J. Limitations of head-up tilt test for evaluating the efficacy of therapeutic interventions in patients with vasovagal syncope: results of a controlled study of etilefrine versus placebo. J Am Coll Cardiol 1995;25:65– 69. 8. Anonymous. Assessment of the cardiac patient for fitness to drive: 1996 update. Can J Cardiol 1996;12:1164 –1170,1175–1182. 9. Grattan E, Jeffcoate GO. Medical factors and road accidents. BMJ 1968;1:75– 79. 10. Epstein SE, Quyyumi AA, Bonow RO. Sounding board. Sudden cardiac death without warning: possible mechanisms and implications for screening asymptomatic populations. N Engl J Med 1989;321:320 –324. 11. Hossack DW. Death at the wheel: a consideration of cardiovascular disease as a contributory factor to road accidents. Med J Aust 1974;1:164 –166. 12. Strickberger SA, Cantillon CO, Friedman PL. When should patients with lethal ventricular arrhythmia resume driving? An analysis of state regulations and physician practices. Ann Intern Med 1991;115:560 –563. 13. Larsen GC, Stupey MR, Walance CG, Griffith KK, Cutler JE, Kron J, McAnuty JH. Recurrent cardiac events in survivors of ventricular fibrillation or tachycardia: implications for driving restrictions. JAMA 1994;271:1335–1339. 14. Cambre S, Silverman ME. Is it safe to drive with an automatic implantable cardioverter-defibrillator or a history of recurrent symptomatic ventricular arrhythmias? Heart Dis Stroke 1993;2:179 –181. 15. Kou WH, Calkins H, Lewis RR, Bolling SF, Kirsch MM, Langberg JJ, de Buitleir M, Sousa J, El-Atassi R, Morady F. Incidence of loss of consciousness during automatic implantable cardioverter-defibrillator shocks. Ann Intern Med 1991;115:942–945.
FEBRUARY 15, 1999