This section covers:

• Summary table
• Introduction
• 3.1 Myocardial ischaemia
• 3.2 Severe hypertension
• 3.3 Arrhythmias and conduction abnormalities
• 3.4 Valvular heart disease
• 3.5 Cardiac failure and cardiomyopathy
• 3.6 Anticoagulation
• 3.7 Congenital heart disease
• 3.8 Aneurysm
• 3.9 Other cardiovascular disease
• 3.10 Heart transplants
• 3.11 Uncomplicated ECG changes

Summary table

The table below summarises the information outlined in this section. However, practitioners should ensure that they are familiar with the guidance outlined in the entire section rather than relying solely on the table. The recommended minimum stand-down periods from driving and guidelines only apply where an individual's medical condition has been adequately treated and stability has been achieved so that road safety is unlikely to be compromised.

Introduction

Ischaemic heart disease is the single most common serious disease for New Zealand males aged under 60. Cardiac history and risk factors should be considered before medical certificates of fitness to drive are issued.

The purpose of this section is to provide guidelines to medical practitioners who are required to assess the fitness of individuals with cardiovascular disease to hold a licence to drive a motor vehicle. These guidelines do not provide comprehensive coverage of all cardiovascular conditions that may influence fitness to drive.

Although the driving risks of collapse and/or sudden death from ischaemic heart disease are not entirely clearly defined, there is evidence that the condition poses a measurably increased risk. The effects of driving long distances and under significant stress should also be taken into account, as well as the fact that most drivers of heavy vehicles will have to be involved with loading and unloading their vehicles, changing tyres and other heavy work that may precipitate infarction (Mittleman et al 1993). The epidemiological evidence indicates that those who have had a previous myocardial infarction or similar event are at greater risk of recurrence than the normal population. There is thus a small but real risk that obliges medical practitioners to adequately consider the risk to public safety that their patients may pose.

For the 2003-2007 period, cardiovascular conditions were estimated to contribute to 9 percent of medical-related crashes. These figures may underestimate the contribution of cardiovascular conditions because 24 percent of medical-related crashes classified as ‘blackouts’ may have had a cardiovascular condition, such as syncope, as an unconfirmed causal factor.

Assessment by a cardiologist

Most individuals with cardiovascular disease who require assessment of fitness to drive should generally be reviewed by a consultant cardiologist or cardiothoracic surgeon. All individuals with cardiovascular disease who hold a higher licence class(s) and/or endorsement(s) generally need to be assessed by a specialist. In some cases, advice not to drive might be reviewed after an appropriate period, and that advice might be withdrawn.

Individuals assessed by a cardiologist as having a high risk of sudden cardiovascular collapse should not drive.

Temporary driving restrictions

Unless specified, after cardiac surgery, individuals may be assessed for cardiovascular fitness to drive only if they are free of musculoskeletal pain and other morbidity that could impair safe driving.

3.1 Myocardial ischaemia

In individuals with ischaemic heart disease, the probability of ischaemia while driving, rather than the mere presence of ischaemic heart disease, should influence the assessment of fitness to drive. Use the new definitions of myocardial infarction based on myocardial proteins Troponins T or I and creatine kinase MB, rather than the previous World Health Organization definition (Joint European Society of Cardiology/American College of Cardiology Committee 2000).

3.1.1 Angina pectoris (proven)

The type and frequency of angina episodes is important in considering whether an individual should or should not drive.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Individuals with angina pectoris at rest or on minimal exertion despite medical therapy should not drive.

When driving may resume or may occur

An individual may be fit to drive if:

• angina pectoris is usually absent on mild exertion, and
• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals with angina pectoris at rest or on minimal exertion despite medical therapy should not drive.

When driving may resume or may occur

An individual with angina pectoris occurring only on strenuous exertion (Canadian class 1) or previous angina pectoris may be fit to drive if there is no evidence of myocardial ischaemia on adequate stress (exercise for > 9 minutes on the Bruce protocol (or equivalent exercise protocol) or pharmacological testing with either echocardiographic or scintigraphic assessment combined with ECG assessment). The Agency may consider individuals with evidence of minimal myocardial ischaemia, if there is a supporting specialist opinion. The Agency may impose licence conditions for regular medical assessment, eg annual reviews.

3.1.2 Angina pectoris (suspected)

Medical standards for all licence classes and/or endorsement types

When angina pectoris is suspected, fitness to drive is as for an individual with proven angina pectoris until and unless a diagnosis of angina pectoris is excluded.

3.1.3 Acute uncomplicated myocardial infarction

The period of convalescence after acute myocardial infarction will vary according to the amount of myocardial necrosis, the extent of obstructive coronary artery disease, the efficacy of any revascularisation procedure, functional capacity, evidence of reversible ischaemia, and predisposition to ventricular tachycardia. The timing of fitness to drive after myocardial infarction should be assessed in the context of convalescence generally.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Driving should cease for at least two weeks after an acute uncomplicated myocardial infarction, subject to a specialist assessment.

When driving may resume or may occur

An individual may be fit to drive two weeks after a myocardial infarction, subject to a specialist assessment, if:

• the left ventricular ejection fraction is greater than 40 percent (otherwise one month if less than or equal to 40 percent), and
• angina pectoris is usually absent on mild exertion, and
• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Driving should cease for at least four weeks after a myocardial infarction, subject to a specialist assessment.

When driving may resume or may occur

An individual may be fit to drive four weeks after a myocardial infarction, subject to a specialist assessment, if:

• the left ventricular ejection fraction is greater than 40 percent, and
• there is no evidence on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic) of myocardial ischaemia.

The Agency may impose licence conditions for regular medical assessment, eg annual reviews.

The Agency may consider individuals with evidence of minimal myocardial ischaemia, if there is a supporting specialist opinion. Angiography may be required to confirm a commercial driver's low-risk status.

3.1.4 Coronary artery bypass surgery

Fitness to drive after coronary artery bypass surgery is influenced by completeness of revascularisation, functional capacity, evidence of reversible myocardial ischaemia and the presence of musculoskeletal or other pain.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Driving should cease for at least four weeks following coronary artery bypass surgery, subject to a specialist assessment.

When driving may resume or may occur

An individual may be fit to drive four weeks after coronary artery bypass surgery, subject to a specialist assessment, if:

• angina pectoris and dyspnoea are usually absent on mild exertion, and
• there is no musculoskeletal or other pain that would interfere with driving, and
• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Driving should cease for at least three months following coronary artery bypass surgery.

When driving may resume or may occur

An individual may be fit to drive three months after coronary artery bypass surgery, subject to a specialist assessment, if:

• there is no evidence of myocardial ischaemia on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic), or
• there is evidence of minimal myocardial ischaemia at a moderate or high level of stress, but at angiography there is complete revascularisation.

The Agency may impose licence conditions for regular medical assessment, eg annual reviews. The Agency may consider individuals with evidence of minimal myocardial ischaemia and/or with incomplete revascularisation at angiography, if there is a supporting specialist opinion.

3.1.5 Coronary angioplasty

The period of convalescence after coronary angioplasty will vary according to symptoms, the extent of disease prior to angioplasty, the efficacy and complications of angioplasty, functional capacity and evidence of reversible myocardial ischaemia after angioplasty. The timing of fitness to drive after coronary angioplasty should be assessed in the context of convalescence generally.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Individuals should not drive for at least two days after coronary angioplasty. Individuals with complications arising from coronary angioplasty, which may impair their ability to drive safely, should not drive until given medical clearance.

When driving may resume or may occur

An individual may be fit to drive two days after coronary angioplasty if angioplasty was not associated with acute myocardial infarction (immediately prior to, during or after angioplasty) or other significant complications.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Individuals should not drive for at least four weeks after coronary angioplasty. Individuals with complications arising from coronary angioplasty, which may impair their ability to drive safely, should not drive. The Agency may require regular review because of the possibility of in-stent restenosis occurring over this time.

When driving may resume or may occur

An individual may be fit to drive four weeks after coronary angioplasty if:

• angioplasty was not associated with acute myocardial infarction (immediately prior to, during or after angioplasty) and there is no evidence of myocardial ischaemia on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic), or
• there is evidence of minimal myocardial ischaemia at a moderate or high level of stress, but at angiography there is complete revascularisation. The Agency may impose licence conditions for regular medical assessment, eg annual reviews.

The Agency may consider individuals with evidence of minimal myocardial ischaemia and/or with incomplete revascularisation at angiography, if there is a supporting specialist opinion.

3.2 Severe hypertension

Treatment for hypertension aims to maintain a sitting blood pressure equal to or less than 140mm Hg systolic and equal to or less than 90mm Hg diastolic.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Individuals for whom treatment causes symptomatic postural hypotension or impaired alertness should not drive until these effects have been satisfactorily remedied.

When driving may resume or may occur

An individual may be fit to drive unless either of the following applies (and provided there is no other condition that would render the individual unfit to drive):

• treatment causes symptomatic postural hypotension, or
• treatment causes impaired alertness.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual is normally considered unfit to drive if:

• the sitting blood pressure is consistently equal to or greater than 200mm Hg systolic, or equal to or greater than 110mm Hg diastolic, or
• treatment causes symptomatic postural hypotension or impaired alertness, or
• there is end-organ damage (cardiac, cerebral, retinal or renal) that would otherwise render the individual unfit to drive.

3.3 Arrhythmias and conduction abnormalities

Individuals with recurrent or persistent arrhythmias causing presyncope or syncope are normally considered unfit to drive. Fitness to drive may be assessed after effective treatment and an appropriate symptom-free interval.

3.3.1 Cardiac arrest

Cardiac arrest may occur secondary to bradycardia or asystole, ventricular tachycardia or fibrillation, or if cardiac output is reduced in association with other arrhythmias. Driving should be resumed only when the underlying cause(s) of cardiac arrest have been effectively treated and the individual has remained asymptomatic for an adequate period.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive for at least two months following a cardiac arrest.

When driving may resume or may occur

An individual may be fit to drive two months after a cardiac arrest, subject to a specialist assessment and provided there is no other condition that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual is normally considered permanently unfit to drive, unless:

• cardiac arrest had occurred within two days of acute myocardial infarction, and the individual subsequently did not have inducible ventricular tachycardia at electrophysiological study, and there was no other condition that would render the individual unfit to drive, or
• cardiac arrest had been associated with an arrhythmia that was subsequently cured by surgery or catheter ablation, and the individual subsequently did not have inducible ventricular tachycardia at electrophysiological study, and there was no other condition that would render the individual unfit to drive, or
• cardiac arrest had been associated with factors that could be avoided in the future, and there was no other condition that would render the individual unfit to drive.

In the circumstances listed above, fitness to drive may be assessed following a symptom-free interval of at least three months after cardiac arrest. Specialist assessment is required before an individual returns to driving. The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist reviews.

3.3.2 Syncope and presyncope

Presyncope and syncope may occur secondary to arrhythmias, medications and other factors. Driving should cease until the underlying cause(s) of presyncope and/or syncope have been identified and effectively treated, and the individual has remained asymptomatic for an adequate period. Where the cause of presyncope and/or syncope is not identified, individuals should not drive for the periods outlined below.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive for a symptom-free period of at least two months following syncope.

When driving may resume or may occur

An individual may be fit to drive following a symptom-free interval of at least two months after syncope, provided there is no other condition that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual is normally considered unfit to drive, unless:

• all the factors leading to presyncope or syncope have been identified and treated effectively, and
• there is no other condition that would render the individual unfit to drive.

Fitness to drive may be assessed following a symptom-free interval of at least three months after syncope. The Agency may impose licence conditions for regular medical assessment, eg annual reviews.

3.3.3 Cardiac arrhythmias

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

See section 3.3.4 for individuals who have a pacemaker implanted.

Atrial fibrillation does not normally require driving restrictions unless complicated by episodes of syncope or dizziness. In these circumstances, individuals should not drive until the condition has stabilised under satisfactory treatment.

The situation with regard to other forms of arrhythmias, such as supraventricular tachycardias, Wolff-Parkinson-White syndrome and other conduction disorders, will depend on any history of collapse, dizziness or syncope. A symptom-free period of at least three months on treatment or following corrective surgery will normally be required before allowing individuals to resume driving.

Individuals not treated by curative surgery may be required to have an annual cardiologist assessment as a condition for holding a licence to drive.

An individual who has undergone radiofrequency ablation may be fit to drive six weeks after it if:

• assessed by a specialist
• there is an absence of symptoms
• an ECG is normal, where relevant
• there is no other condition that would render the individual unfit to drive.

Individuals with untreated ventricular tachycardia should not drive. Individuals with ventricular tachycardia or any arrhythmia likely to cause syncope or predispose to sudden death are generally considered unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

Individuals with a history of recurrent or persistent arrhythmia should be considered unfit to apply for and hold a licence. Individuals with uncomplicated atrial fibrillation do not generally have driving restrictions unless complicated by episodes of syncope or dizziness or other symptoms. A period of at least six months free of symptoms is generally required and licences may be subject to the condition of an annual cardiac assessment. Individuals with ventricular tachycardia or any arrhythmia likely to cause syncope or predispose to sudden death are generally considered unfit to drive. The Agency may consider granting individuals with a licence or endorsement based on a supporting specialist report where sound reasons exist.

3.3.4 Pacemaker

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive for at least two weeks after successful implantation of a pacemaker.

When driving may resume or may occur

An individual may be fit to drive two weeks after implantation of a pacemaker provided there is no other condition that would render the individual unfit to drive. Return to driving subject to specialist assessment. Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O licence endorsement.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual should not drive for at least one month after implantation of a pacemaker.

When driving may resume or may occur

An individual may be fit to drive one month after implantation of a pacemaker if:

• there are normal haemodynamic responses at a moderate level of exercise, and
• there is no other condition that would render the individual unfit to drive.

Specialist assessment should be undertaken before driving can resume.

The Agency may impose licence conditions for regular medical assessment, eg annual reviews.

3.3.5 Automatic implantable cardioverter defibrillator

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive for at least six months after implantation of an automatic cardioverter defibrillator.

Individuals who have an implanted automatic cardioverter defibrillator for prophylactic reasons should not drive for at least two weeks after implantation. Return to driving is subject to specialist assessment. If the device discharges, then an individual should stop driving for six months unless sound reasons exist for an earlier return to driving. When the batteries are changed, driving should cease for one month.

When driving may resume or may occur

An individual may be fit to drive six months after implantation of an automatic cardioverter defibrillator, provided there is no other condition that would render the individual unfit to drive. Specialist assessment should be undertaken before driving can resume.

The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist review. An individual who has had an implanted automatic cardioverter defibrillator for prophylactic reasons can drive two weeks after implantation subject to specialist assessment.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual with an implanted automatic cardioverter defibrillator is normally considered unfit to drive.

3.3.6 Other arrhythmias and electrocardiographic abnormalities

Atrial fibrillation may be secondary to other arrhythmias, myocardial ischaemia, valvular or other heart disease, and thyrotoxicosis. The assessment of fitness to drive should take account of factors that may cause or precipitate atrial fibrillation, and whether treatment is likely to abolish atrial fibrillation.

Supraventricular and ventricular tachycardia may be due to re-entry utilising electrical pathways that may be modified medically or cured by catheter ablation or surgery. The assessment of fitness to drive should take account of potentially curative therapy. Conduction abnormalities may occur in isolation or be associated with other heart disease or drug therapy.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive if they have arrhythmias or other electrocardiographic abnormalities that could cause presyncope or other symptoms that might impair driving.

When driving may resume or may occur

Individuals with arrhythmias or other electrocardiographic abnormalities that do not cause presyncope (or other symptoms that might impair driving) may be fit to drive if there is no other condition that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual should not drive if they have arrhythmias or other electrocardiographic abnormalities that could cause presyncope or other symptoms that might impair driving.

When driving may resume or may occur

Individuals with arrhythmias or other electrocardiographic abnormalities that do not cause presyncope (or other symptoms that might impair driving) may be fit to drive if there is no other condition that would render the individual unfit to drive. The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist's review.

3.4 Valvular heart disease

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual may be fit to drive four weeks after successful valve surgery. Specialist assessment should be undertaken before driving can resume. An individual should not drive if they have dyspnoea on mild exertion.

When driving may resume or may occur

An individual may be fit to drive four weeks after successful valve surgery if:

• there are no electrocardiographic changes, symptoms, arrhythmias, cardiac failure, poorly controlled anticoagulant therapy (see section 3.6), severe hypertension or other conditions that would render the individual unfit to drive
• there is no sternotomy or other pain that would interfere with driving.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual is normally considered unfit to drive if:

• there is any clinical evidence of valvular disease, with or without surgical repair or replacement, associated with dyspnoea, chest pain, symptomatic arrhythmia, dizziness or a history of embolism, or
• there are electrocardiographic changes, symptoms, arrhythmias, cardiac failure, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive, or
• there is echocardiographic evidence of severe mitral stenosis or severe aortic stenosis.

When driving may resume or may occur

An individual may be fit to drive if there is only mild valvular disease of no haemodynamic significance, and there are no conditions that would otherwise render the individual unfit to drive.

An individual may be fit to drive three months after successful valve surgery, if there is no evidence of valvular dysfunction and there are no electrocardiographic changes, symptoms, arrhythmias, cardiac failure, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive. Specialist assessment should be undertaken before driving can resume. The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist review.

3.5 Cardiac failure and cardiomyopathy

Cardiac failure is a predictor of risk of sudden death. Individuals with uncontrolled or recent (within the last two weeks) uncontrolled heart failure should not drive.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

Individuals with hypertrophic cardiomyopathy and syncope should not drive.

When driving may resume or may occur

An individual may be fit to drive if:

• dyspnoea is usually absent on mild exertion, and
• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive.

The Agency may consider granting individuals with a licence or endorsement based on a supporting specialist report.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

Generally, individuals will be unfit to drive. However, the Agency may consider granting individuals with a licence or endorsement based on a supporting specialist report. Individuals with hypertrophic cardiomyopathy and syncope should not drive.

When driving may resume or may occur

Asymptomatic individuals with hypertrophic cardiomyopathy are generally considered unfit to drive. However, the Agency may consider granting individuals with a licence or endorsement based on a supporting specialist report. An individual with heart failure or cardiomyopathy (ejection fraction equal to or greater than 40 percent) may be fit to drive following a specialist review. Asymptomatic individuals with hypertrophy of the left ventricular wall less than or equal to 25mm may be fit to drive following a specialist review.

3.6 Anticoagulation

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving may resume or may occur

An individual may be fit to drive if:

• anticoagulation is maintained at the appropriate degree for the underlying condition, and
• there are no electrocardiographic changes, symptoms, arrhythmias, cardiac failure, severe hypertension or other conditions that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving may resume or may occur

An individual may be fit to drive if:

• anticoagulation is maintained at the appropriate degree for the underlying condition, and
• there are no electrocardiographic changes, symptoms, arrhythmias, cardiac failure, severe hypertension or other conditions that would render the individual unfit to drive.

The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist review.

3.7 Congenital heart disease

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual should not drive for at least six weeks following successful surgery for congenital heart disease. Specialist assessment should be undertaken before driving can resume.

When driving may resume or may occur

An individual may be fit to drive six weeks after successful surgery for congenital heart disease if there are no electrocardiographic changes, symptoms, arrhythmias, cardiac failure, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving may resume or may occur

Individuals with asymptomatic minor congenital heart disorders (including mild pulmonary stenosis, a small atrial or ventricular septal defect, a bicuspid aortic valve without stenosis, and mild coarctation of the aorta without aortic aneurysm) may be fit to drive if there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6), severe hypertension or other conditions that would render the individual unfit to drive. An individual may be fit to drive three months after successful surgery for congenital heart disease if:

• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive, and
• there is no evidence of myocardial ischaemia on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic).

The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist review. Specialist assessment should be undertaken before driving can resume.

3.8 Aneurysm

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving should cease

An individual with a thoracic aneurysm of greater than 6.5 cm diameter, or abdominal aortic aneurysm of greater than 5.5 cm, or another vascular abnormality at risk of dissection or rupture, is generally considered unfit to drive. Individuals with Marfans Syndrome should not drive if they have an aneurysm of greater than 4.5 cm.

In exceptional circumstances, the Agency may grant a licence subject to a favourable specialist report.

When driving may resume or may occur

An individual may be fit to drive six weeks after successful surgery.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving should cease

An individual with a thoracic aneurysm of greater than 6.5 cm diameter, or abdominal aortic aneurysm of greater than 5.5 cm, or another vascular abnormality at risk of dissection or rupture, is normally considered unfit to drive. Individuals with Marfans Syndrome should not drive if they have an aneurysm of greater than 4.5 cm.

When driving may resume or may occur

The possibility of returning to driving after successful surgery may be reviewed three months after such surgery, if there are no significant complications. Specialist assessment should be undertaken before driving resumes.

3.9 Other cardiovascular disease

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving may resume or may occur

An individual may be fit to drive, provided that symptoms are absent on mild exertion, if:

• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive, and
• there is no evidence of myocardial ischaemia on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic).

Specialist assessment should be undertaken before driving resumes.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

When driving may resume or may occur

An asymptomatic individual may be fit to drive if:

• there are no electrocardiographic changes, symptoms, arrhythmias, poorly controlled anticoagulant therapy (see section 3.6 ), severe hypertension or other conditions that would render the individual unfit to drive, and
• there is no evidence of myocardial ischaemia on adequate stress (exercise or pharmacological) testing (electrocardiographic, echocardiographic or scintigraphic).

The Agency may impose licence conditions for regular medical assessment, eg annual cardiologist review. Specialist assessment should be undertaken before driving resumes.

3.10 Heart transplants

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

• See appendix 3

When driving may resume or may occur

Successful transplants do not pose a bar to driving unless there are ongoing symptoms. An individual may be fit to drive six weeks after a successful heart or heart