Arrhythmias

Question 1

Certification is dependent on the _____ ______, not on the use of anticoagulants per se.

Answer 1

underlying condition

Question 2

3 reasons to disqualify a driver on anticoagulant therapy

Answer 2

On anticoagulation for less than 1 month
INR either is not monitored or is not therapedic
patient is less than 2 months post MI or has some kind of disqualifying underlying disease

Question 3

If the driver is on, certification depends on the underlying condition, not on the use of anticoagulation itself. The underlying disease is not necessarily disqualifying. How long must a patient who takes anticoagulation be on it before you consider certification?

Answer 3

At least one month

You cannot certify patient on anticoagulation unless they’ve been on it for at least one month.

Question 4

If the patient is taking anticoagulation, what kind of monitoring do they require?

Answer 4

-INR must be monitored at least monthly
-driver must show a copy of results
-driver must also show prothrombin time
-cannot certify if INR is not being monitored; cannot certify if INR is not therapeutic

Question 5

If a driver is taking anticoagulation because of myocardial infarction, they must be how many months past their myocardial infarction before you can consider certification?

Answer 5

Must be at least two months post MI

Question 6

For patients on anticoagulant, but are important considerations?

Answer 6

Is the underlying disease disqualifying?
What’s the risk for sudden death?
What is the risk for cerebral hypoperfusion and loss of consciousness?

Question 7

Regarding sudden death, the majority are due to which arrhythmias?

Answer 7

-Ventricular tachycardia
-ventricular fibrillation
arrhythmias occur most often in patients who have no prior diagnosis of heart disease. However, the underlying heart disease is what determines the prognosis.

Question 8

When can a patient with an arrhythmia receive certification?

Answer 8

When the dysrhythmia does not increase risk for cerebral hypoperfusion and/or impaired consciousness?

Question 9

When must a patient with an arrhythmia be disqualified?

Answer 9

-When it risk for cerebral hypoperfusion and/or impaired consciousness
-when underlying condition is disqualifying
-when at risk for sudden death

Recall that the two dysrhythmias most frequently causing sudden death are ventricular tachycardia and ventricular fibrillation.

Question 10

Is SVT normally considered to be a risk for sudden death?

Answer 10

No. It does not normally cause loss of consciousness or compromise cerebral function.
-Can treat it medically
-catheter ablation usually allows drug therapy to be withdrawn

So SVT is not considered to be a disqualifying dysrhythmia.

Question 11

Is atrial fibrillation normally associated with loss of consciousness?

Answer 11

-It rarely causes unconsciousness or impairs ability to drive
-main risk with each of the relation is that it generates atrial thrombi that enter the peripheral system and can cause a stroke
-often manifests as palpitations

Question 12

Describe the waiting period required for the main supraventricular arrhythmias.

Answer 12

Minimum one month waiting period for:
-atrial fibrillation adequately anticoagulated
-ablation and atrial flutter
-asymptomatic or asymptomatic aftertreatment for diagnosis of:
* AV node reentrant tachycardia
* Wolf Parkinson White syndrome
* atrial tachycardia
* junctional tachycardia

Question 13

For what period of time can a patient with a supraventricular arrhythmia be certified?

Answer 13

Certify/recertify for up to one year provided that the driver has:
* controlled heart rate
* if anticoagulated, INR must be therapeutic and patient must be tolerating the treatment
* no underlying disqualifying disease
* cardiology clearance/annual cardiology exam
* annual medical exam

Question 14

When must a driver with supraventricular arrhythmias be disqualified?

Answer 14

-Loss of consciousness
-compromised cerebral function
-history of resuscitation for sudden death

Question 15

If a patient has a ventricular arrhythmia, what factors affect certification?

Answer 15

-Left ventricular ejection fraction
-nonsustained ventricular tachycardia
-ventricular tachycardia

Question 16

If a patient is diagnosed with a ventricular arrhythmia, what is the minimum waiting period after treatment and diagnosis?

Answer 16

Minimum waiting period of one month after treatment in patients with a ventricular arrhythmia who also have a diagnosis of:
-coronary heart disease
-right ventricular outflow ventricular tachycardia
-idiopathic left ventricular tachycardia

Question 17

If a driver with a ventricular dysrhythmia is eligible, how long may you certify or recertify this driver?

Answer 17

-Certify or recertify for up to one year if the driver meets all the following criteria:
-asymptomatic
-has an identified, non-disqualifying cardiac etiology
-clearance from a cardiovascular specialist

Question 18

When must a driver with ventricular arrhythmias be disqualified?

Answer 18

-Symptomatic
-sustained ventricular tachycardia
-nonsustained ventricular tachycardia with left ventricular ejection fraction less than 40%
-diagnosis of any of the following:
* hypertrophic cardiomyopathy
* Long QT interval syndrome
* Brugada syndrome

Question 19

What kind of follow-up does a patient with a ventricular of it may require?

Answer 19

-Annual exam with cardiovascular specialist
-annual medical exam

Question 20

List 3 diagnoses which prevent certification of a driver with ventricular arrhythmias.

Answer 20

• hypertrophic cardiomyopathy
• Long QT interval syndrome
• Brugada syndrome

Question 21

What are the qualification guidelines for a driver with an implantable cardioverter-defibrillator or a combination ICD/pacemaker?

Answer 21

These patients are always disqualified.

The devices treat cardiac arrest, ventricular fibrillation, or ventricular tachycardia by delivering rapid pacing stimuli or electric shock. These devices treat, but cannot prevent, dysrhythmias. This means that a person who has an ICD is at risk for syncope.

If somebody’s ICD has fired, then they probably have either had an episode of ventricular tachycardia or ventricular fibrillation. Patients who require an ICD are at high risk for sudden incapacitation, syncope, and sudden death. Therefore, they can never be certified.

Question 22

Pacemakers can be used to treat bradycardia. Name four indications for pacemaker insertion.

Answer 22

1. Sinus node dysfunction
   -prognosis dependent underlying disease
   -pacemaker helps protect the patient against cerebral hypoperfusion
2. AV block
   -prognosis depends on underlying disease
   -pacemaker protects the patient from cerebral hypoperfusion
3. Cardiogenic syncope
   -excellent long-term prognosis
   -risk of syncope is due to bradycardia and/or hypotension
4. Hypersensitive carotid sinus with syncope
   -excellent long-term prognosis
   -there’s a risk of syncope due to bradycardia and/or hypertension

The pacemaker increases the heart rate in a patient with bradycardia; this helps prevent cerebral hypoperfusion.

Question 23

What are the qualification guidelines for a driver with a pacemaker?

Answer 23

You have to consider the underlying cause of the bradycardia when making a decision about whether or not to certify the driver.

Question 24

For what period of time can you certify a driver who has a pacemaker?

Answer 24

Certify for up to one year if the driver meets the following criteria:
-presence of a functioning pacemaker and completion of routine pacemaker checks
-no disqualifying underlying disease
-pacemaker has been implanted for at least one month

Question 25

Suppose you’re evaluating a driver who has a history of pacemaker implantation. The device was received three weeks ago and patient is asymptomatic. They have no other disqualifying conditions. Can they be certified?

Answer 25

No. The driver’s pacemaker must have been implanted for at least one month before you can consider certification.

Question 26

List 3 cardiac diagnoses which prevent certification of a driver.

Answer 26

• hypertrophic cardiomyopathy
• Long QT interval syndrome
• Brugada syndrome

Question 27

There are specific pacemaker guidelines regarding certification when a patient has sinus node dysfunction or AV block as the reason for their pacemaker. Under what conditions may a driver who got a pacemaker to fix sinus node dysfunction or AV block be certified?

Answer 27

Must be at least one month past implantation
must have documentation of correct functioning of the pacemaker

Question 28

After driver receives a pacemaker to fix sinus node dysfunction or atrioventricular block, what is the minimum waiting period s/p pacer implantation before you can consider certification of the driver?

Answer 28

One month

Question 29

There are specific pacemaker guidelines regarding certification when a patient has sinus node dysfunction or AV block as the reason for their pacemaker. Under what conditions may a driver who got a pacemaker to fix sinus node dysfunction or AV block disqualified?

Answer 29

• Driver doesn’t have a pacemaker
• driver is less than one month post insertion

Question 30

For how long can a driver with a pacemaker that was implanted to fix sinus node dysfunction or AV block be recertified?

Answer 30

• Annually
• must have documented pacemaker checks

Question 31

There are specific guidelines regarding certification when a patient received a pacemaker to treat neurocardiogenic syncope or hypersensitive carotid sinus with syncope. When can these patients be certified?

Answer 31

*At least three months post insertion with documentation that the pacemaker is function correctly
* absence of symptom recurrence

Question 32

There are specific guidelines regarding certification when a patient received a pacemaker to treat cardiogenic syncope or hypersensitive carotid sinus with syncope. When are these patients disqualified from certification?

Answer 32

• symptomatic
• less than three months post insertion

Question 33

When a driver receives a pacemaker to treat cardiogenic syncope or hypersensitive carotid sinus with syncope, what’s the minimum waiting period before you can consider certification?

Answer 33

Three months

Question 34

For how long can a driver with a pacemaker that was implanted to treat neural cardiogenic syncope or hypersensitive carotid sinus with syncope be recertified?

Answer 34

• Annually
• must have document pacemaker checks
• must be asymptomatic

Question 35

What kind of follow-up does a patient with a pacemaker require in order to remain eligible for recertification?

Answer 35

*Compliant with schedule pacemaker function checks
* provide documentation pacemaker checks during examination
* annual medical exam

Question 36

Syncope is a symptom, rather than an actual disease. What is the recommended waiting period after patient had a syncopal event before they can be certified?

Answer 36

-No specific recommended waiting
period
-must consider the cost the syncope, if you can identify it
-syncope caused by cardiac conduction problems must be treated before the driver can be certified
-syncope caused by neurologic problems must be evaluated prior to certification
-do not certify the driver until the etiology of syncope is known in the treatment has been shown to be safe and effective
-No specific recommended waiting
period
-must consider the cost the syncope, if you can identify it
-syncope caused by cardiac conduction problems must be treated before the driver can be certified
-syncope caused by neurologic problems must be evaluated prior to certification
-do not certify the driver until the etiology of syncope is known in the treatment has been shown to be safe and effective

Question 37

When can a driver with syncope be certified? For what period of time can the patient was syncope be certified?

Answer 37

Can be certified for a maximum of one year if the following conditions are met:
* treated for underlying disease
* asymptomatic
* tolerates medications and treatments
* low risk for syncopal episode or near single episode
* clearance from the appropriate specialist-cardiologist or neurologist
* must have annual medical exam

Question 38

When does syncope disqualify a driver?

Answer 38

• syncope occurs as a consequence of the disease process regardless of underlying heart disease
• high risk for syncopal episode or near syncopal episode, regardless of the underlying cause
• etiology of the syncope is unknown