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 Table of Contents  
ORIGINAL ARTICLES
Year : 2019  |  Volume : 9  |  Issue : 4  |  Page : 148-153

Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?


1 Department of Nuclear Medicine, London Health Sciences Centre, London, Canada, Department of Cardiac Imaging, Prince Sultan Cardiac Center Qassim PSCCQ, Buraydah, El Qassim, Saudi Arabia
2 Faculty of Medicine, Suliman Al Rajhi Colleges, Buraydah, El Qassim, Saudi Arabia, Internal Medicine Department, Faculty of Medicine, Cairo University, Egypt, Saudi Arabia
3 Faculty of Medicine, Suliman Al Rajhi Colleges, Buraydah, El Qassim, Saudi Arabia, Critical Care Medicine Department, Faculty of Medicine, Cairo University, Egypt, Saudi Arabia
4 Department of Cardiac Imaging, Prince Sultan Cardiac Center Qassim PSCCQ, Buraydah, El Qassim, Saudi Arabia
5 Department of Cardiology, Prince Mohammad Bin Abdulaziz Hospital, Riyadh, Saudi Arabia
6 Department of medicine, College of Medicine, Qassim University, El Qassim, Saudi Arabia
7 Department of Pharmacology, College of Medicine, Qassim University, El Qassim, Saudi Arabia

Date of Web Publication3-Oct-2019

Correspondence Address:
Rami M Abazid
Department of Nuclear Medicine, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, ON, N6A 5W9.
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajm.AJM_69_19

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   Abstract 

Objective: Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients. Materials and Methods: We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients’ demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients’ medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period. Results: In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively). Conclusion: Patient–physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs.

Keywords: Cardiovascular diseases, medical fitness to drive, motor vehicle accidents, Saudi Arabia


How to cite this article:
Abazid RM, Ewid M, Sherif H, Smettei OA, Salim Khan A, Altorbag AA, Alharbi MF, Aljaber AN, Alharbi SM, Altorbak NA, Altorbak SA, Almeman A. Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?. Avicenna J Med 2019;9:148-53

How to cite this URL:
Abazid RM, Ewid M, Sherif H, Smettei OA, Salim Khan A, Altorbag AA, Alharbi MF, Aljaber AN, Alharbi SM, Altorbak NA, Altorbak SA, Almeman A. Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?. Avicenna J Med [serial online] 2019 [cited 2019 Oct 16];9:148-53. Available from: http://www.avicennajmed.com/text.asp?2019/9/4/148/268509




   Introduction Top


The driving of vehicles is considered an important mode of transportation, public, and private worldwide. In order to drive safely, drivers should have average motor, visual, and cognitive functions.[1] Multiple heath disorders can affect driving capacity and the ability to drive safely. In particular, cardiovascular diseases (CVDs) can result in impairment/loss of consciousness because of syncope, pre-syncope, and faintness, which have a remarkable impact on medical fitness to drive (MFTD) and should be carefully taken into account when assessing the capability of cardiac patients to drive vehicles.[2],[3] Importantly, a temporary or permanent driving restriction should be considered in all symptomatic patients with CVD based on the severity of their symptoms and the reversibility of the condition.[4],[5] Most western countries have regulatory bodies that are responsible for providing regulations to health-care workers and to set proper guidelines for assessment of MFTD, cessation periods, and the requirements for resuming driving;[6],[7],[8] enforcement of these guidelines has been shown to result in a 45% reduction in motor vehicle accidents (MVAs) related to drivers with medical conditions.[9]

MVAs account for 11.7% of the total mortalities in Saudi Arabia and were consistently reported as the third leading cause of death between 2005 and 2010.[10] Several studies worldwide have shown that patients with CVD are at a higher risk for MVA that put them, their families, and the public in great danger.[11],[12],[13] As similar studies have not been conducted in the Kingdom of Saudi Arabia, the aim of this study was to evaluate the awareness of such patients about the driving recommendations and regulations, in particular those related to CVDs, and to assess the incidence of MVA among patients with CVD in Saudi Arabia.

The primary objective of this study is to evaluate the adherence to driving restriction guidelines of patients visiting a tertiary cardiac care center in the central province of Saudi Arabia.


   Materials and methods Top


This is a cross-sectional observational descriptive study, based on a survey administered between February and April 2018, and the data were collected primarily by a questionnaire. After providing written consent, all male patients who were older than 18 years, who had been diagnosed as having a CVD, and who were visiting an outpatient department during the study period were included and were invited to complete the study questionnaire, which contains 12 questions regarding driving caution. In addition, we specifically asked the participants if they had received any recommendations regarding MFTD based on their diseases by their treating physicians.

The participants’ demographics, drug history, and clinical diagnosis were all obtained from the patients’ medical records, and included any history of coronary artery disease, revascularization, cardiomyopathy, arrhythmias, device implantation, and echocardiography parameters (ejection fraction and the presence of significant valvular heart disease); in addition, we reported cardiac symptoms such as chest pain, palpitation, syncope (loss of consciousness), pre-syncope (impairment of consciousness), and dyspnea New York Heart Association (NYHA) class (Class I, no shortness of breath with ordinary physical activity; Class II, mild dyspnea with ordinary physical activity; and Classes III and IV, dyspnea with minimal physical activities and at rest, respectively). Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period; additionally, those patients who refused to sign the study’s informed consent form were excluded. The study protocol had been approved by the regional and institutional ethical committees.

Survey questions

The survey questions are all in Arabic and were translated into English for the sake of the publication process. The responses were obtained and documented by trained physicians. Validation of the questionnaire had been constructed in five phases:

  • Phase І: Diseases and symptoms that increase the risk of MVAs were put together based on international driving guidelines.[1]


  • Phase ІІ: Questions were selected by expert cardiologists to detect whether the accidents resulted from symptoms related to CVD while driving the vehicles.


  • Phase ІІІ: Contents were validated through a pilot test among a group of experts.


  • Phase ІV: Contents were validated through a pilot test among a group of participants.


  • Phase V: Reliability was tested using Cronbach’s α coefficient.


Survey validation

For Phases І and ІІ, an extensive literature review was conducted on driving-related causality and international guidelines. The appropriate items were prepared for the questionnaire and included the risk factors. A group of experts conducted these phases, including three cardiologists, a clinical pharmacist, a nurse, and a socialist. All questionnaire items were amended accordingly to be short and focused on MVAs related to cardiac events. The first part of the survey asked about socio-demographics, and the second part was for the patients. For Phases ІІІ and ІV, the survey was tested with eight health-care providers (four cardiologists and four cardiac care unit nurses) and 15 patients with CVDs to assess the content validity. The entire pilot study was met with positive responses, and participants expressed that the survey questions were easy to understand. Five patients requested that the language in questions 4 and 5 be amended so that it could be more easily understood; those questions were edited accordingly. In Phase V, the amended survey was administered to 50 patients, and showed a good internal consistency with a Cronbach’s α of 0.75–0.85.

Statistical analysis

Quantitative variables were expressed as means ± standard deviations, and categorical variables were expressed as frequencies. A two-sample t-test was used for normally distributed continuous variables, and a chi-squared test was run for categorical variables. A value of P < 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for the Social Sciences software for Windows (version 19.0; SPSS, Chicago, IL).


   Results Top


Baseline characteristics

A total of 800 men participated in this study. The majority of the participants were Saudi (95%), and the mean age was 54 ± 12 years. We found that 221 (27.6%) of the participants had ejection fraction <40%. Of the total, 526 (66%) had a history of a previous hospitalization. The most common CVDs across the study population were chronic stable angina (371 [46%]) followed by a history of acute coronary syndrome (338 [42%]). Other CVD distributions are presented in [Table 1].
Table 1: Disease distribution among our patients

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Survey responses

We found that 95% of the patients were non-commercial car drivers, and 5% were drivers of large cars such as trucks. The mean time between disease diagnosis and conducting the survey was about 6.2 ± 4 years. The majority of patients, 70%, denied having received any counseling or taking part in any discussions about driving during the hospitalization period or clinic follow-ups. However, driving counseling had been provided to 241 participants (30%), of which 207 (25%) were advised not to drive for a period of between one week and six months. Three patients had been permanently forbidden to drive (two patients by ophthalmologists and one by a cardiologist). The details of participant responses to the survey questions are listed in [Table 2].
Table 2: Survey responses

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Vehicle accidents

We found that 39 of 800 (5% of the patients) had a history of car accidents during the follow-up period. Twenty of those 39 (51%) were preceded by cardiac symptoms (nine [23%] patients had experienced syncope and/or pre-syncope, six [15.5%] patients had chest pain, four [10%] patients had palpitations, and one [2.5%] patient had dyspnea). We found that the presence of a dyspnea NYHA class ≥2 and a history of syncope/pre-syncope were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively) [Figure 1] and [Table 3].
Figure 1: Comparison between patients with and without motor vehicle accident (MVA) regarding symptoms preceding the accident

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,
Table 3: Comparison between patients with and without motor vehicle accidents

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   Discussion Top


In this study, we investigated the degree of awareness to MFTD recommendations in patients with CVDs and how often they were counseled in this regard by cardiologists; we found that 70% of patients denied being asked about MFTD during hospitalization and/or outpatient clinic follow-ups. Furthermore, we found that MVAs were significantly more common in patients who had dyspnea NYHA class ≥2 or a prior history of syncope.

MVAs have been reported as the third leading cause of death and account for 11.7% of the total mortalities in Saudi Arabia.[10] In addition, a report from the World Health Organization (WHO) in 2013 stated that Saudi Arabia had the highest MVA fatality rate among countries with high incomes,[14] reaching 24 fatalities per 100,000 people, 2.4 times higher than the rate in the United States.[15] Importantly, there are five road safety pillars identified by the WHO: road infrastructure, road safety policy, safe vehicles, post-crash care, and road users’ safe behavior. Of note, road users’ poor behavior has a detrimental impact on the incidence and fatality rate of MVAs, and it has been reported as the most common cause of MVAs in different regions across Saudi Arabia.[16] Other road user–related factors that influence MVAs are health abnormalities affecting cognitive, vision, or motor functions; of particular interest for this study are neurological and CVDs that result in impairment of consciousness levels due to drowsiness, syncope, or pre-syncope.

Our 2019 survey of cardiologists’ awareness of the international driving guidelines showed that 70% were aware of them [17]; however, in this study, only 30% of the patients were counseled by their cardiologists about MFTD. This contradiction reflects an insufficiency in patient–physician communications and a low level of discussion regarding MFTD. Thus, further efforts should be undertaken to transmit physicians’ knowledge and information to patients through efficient discussion about MFTD, risks, and driving cessation periods; in this regards, we suggest providing a checklist of discharge recommendations that includes counseling about driving, cessation periods, and the need for any further testing before providing patients with permission to drive.

A recent study conducted by Alkharboush et al.[4] in Saudi Arabia showed similar results to ours, in which only 15% of primary care physicians had questioned their patients about MFTD, whereas the rest believed that this is a responsibility belonging either to the patients or the local traffic authorities.

The existing international driving agencies and the published guidelines recommend risk assessment for patients with diabetes mellitus and the possibilities of developing hypoglycemic or hyperglycemic attacks, which require MFTD advice; of note, our study population also has a high prevalence of diabetes (54%). Nevertheless, less than 1% of the study cohort had been educated regarding MFTD by either endocrinologists or general practitioners, which highlights the need for further studies to assess the MFTD awareness among health-care providers of different medical specialties.

It is interesting to note that accident rates and consequences (such as property damage, public injuries, and fatality rate) are significantly higher in male drivers compared with women[18]; however, no women were included in our study, as it was illegal for women to drive in Saudi Arabia during the study period. However, with the recent legislation allowing women to drive, further studies that include women should be conducted.

Our study is important in that it targeted road users, investigating their perception about the effect of their CVDs on performing safe vehicle driving; in addition, it highlights the importance of the formulation and implementing of strict guidelines about MFTD in Saudi Arabia through collaboration between the Ministry of Health, the Saudi Commission for Health Specialties, the Saudi Heart Association, and the national traffic authorities. This would be similar to the current guidelines in Canada.[19]

Our study has many limitations: it is a single-center analysis, only patients engaging in follow-ups at a cardiology clinic were included, whereas no other medical specialties (such as neurology or endocrinology) were included, it only included men, and MVAs in our study may not be fully represented because accidents that resulted in death or serious damage would not be reported because of missed clinic follow-ups.


   Conclusion Top


We found that only 30% of the patients with CVDs had been counseled by physicians about MFTD, and MVAs were significantly more common in patients who had dyspnea NYHA class ≥2 or a prior history of syncope. Legislation and clinical implementation of MFTD guidelines is warranted in Saudi Arabia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
UK Government Digital Services. Assessing Fitness to Drive: A Guide for Medical Professionals: Advice for Medical Professionals for Assessing Fitness to Drive. Driver and Vehicle Licensing Agency. Available from: (https://www.gov.uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals). [Last accessed on 20 Feb. 2019].  Back to cited text no. 1
    
2.
Lee JD Fifty years of driving safety research. Hum Factors: J Hum Factors Ergonomics Soc 2008;50:521-8.  Back to cited text no. 2
    
3.
Moon S, Ranchet M, Tant M, Akinwuntan AE, Devos H Comparison of unsafe driving across medical conditions. Mayo Clin Proc 2017;92:1341-50.  Back to cited text no. 3
    
4.
Alkharboush GA, Al Rashed FA, Saleem AH, Alnajashi IS, Almeneessier AS, Olaish AH, et al. Assessment of patients’ medical fitness to drive by primary care physicians: A cross-sectional study. Traffic Inj Prev 2017;18:488-92.  Back to cited text no. 4
    
5.
Mansuri FA, Al-Zalabani AH, Zalat MM, Qabshawi RI Road safety and road traffic accidents in Saudi Arabia: A systematic review of existing evidence. Saudi Med J 2015;36:418-24.  Back to cited text no. 5
    
6.
Hradec J, Táborský M, Toušek F, Skalická H Assessing cardiac patients for fitness to drive motor vehicles: Expert consensus statement of the Czech Society of Cardiology—2012 update. Cor et Vasa 2013;55:e217-24.  Back to cited text no. 6
    
7.
Molnar FJ, Byszewski AM, Marshall SC, Man-Son-Hing M In-office evaluation of medical fitness to drive: Practical approaches for assessing older people. Can Fam Physician 2005;51: 372-9.  Back to cited text no. 7
    
8.
Hogan DB Which older patients are competent to drive? Approaches to office-based assessment. Can Fam Physician 2005;51:362–368.  Back to cited text no. 8
    
9.
Redelmeier DA, Yarnell CJ, Thiruchelvam D, Tibshirani RJ Physicians’ warnings for unfit drivers and the risk of trauma from road crashes. N Engl J Med 2012;367:1228-36.  Back to cited text no. 9
    
10.
Memish ZA, Jaber S, Mokdad AH, AlMazroa MA, Murray CJL, Al Rabeeah AA, Saudi Burden of Disease Collaborators. Burden of disease, injuries, and risk factors in the Kingdom of Saudi Arabia, 1990–2010. Prevent Chron Dis 2014;11:E169.  Back to cited text no. 10
    
11.
Meuser TM, Carr DB, Ulfarsson GF Motor-vehicle crash history and licensing outcomes for older drivers reported as medically impaired in Missouri. Accid Anal Prev 2009;41:246-52.  Back to cited text no. 11
    
12.
Redelmeier DA, Kenshole AB, Ray JG Motor vehicle crashes in diabetic patients with tight glycemic control: A population-based case control analysis. PLoS Med 2009;6:e1000192.  Back to cited text no. 12
    
13.
Antin JF, Lockhart TE, Stanley LM, Guo F Comparing the impairment profiles of older drivers and non-drivers: Toward the development of a fitness-to-drive model. Saf Sci 2012;50:333-41.  Back to cited text no. 13
    
14.
World Health Organization. Global Status Report on Road Safety. Geneva, Switzerland: World Health Organization; 2013. Available from: http://www.who.int/violence_injury_prevention/road_safety_status/2013/en. [Last accessed on 14 Feb. 2019].  Back to cited text no. 14
    
15.
The Cooperation Council for the Arab States of the Gulf (GCC). Statistics Department; 2012. Available from: http://www.gcc-sg.org/eng. [Last accessed on 13 Jan. 2019].  Back to cited text no. 15
    
16.
World Health Organization. A Decade of Action for Road Safety: A Brief Planning Document. Geneva, Switzerland: World Health Organization; 2011. Available from: www.who.int/roadsafety/Decade_of_action.pdf. [Last accessed on 24 Jan. 2019].  Back to cited text no. 16
    
17.
Abazid RM, Almeman A, Sakr H, Eldesoky AF, Eissa HM, Alharbi TH, et al. Awareness of fitness to drive among cardiologists in Saudi Arabia. Saudi Med J 2019;40:93-6.  Back to cited text no. 17
    
18.
Al-Balbissi AH Role of gender in road accidents. Traffic Inj Prev 2003;4:64-73.  Back to cited text no. 18
    
19.
Dow J, Simpson C, Molnar F, Gillespie I, Bergeron D, Brook E, et al, editors. CMA Driver’s Guide: Determining Medical Fitness to Operate Motor Vehicles. 9th ed. Ottawa, ON: Canadian Medical Association;2019.  Back to cited text no. 19
    


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