Download Heart disease regulations: implications for work and play

Mills and Boon Heart disease part 2_Layout 1 17/09/2014 11:24 Page 1
CARDIOVASCULAR MEDICINE
31
Heart disease regulations:
implications for work and
play – part 2
NICHOLAS L. MILLS AND NICHOLAS A. BOON
Authorities may impose
restrictions on the activities
of patients with heart
disease in order to protect
the individual, society or the
interests of their institution.
In the second article of this
two-part series, the authors
look at the scientific basis
underpinning current advice
on driving, flying and a
range of sporting activities.
n part 1 of this series, we outlined the
concept of acceptable risk and discussed
the implications for patients with coronary
artery disease and implanted devices.1 Here,
we look at the implications of heart disease
for drivers, air passengers, divers (Figure 1),
climbers and professional athletes.
I
HEART DISEASE AND DRIVING
In the UK, 1 per cent of the 130 000 road
traffic accidents per annum occur as a
result of an underlying medical condition.2
The Road Traffic Act 1988 sets out the legal
basis through which the Driver and Vehicle
Licensing Agency (DVLA) has responsibility
to ensure that all licence holders are fit
to drive. The DVLA publishes national
guidelines that outline restrictions for
all categories of licence holders for all
relevant medical conditions, and these
guidelines are updated twice a year.3
TRENDS IN UROLOGY & MEN’S HEALTH
Figure 1. Diving poses special risks to patients with heart disease ( ”Photostock Israel/Science
Photo Library)
The medical standards for drivers of heavygoods and passenger-carrying vehicles
(group 2) are higher than those for drivers
of cars or motorcycles (group 1), because
of the size and weight of the vehicle, and
the length of time the driver spends at the
wheel (Table 1). Indeed, the case fatality
rates for accidents involving these vehicles
are three- to fourfold greater than those
involving ordinary private cars. Thus,
following an acute coronary syndrome,
group 1 licence holders are allowed
to return to driving after one week if
they have undergone percutaneous
revascularisation or four weeks if they have
not been revascularised, and do not need
to inform the DVLA. In contrast, group 2
SEPTEMBER/OCTOBER 2014
Nicholas L. Mills, PhD, MRCP, Consultant
Cardiologist; Nicholas A. Boon, MD, FRCP,
Consultant Cardiologist, Royal Infirmary
of Edinburgh
www.trendsinurology.com
Mills and Boon Heart disease part 2_Layout 1 17/09/2014 11:25 Page 2
CARDIOVASCULAR MEDICINE
32
Condition
Group 1
Group 2*
Angina pectoris
Driving must cease when symptoms occur at
rest, with emotion or at the wheel
Refusal or revocation with continuing symptoms
(treated and/or untreated) (r1)
Acute coronary syndrome
If successfully treated by coronary angioplasty,
driving may recommence after 1 week
provided no urgent revascularisation planned
and LVEF >40%
All acute coronary syndromes disqualify the
licence holder from driving for at least 6 weeks
(r1)
If not successfully treated by coronary
angioplasty, driving may recommence after
4 weeks
Elective PCI
Driving must cease for at least 1 week
Disqualifies from driving for at least 6 weeks (r1)
Elective CABG
Driving must cease for at least 4 weeks
Disqualifies from driving for at least 3 months (r2)
Heart failure
Driving may continue if no symptoms that
may distract driver’s attention
Disqualifies from driving if symptomatic (r3)
Pacemaker implant
Driving must cease for at least 1 week
Disqualifies from driving for 6 weeks (r4)
ICD implant
– Ventricular
arrhythmia with
incapacity
Should not drive for 6 months after implant
or after any device therapy (shock or
anti-tachycardia pacing)*
Permanent bar
Should not drive for 2 years if device therapy
accompanied by incapacity*
– Sustained ventricular
arrhythmia, no incapacity
Should not drive for 1 month after ICD implant
providing LVEF >35%, no fast VT (RR <250ms),
induced VT can be pace-terminated by the ICD
and as above for device therapy*
Permanent bar
– Prophylaxis
Should not drive for 1 month after ICD implant
and as above for device therapy*
Permanent bar
*Notifiable to the DVLA: all categories for group 2 and selected group 1 licence holders. r, Relicensing may be permitted provided the
following requirements can be met: r1, free from angina for 6 weeks and exercise or other functional test requirements can be met;
r2, free from angina for 3 months with no evidence of significant impairment of left ventricular function (LVEF ≥40%) and exercise or
other functional test requirements can be met; r3, asymptomatic, LVEF ≥40% and no other disqualifying condition with exercise or other
functional testing possibly required depending on the likely cause for the heart failure; r4, 6 weeks if no other disqualifying condition.
LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; CABG, coronary artery bypass grafting; ICD, implantable
cardioverter defibrillator; VT, ventricular tachycardia.
Table 1. Driver and Vehicle Licensing Agency (DVLA) driving restrictions for group 1 and 2 licence holders with selected cardiovascular
conditions3
www.trendsinurology.com
TRENDS IN UROLOGY & MEN’S HEALTH
SEPTEMBER/OCTOBER 2014
Mills and Boon Heart disease part 2_Layout 1 17/09/2014 11:25 Page 3
CARDIOVASCULAR MEDICINE
33
licence holders must inform the DVLA and
are disqualified from driving for at least six
weeks, with relicensing permitted only
following an exercise test or equivalent
functional assessment. It is the duty of the
licence holder to notify DVLA of any medical
condition that may affect safe driving.
AIR TRAVEL
A combination of factors encountered during
air travel, including forced immobility, low
humidity, cosmic rays and hypobaric hypoxia,
may have adverse effects on health.4 Most
aircraft have limited facilities for healthcare
and anyone who becomes ill in this
environment may have a worse outcome.
Nevertheless, a working party of the British
Cardiovascular Society has concluded that
there are very few cardiovascular conditions
that warrant denial of the right to fly as a
passenger (Table 2).5
Commercial airlines typically fly at
altitudes of 7000–12 000 metres, and in
spite of the use of pressurised cabins, air
travel induces hypobaric hypoxaemia.
International regulations specify that
commercial aircraft are required to be
pressurised to the equivalent pressure
encountered at an altitude of 2438 metres.
At this pressure-altitude the cabin oxygen
partial pressure is 15.7kPa and therefore
oxygen saturations in healthy individuals
are between 90 and 93 per cent.
Experimental studies suggest that these
blood oxygen saturations have few adverse
effects and are unlikely to trigger myocardial
ischaemia, myocardial infarction, left
ventricular failure or arrhythmia in patients
with stable ischaemic heart disease.4 Patients
with severe cardiopulmonary disease (eg
Eisenmenger’s syndrome) may deteriorate as
a result of additional hypoxia during flight.
All commercial airlines provide access to
oxygen for medical use if required. Patients
who have undergone thoracic surgery should
not fly for at least 10 days because they may
have air in the chest, which could expand
at altitude, resulting in pneumothorax or
surgical emphysema.
TRENDS IN UROLOGY & MEN’S HEALTH
Condition
Functional status Restriction or guidance
Angina
CCS I-II
CCS III
CCS IV
Post-myocardial
Low risk
infarction*
Medium risk
High risk
Elective PCI
–
Elective CABG
–
Acute heart failure
–
Chronic heart failure or NYHA I and II
valvular heart disease NYHA III
NYHA IV
Cyanotic congenital
heart disease
NYHA I and II
NYHA III
Pacemaker implant
ICD implant
NYHA IV
–
–
Arrhythmia
Ablation therapy
–
–
No restriction
Airport assistance
Defer travel, medical escort, oxygen
Fly after 3 days
Fly after 10 days
Defer travel until stable
Fly after 2 days
Fly after 10 days if no complications
Fly after 6 weeks if stabilised
No restrictions
May require in-flight oxygen
Defer travel or in-flight oxygen and
assistance
May require in-flight oxygen
May require in-flight oxygen, airport
assistance
In-flight oxygen and airport assistance
Fly after 2 days
Defer for 1 month post-implant or
device therapy (shock)
No restriction
Fly after 2 days
CCS, Canadian Classification Score; NYHA, New York Heart Association; PCI, percutaneous
coronary intervention; CABG, coronary artery bypass grafting; ICD, implantable
cardioverter defibrillator. *Low risk: age <65, first event, successful reperfusion, ejection
fraction (EF) >45%, no complications, no planned investigations or interventions;
medium risk: EF >40%, no symptoms of heart failure, no evidence of inducible ischaemia
or arrhythmia, no planned investigations or interventions; high risk: EF <40% with signs
and symptoms of heart failure, or those pending planned investigation, revascularisation
or device therapy.
Table 2. Restrictions for commercial air flight in patients with cardiovascular disease, adapted
from a recent British Cardiovascular Society working party report5
PARTICIPATION IN SPORTS
Clinicians are often asked to advise men with
heart disease if they are fit to participate in
sporting activities. Any recommendations
should take into account the type and
intensity of exercise performed, the risk of a
sudden debilitating event, and the impact
that such an event might have on other
participants. By way of illustration, we
discuss the implications of heart disease for
divers, climbers and professional athletes.
In the UK, professional divers are subject to
detailed regular medical examinations under
the auspices of the Health and Safety
Executive; the discovery of organic heart
disease will be considered a bar to occupational
diving unless it is deemed by a cardiologist to
be haemodynamically unimportant.
Diving
Diving is perceived by many to be a
hazardous activity; fatal accidents are
The UK Sport Diving Medical Committee
provides amateur divers with an assessment of
fitness to dive against a set of uniform medical
SEPTEMBER/OCTOBER 2014
certainly more common among professional
divers than in many other high-risk
occupations such as construction.
www.trendsinurology.com
Mills and Boon Heart disease part 2_Layout 1 17/09/2014 11:25 Page 4
CARDIOVASCULAR MEDICINE
34
standards through a network of physicians
with accredited diving medicine expertise.
Restrictions are imposed on divers with
conditions that may cause sudden or
unexpected incapacity that could be hazardous
to the individual or his or her diving partner;
for example, limits are imposed for both depth
and dive times in patients with arrhythmias
so that, in the event of symptoms, they can
return to the surface safely without prolonged
decompression stops.
usually advised to undergo percutaneous
closure. Screening for a PFO is not
considered necessary for recreational divers.
Nevertheless, contrast echocardiography
should be advised in any diver who has
suffered a neurological, cutaneous or
cardiorespiratory decompression illness; this
is particularly important if the individual has
a history of migraine with aura (a condition
that is associated with PFO) or there was
nothing untoward in the dive profile.
During decompression at the end of a dive,
bubbles of nitrogen gas are liberated from
solution and can be detected in venous
blood; paradoxical gas embolism may
occur if the diver has a structural defect
capable of intra-cardiac shunting, such
as an atrial septal defect, and this is
recognised as an important cause of
neurological decompression illness.6,7
Effect of altitude
Every year millions of tourists and
mountaineers visit high-altitude locations,
where inadequate acclimatisation can result
in a spectrum of illnesses. Acute mountain
sickness is defined as a syndrome of nonspecific symptoms including headache,
gastrointestinal disturbance, insomnia and
fatigue occurring in an unacclimatised
person who has recently arrived at an
altitude above 2500 metres.8 High-altitude
pulmonary oedema and high-altitude
cerebral oedema represent the end-stage of
acute mountain sickness and can be fatal if
not identified and treated promptly.
Patent foramen ovale (PFO) is found in
approximately 20 per cent of the general
population and may predispose to
paradoxical embolism in some circumstances.
In the UK, most professional divers
are screened for a PFO by contrast
echocardiography, and those who are
found to have a significant defect are
The partial pressure of oxygen is reduced by
20 per cent at 2500 metres and by up to
60 per cent at 8000 metres, resulting in acute
changes in cardiopulmonary physiology that
include pulmonary and systemic arterial
vasoconstriction, augmentation of the
sympathetic nervous system, with increases
in heart rate and myocardial contractility.9
These physiological effects could in theory
trigger an acute coronary syndrome or cause
acute decompensation in patients with
congestive cardiac failure or pulmonary
hypertension. Patients with class 3 or 4 heart
failure or unstable angina and those with
severe pulmonary hypertension should
therefore be advised to avoid ascending to
altitudes above 1500 metres.
A recent review of the literature suggests
that patients with stable coronary artery
disease (Canadian Cardiovascular Society
functional class I or II) can travel to
altitudes of 3000–5000 metres with
minimal risk;9 nevertheless, it is
recommended that such patients ascend
slowly and minimise physical activity for
the first three to four days at altitude.
Professional athletes
While the incidence of sudden death among
athletes is very low (Figure 2), many have
argued for cardiovascular screening of
professional athletes and elite sports men
and women.10 Most screening programmes
involve documentation of any personal and
family history of cardiovascular disease,
physical examination and ECG recordings.
Recent evidence from a large prospective
screening programme in Italy that included
a 12-lead ECG suggested that this method
of identifying and disqualifying athletes
with hypertrophic cardiomyopathy may
have prevented some deaths.11 On the
other hand, the yield of most screening
programmes is very low; in the Italian
project, for example, screening 33 735
athletes identified only 22 new cases of
hypertrophic cardiomyopathy.
Figure 2. Cardiac arrest among elite athletes is very rare, but high-profile events, such as the
collapse of Fabrice Muamba during a football match, have triggered intense interest in the
value of pre-participation screening (”Getty Images)
www.trendsinurology.com
Moreover, screening tends to unearth many
equivocal or borderline abnormalities that
TRENDS IN UROLOGY & MEN’S HEALTH
SEPTEMBER/OCTOBER 2014
Mills and Boon Heart disease part 2_Layout 1 17/09/2014 11:25 Page 5
CARDIOVASCULAR MEDICINE
35
require careful investigation and may
generate a lot of potentially unnecessary
expense and anxiety; indeed, it is notoriously
difficult to distinguish mild hypertrophic
cardiomyopathy from physiological left
ventricular hypertrophy or ‘athlete’s heart’.
This remains a controversial issue; thus,
many sporting bodies and organisations now
recommend or require active participants to
undergo cardiovascular screening, while
most health authorities continue to advise
against universal pre-participation screening
of athletes and other sportsmen (Box 1).12
BOX 1. Sport and heart disease
l Sudden death in young athletes is a rare tragedy that is often caused by
unrecognised cardiovascular disease, particularly hypertrophic cardiomyopathy
l Pre-participation screening is recommended by many authorities, although
it is often difficult to distinguish hypertrophic cardiomyopathy from
physiological left ventricular hypertrophy caused by athletic training
l The optimum mode of screening remains controversial, but should include
a minimum of medical history, family history and physical examination.
Additional tests such as 12-lead ECG and echocardiography may be helpful,
but have been shown to generate many false-positive results
l Patients with poor left ventricular function, exercise-induced arrhythmias,
ischaemia and syncope, and those with significant valvular heart disease
(particularly aortic stenosis) should be advised to avoid high-intensity
sports activity
SPECIAL OCCUPATIONS
Employees with heart disease may experience
discrimination because of the potential risk
of sudden incapacity. The risk can usually be
quantified and, if deemed unacceptable, the
employee may qualify for critical illness
benefits. The level of risk that is acceptable
will depend on the underlying medical
condition and the nature of the occupation.
For example, drivers of mainline trains and
tankers are not permitted to work following
an acute myocardial infarction, because of
the potential for incapacity to harm large
numbers of innocent people. Separate
specific regulations are available for pilots,
firemen, seamen, the armed forces, police,
offshore workers, scaffolders, arc welders,
and many others. Dedicated occupational
health services are usually available to help
and advise affected employees and may
request reports or specific investigations
from the treating clinician.
Declaration of interests: none declared.
KEY POINTS
• The medical standards for airplane pilots, professional divers and the drivers
of heavy-goods and passenger-carrying vehicles are exacting and usually
require specialist assessment and investigation
• There are very few cardiovascular conditions that warrant denial of the right
to fly as a passenger; however, people who are potentially vulnerable to a fall
in oxygen saturations may require supplementary oxygen during flight
• Patients with very poor left ventricular function, severe hypertrophic obstructive
cardiomyopathy, critical valvular heart disease and unstable coronary disease
should be advised to avoid high-intensity sports because extreme exertion can
sometimes trigger myocardial infarction and/or malignant arrhythmias
4.
5.
REFERENCES
1.
2.
3.
Mills NL, Boon NA. Heart disease regulations:
implications for work and play – part 1.
Trends Urol Mens Health 2014;5(4):9–11.
Department of Transport. Reported
road casualties Great Britain 2012.
www.gov.uk/government/publications/
reported-road-casualties-great-britainannual-report-2012
Driver and Vehicle Licensing Agency.
At a glance guide to the current
TRENDS IN UROLOGY & MEN’S HEALTH
6.
7.
SEPTEMBER/OCTOBER 2014
medical standards of fitness to drive.
Swansea: Drivers Medical Group, 2013.
www.gov.uk/ government/publications/
at-a-glance
Silverman D, Gendreau M. Medical issues
associated with commercial flights. Lancet
2009;373:2067–77.
Smith D, Toff W, Joy M, et al. Fitness to
fly for passengers with cardiovascular
disease. British Cardiovascular Society
Working Group. Heart 2010;96:1–16.
www.bcs.com/documents/BCS_FITNESS_
TO_FLY_REPORT.pdf
Wilmshurst PT, Byrne JC, Webb-Peploe MM.
Relation between interatrial shunts and
decompression sickness in divers. Lancet
1989;2:1302–6.
Moon RE, Camporesi EM, Kisslo JA. Patent
foramen ovale and decompression sickness in
divers. Lancet 1989;1:513–14.
8.
9.
10.
11.
12.
Hackett PH, Roach RC. High-altitude illness.
N Engl J Med 2001;345:107–14.
Bartsch P, Gibbs JS. Effect of altitude
on the heart and the lungs. Circulation
2007;116:2191–202.
Crawford MH. Screening athletes for heart
disease. Heart 2007;93:875.
Corrado D, Basso C, Schiavon M, Thiene G.
Screening for hypertrophic cardiomyopathy in
young athletes. N Engl J Med 1998; 339:364–9.
Maron BJ, Thompson PD, Ackerman MJ,
et al. Recommendations and considerations
related to preparticipation screening for
cardiovascular abnormalities in competitive
athletes: 2007 update: a scientific
statement from the American Heart
Association Council on Nutrition, Physical
Activity, and Metabolism: endorsed by the
American College of Cardiology Foundation.
Circulation 2007;115:1643–55.
www.trendsinurology.com