Driving Guidelines for Arrhythmia/Syncope

Abbreviations

ICD – Implantable cardiac defibrillator

VF – Ventricular fibrillation

VT – Ventricular tachycardia

AV – Atrioventricular

AF – Atrial fibrillation

Introduction

Syncope is a common condition associated with a wide spectrum of risk of recurrent episodes.

Largely, syncope can be categorized as reflex-mediated, orthostatic, and cardiac (tachyarrhythmias, bradyarrhythmias, valvular or obstructive) in origin.

The CCS updated the fitness to drive guidelines in 2023 to reflect societal risk tolerance of serious injury or death secondary to a syncopal event leading to a motor vehicle accident. Similarly, this update reflected societal tolerance for a bradyarrhythmia, tachyarrhythmia, or complications associated with an implantable cardiac device to lead a motor vehicle accident.

Syncope

Condition	Private driving	Commercial driving
Single episodes of typical vasovagal syncope	No restriction
Recurrent (within 12 months) vasovagal syncope	No restriction
Syncope with a reversible cause of treated (ed, orthostatic, hemorrhage, dehydration)	May resume driving after 1 week	May resume driving after 1 month
Situational syncope with avoidable trigger (eg 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 (12 months)	May resume driving after 3 months	May resume driving after 12 months

Implantable Cardiac Defibrillators

Condition	Private Driving	Commercial driving
Transvenous ICDs
Primary prophylaxis	May resume driving 1 week after implantation	Disqualified
Secondary prophylaxis for VF or VT with impaired level of consciousness	May resume driving 3 months after last incapacitating event	Disqualified
Secondary prophylaxis for sustained VT without impaired consciousness	May resume driving 1 week after implantation	Disqualified
Subcutaneous ICD	Same recommendations as primary and secondary prophylaxis 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
Appropriate ICD shock, or any ICD therapy without impaired level of consciousness or otherwise disabling	May resume driving 1 week after event	Disqualified
Inappropriate ICD therapies	No restriction	Disqualified
Electrical storm (≥ 3 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

Pacemakers

Condition	Private and commercial driving
Transvenous and leadless pacemakers, with previous impaired consciousness or high-grade AV block	Disqualified for 1 week after implantation, after which patient may resume driving
Transvenous and leadless pacemakers, without impaired consciousness or high-grade AV block	No restriction
Generator change	No restriction
Upgrade/lead revision	If there is a history of impaired level of consciousness or high-grade AV block, patient is disqualified for 1 week, after which patient may resume driving Otherwise no restriction

Tachyarrhythmias

Condition	Private driving	Commercial driving
Ventricular arrhythmias	May resume driving 3 months after index event	Disqualified
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 an ICD)	May resume driving 3 months after event	Disqualified
Sustained VT with structurally normal heart (ie, idiopathic VT) without impaired level of consciousness	May resume driving 1 week after event, and with satisfactory control	Disqualified
SVT, AF/AFL
SVT/AF/AFL with impaired level of consciousness	Disqualified until satisfactory control
SVT/AF/AFL without impaired level of consciousness	No restriction
After electrophysiology study or catheter ablation procedure	May resume driving 48 hours after procedure if no new conduction disturbance, dysrhythmias, or exacerbation of underlying condition

Bradyarrythmias

Condition	Private and commercial driving
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
Symptomatic pauses (≥5 seconds) during AF (pauses during AF or conversion pauses)	Disqualified until appropriate pacemaker therapy
AV and fascicular block
Isolated first-degree AV block	No restriction if no impaired level of consciousness
Isolated RBB, 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 and bifascicular block	No restriction if no impaired level of consciousness
Second-degree AV block; Mobitz II	Disqualified until appropriate pacemaker therapy
Alternating LBBB and RBBB	Disqualified until appropriate pacemaker therapy
Acquired third-degree AV block	Disqualified until appropriate pacemaker therapy or successful resolution in the case of a reversible cause (eg, inferior STEMI or Lyme carditis)
Congenital third-degree AV block	No restriction if no impaired level of consciousness

Reference

CCS 2023 Fitness to Drive Guideline

Authors

Author: Pavel Antiperovitch (MD, FRCPC, Cardiology)
Second Author: Shaun Hanycz (MD, Internal Medicine Resident)
Reviewer: Atul Jaidka (MD, FRCPC, Cardiology)
Copy Editor: Perri Deacon (Medical Student)
Last Updated: September 18, 2024
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