1.  Sinus and Primary Atrial Arrhythmias

• Sinus arrhythmia was considered a normal variant of no consequence.

• Symptomatic sinus bradycardia or tachycardia is abnormal and requires a search for it s cause.

• Asymptomatic sinus bradycardia or tachycardia in the absence of underlying relevant diseases should not be disqualifying.

• Isolated atrial premature beats (symptomatic or not) and not requiring therapy were not considered disqualifying.

• Atrial fibrillation and flutter are usually associated with disease states and should preclude commercial driving until adequately evaluated and treated.

• Multifocal atrial tachycardia is usually associated with serious underlying metabolic or pulmonary disease. Patients with this arrhythmia should not be considered fit for driving.

2.  Junctional rhythms and Paroxysmal Supraventricular Tachycardia

• Non-paroxysmal junctional tachycardia was considered to be closely associated with disease states and digitalis toxicity. Medical evaluation is required and driving permitted only if the arrhythmia is asymptomatic and cardiac disease states are excluded.

• Paroxysmal supraventricular tachycardia (SVT)  was considered acceptable if well controlled with any acceptable medical regiment. The same recommendation was provided for patients with ventricular pre-excitation (eg, Wolff-Parkinson-White syndrome), and this subset is not qualified for commercial motor vehicle operation.

3. Ventricular Dysrhythmia

• Low grade 3 and above (ie. multiform premature complexes, couplets, three or more consecutively , and R-on-T phenomenon) ventricular arrhythmias were disqualifying unless cleared by a cardiologist on a case-by-case basis.

• Sustained or non-sustained ventricular tachycardia, whether symptomatic or not, was considered disqualifying.

4.  Heart Block

• First-and second-degree type 1 atrioventricular (AV)  block were not considered problematic. The implication of narrow versus wide QRS complexes in the setting of second-degree type 1 AV block was not addressed.

• Second-degree type 11 AV  and third-degree AV block were considered disqualifying. Congenital AV  block was not addressed.

• Bundle-branch blocks and fascicular blocks should prompt a search for evidence of intrinsic cardiac abnormalities, but in the absence of such diseases they should not be disqualifying.

5.  Pacemakers

• The majority opinion concluded that insertion of a pacemaker should not in itself be disqualifying, although specialized follow-up was advised. However, a dissenting minority opinion recommending disqualification was included in the report.  This opinion recommended disqualification due to total lack of certainty for pacemaker operation. The concept of pacemaker dependency was not addressed.

6.  Sudden Death

• For patients who have survived cardiac arrest, the consensus of the conference was that they still carry a substantial risk of additional episodes and should not be considered fit for commercial driving irrespective of the success of subsequent therapy. The impact of ISD treatment was not a consideration at the time of the report.

7.  Cardiovascular Pharmacological Agents

• For patients receiving beta blockers, concern was raised regarding impaired mental alertness and development of depression and somnolence. Case-by-case decisions with respect to driving qualification were implied. In general, calcium channel blockers were accorded a higher level of safety with respect to driving risk.

• In regard to Vaughn Williams Class 1 and 111 agents, the conference provided a timely warning against use of antiarrhythmic agents for common benign arrhythmias, pointing out that they often provided no benefit and often cause a worsening of ectopy. They recommended that patients who require such drugs undergo a comparative evaluation before and afterward. The specifics of the recommended evaluations would now be considered inadequate and therefore are not included here.