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Circulation. 2017;136:e60–e122. DOI: 10.1161/CIR.0000000000000499 August 1, 2017 e93 CLINICAL STATEMENTS AND GUIDELINES

Recommendation for Driving and Syncope

COR LOE Recommendation IIa C-EO It can be beneficial for healthcare providers managing patients with syncope to know the driving laws and restrictions in their regions and discuss implications with the patient.

N/A The writing committee encourages healthcare providers who care for patients with syncope to know pertinent driving laws and restrictions in their region (eg, states or provinces), as well as the duty of drivers or physicians to report inability of an individual to drive a motor vehicle. The Risk of Harm formula simply estimates risk and does not supersede local driving regulations.692 In the United States, private driving is state regulated, but commercial driving requiring a US Department of Transportation commercial driver’s license is federally regulated. Recommendations about commercial driving are more a legal than a medical matter, and are not within the purview of this guideline. Physicians providing care to commercial drivers should be familiar with US Department of Transportation policy.695

Individual states may require reporting of drivers who faint. Many patients do not stop driving despite advice to do so, regardless of the duration of restriction.696,697 Although physicians have an obligation to maintain confidentiality, if a patient’s condition poses a significant risk to others, then this information should be reported as specific laws require.

certain groups, such as younger and older adults, are allowed to drive despite their higher risk of causing harm for reasons other than syncope.693 The societally acceptable risk of injury and death due to motor vehicle accidents has been quantified from an analysis of accident data collected in the United States, United Kingdom, and Canada.694 In the general population, the yearly risk of serious injury and death is 0.067%, or 1 in 1500.694 The 418 patients in POST I and POST II had a median of 3 vasovagal faints in 1 year but had no serious injuries or deaths and only 2 minor accidents in the subsequent year.694 This provides an estimated yearly risk of serious injury and death in the V VS population of <0.0017%, less than the Risk of Harm formula predicted.692 However, for patients with other etiologies of syncope or those in whom syncope occurred without prodrome or warning, the risk of causing harm may be higher than for patients with V VS. Public policies, laws, and regulations have not been adapted to these results, and providers caring for patients with syncope should be aware of pertinent local driving laws and restrictions. Although untreated syncope may disqualify patients from driving, effective treatment reduces the risk enough to permit driving after a period of observation has elapsed without recurrent syncope. Regulatory agencies are more likely to disqualify commercial drivers than private drivers because of the amount of driving and the impact of accidents (ie, commercial drivers typically operate vehicles heavier than private automobiles). As the risk of recurrent syncope decreases with treatment or with the natural history of a disease process, the risk of harm may become low enough for private drivers to resuming driving, but not necessarily for commercial drivers because of the higher risk of harm. The suggestions in Table 10 provide general guidance for private drivers. Most suggestions are based on expert opinion and supported by limited data. Commercial driving in the United States is governed by federal law and administered by the US Department of Transportation.695

10.5 Athletes: Recommendations

Syncope occurring in the athlete is predominantly of vasovagal origin, but underlying cardiac conditions may place athletes at undue risk for adverse events.703 Syncope during exercise is associated with increased probability of cardiac causes of syncope (Table 4). A thorough history, differentiating syncope occurring during exercise from syncope occurring after exercise or at other times, with typical characteristics of dehydration or V VS, is critically important during initial evaluation. The definition of an athlete is imprecise, but athlete can be defined as someone who engages in routine vigorous training (eg, >150 minutes per week) and is skilled in exercises, sports, or games requiring physical strength, agility, or stamina.704 More importantly, cardiac adaptations to high levels of exercise may lead to the “athlete’s heart” and thus alter the myocardial sub- strate.705 Primary or secondary prevention of syncope, morbidity, and mortality in at-risk athletes is a major consideration, but current strategies are largely inadequate.706 The current evidence base is insufficient to support general screening with ECG or echocardiography at baseline.706,707

Several approved therapeutics, especially macrolide antibiotics and antihistamines/decongestants, have been associated with syncopal episodes.708 Performance-enhancing agents, such as somatotrophic compounds and amphetamine-like stimulants, are associated with precipitous collapse. A careful history is required in the athlete with syncope to rule out exposure to any of these agents.709 Similarly, before drugs are prescribed to highly competitive athletes, it is prudent to determine whether the drug or its metabolites are on lists of banned substances.

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