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

Cardiovascular conditions or diseases can lead to a sudden impairment of the cerebral functions that constitutes a danger to road safety. These conditions represent grounds for establishing temporary or permanent restrictions to driving. In current practice, the question “Doctor, am I allowed to drive?” is probably addressed mostly at cardiologists. The risk of stroke, acute myocardial infarction, malignant arrhythmia, syncope, or hypotension while driving are risks that cause road accidents and are difficult to assess. Each country had tried to come up with its own regulations, and in 2016 the European Union aimed to standardize these indications by introducing Directive 2016/1106 of July 7th, 2016 [1] (replacing the 2006 one [2]). This document had to be transposed for the legislations of each of the EU member countries. New cardiac problems were included, such as stents and some specific cardiomyopathies, and the previously applied knowledge was updated. The document left the door open to future changes in practice by considering a wide range of new therapeutic options, such as circulatory assistance.

The countries that have performed the most studies on the risk of major cardiovascular events while driving are Canada and Australia [3]. The Canadian Society of Cardiology applied a risk estimation formula to its guidelines for driving – a formula that has been adopted by the EU expert group report and formed the basis of its new directive [4]. The formula includes the time at the wheel, the type of vehicle, the risk of sudden incapacitation, and the probability that this incapacitation will result in harm.

Germany has its own pocket guidelines and the most publications on this subject [5]. Switzerland, inspired by the German model, adapted and completed Germany’s recommendations [6]. United Kingdom, through the authority of the Driver & Vehicle Licensing Agency (DVLA) makes the doctor fully responsible for informing the patient in common cases of cardiovascular diseases (angina, acute coronary syndrome, coronary angioplasty, coronary bypass or valve surgery) if they drive cars or motorcycles; the drivers of buses, coaches, or lorries must report to the DVLA themselves [7]. In Switzerland, irrespective of the doctor’s right to report, a doctor is obliged to inform his patient about his fitness to drive. The Swiss have developed another authority, namely, the “level 4 doctor” who is a specialist in traffic medicine and can decide whether a citizen can drive without the minimum medical requirements or can drive under restrictions, only on certain sections and types of road.

It is crucial to distinguish between the primary risk and the secondary risk, which arises when a patient has already experienced a significant cardiovascular event. Notably, the focus is on the effectiveness of the treatment. It is not solely the disease itself that carries the greatest weight, but rather the timing of its occurrence and the level of control achieved. For instance, a patient with recent myocardial infarction who presents with NYHA III heart failure and an ejection fraction of 25% may be permitted to resume driving within one week provided their condition is adequately managed. On the other hand, an elective bypass patient or a patient with newly diagnosed symptomatic atrial fibrillation may need to wait four weeks before resuming driving activities.

Romania also has regulations, published in 2017, that were inspired by the European model [8]. They are loosely divided into two large parts, the group in which driving is allowed only after “the condition in question has been effectively treated and subject to the opinion issued by the cardiology specialist” and the group for which driving is not allowed at all. Moreover, this division refers to obtaining or renewing the driving permit. Otherwise, any doctor, not just the family doctor (as was the case until recently), will be able to send a driver for examination in an authorized clinic and, within a maximum of three working days from the communication, the driver is obliged to present himself at the indicated clinic for a specialized medical examination. If the condition is confirmed, the clinic will have to inform the traffic police, and the driver will temporarily lose the right to use the license. In this way, this filter is relativized, and different patients with the same disease can be passed or exempted from these measures.

Many cardiologists do not know what to recommend to their patients whom they diagnose with heart diseases. Moreover, many cardiologists believe that they do not represent the authority that should decide in this regard. After all, the right to drive or not is a legal right and not a medical one. The aim of ethics as well as legislation is to ensure that the rights of the individual do not override the protections for the safety of fellow citizens and at the same time ensure that the rights of society to restrict individual actions are limited. Many heart diseases seem apparently “stable,” and a definitive decision is difficult to make, especially for a patient whose driving is integrated into his job. To avoid inequity and remain neutral on the basis of current evidence, in 2019 the Swiss model approved and established a working group comprising two parts: the Swiss Society of Cardiology and the Traffic Medicine Section of the Swiss Society of Legal Medicine. The aim of this interactive review was to translate the recommendations from this official communication into simplified indications (with tables) with the help of clinical scenarios and evocative cases.

The main causes of traffic accidents are violation of traffic rules, lack of attention, and poor vehicular condition. Illness causes fewer than 0.5% of accidents resulting in injuries and rarely result in injury to someone other than the driver [9]. Evidence suggests that people who develop severe and even fatal coronary attacks while driving may have sufficient warning to slow down or stop before losing consciousness, since fewer than half of these accidents result in property damage and injury [10]. However, sometimes no warning occurs, or a warning sign is misinterpreted or ignored, and this may result in severe injury or death to the driver and other users of the road. Collapse from ischemic heart disease (nonfatal and fatal) appears to account for around 15% of sudden illness crashes, which in turn account for about 1 in 1,000 reportable crashes. Thus, ischemic heart disease poses a relatively small but increasing risk [11].

Disease-specific guidelines are provided in the text. When more than one disease coexists, the more restrictive recommendation prevails. All cardiovascular diseases in this section carry the risk of progression, and therefore in all cases the issue or renewal of the license may be subject to periodic assessment especially if there is risk of deterioration.

There is a lot of heterogeneity in the group of individuals with a particular heart condition (for example, stage and duration of disease, co-morbidities, risk factor profile, and compliance to treatment). It is required a priori to establish two essential groups participating as members of the driving public:

Group 1 is formed by drivers of vehicles of categories A, A1, A2, AM, B, B1, and BE. These comprise drivers of, e.g., motorcycles, passenger cars, and other small vehicles with or without a trailer.

In the following section, we will transform the information on the tables with indications of the Swiss Society of Cardiology and the Swiss Society of Forensic Medicine into fictitious cases.

The cardiologist’s obligation to inform his/her patient about the right to drive or not is underestimated and underrepresented. This practical guide aims to assist physicians in approaching the legal aspects of their job in a more accessible manner, recognizing its equal importance alongside the medical component.

Fortunately, the risk of a road accident due to a cardiovascular disease remains low. As a general rule, the restrictions are more severe for professional drivers. Normal drivers can drive with any ejection fraction if they are compensated, soon after a myocardial infarction (regardless of whether they are stented or not), immediately after PM or ICD implantation; the professionals always need a waiting period, an EF of over 35%, and a negative stress test. In the case of PM, professional drivers also have to wait, and unfortunately wearing an ICD completely contraindicates driving in this category. Driving is also permitted with a left ventricular assist device, after a heart transplant, or with Brugada syndrome (if the patient receives an ICD).

Disease-specific guidelines are provided in the text. When more than one disease coexists, the more restrictive recommendation prevails. All cardiovascular diseases in this section carry the risk of progression, and therefore in all cases the issue or renewal of the license may be subject to periodic assessment especially if there is risk of deterioration. It must be acknowledged that the group of individuals with a specific heart condition exhibits a wide heterogeneity, including differences in disease stage and duration, co-existing medical conditions, risk factors, and adherence to treatment. Determining whether to grant or deny the privilege to drive remains therefore a challenging decision to make in many scenarios. The author, however, holds the hope that this review has provided insights and instilled more confidence in this ever-evolving and often arbitrary field.

All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.