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Original Investigation |

Syncope and Motor Vehicle Crash Risk A Danish Nationwide Study

Anna-Karin Numé, MD1; Gunnar Gislason, MD, PhD1,2,3; Christine B. Christiansen, MD, PhD1,4; Deewa Zahir, MB1; Mark A. Hlatky, MD5,6; Christian Torp-Pedersen, MD, DSc7; Martin H. Ruwald, MD, PhD1
[+] Author Affiliations
1Department of Cardiology, Copenhagen University Gentofte Hospital, Hellerup, Denmark
2The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
3The Danish Heart Foundation, Copenhagen, Denmark
4The Research House, Aalborg University Hospital, Aalborg, Denmark
5Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California
6Department of Medicine, Stanford University School of Medicine, Stanford, California
7Institute of Health, Science and Technology, Aalborg University, Aalborg, Denmark
JAMA Intern Med. 2016;176(4):503-510. doi:10.1001/jamainternmed.2015.8606.
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Importance  Syncope may have serious consequences for traffic safety. Current clinical guideline recommendations on driving following syncope are primarily based on expert consensus.

Objective  To identify whether there is excess risk of motor vehicle crashes among patients with syncope compared with the general population.

Design, Setting, and Participants  Danish nationwide cohort study from January 1, 2008, to December 31, 2012. Through individual-level linkage of nationwide administrative registers, all Danish residents 18 years or older were identified. Of 4 265 301 eligible Danish residents, we identified 41 039 individuals with a first-time diagnosis of syncope from emergency department or hospital.

Main Outcomes and Measures  Rate of motor vehicle crashes (including nonfatal and fatal crashes), based on multivariate Poisson regression models, using the total Danish population as reference.

Results  The 41 039 patients with syncope had a median age of 66 years (interquartile range [IQR], 47-78 years); 51.0% were women; and 34.8% had cardiovascular disease. Through a median follow-up of 2.0 years (IQR, 0.8-3.3 years), 1791 patients with syncope (4.4%) had a motor vehicle crash, 78.1% of which led to injury (n = 1398) and 0.3% to death (n = 6). The crude incidence rate of motor vehicle crashes was almost doubled among patients with syncope (20.6 per 1000 person-years; 95% CI, 19.7-21.6) compared with the general population (12.1; 95% CI, 12.0-12.1), with a rate ratio (RR) of 1.83 (95% CI, 1.74-1.91) after adjustment for age, sex, socioeconomic position, and relevant comorbidities and pharmacotherapy. Men had a relatively higher rate of motor vehicle crashes (RR, 1.91; 95% CI, 1.79-2.03) than women (RR, 1.74; 95% CI, 1.63-1.87). The excess risk of motor vehicle crashes persisted throughout the follow-up period. The 5-year crash risk following syncope was 8.2% (95% CI, 7.5%-8.8%) among the population aged 18 to 69 years compared with 5.1% (95% CI, 4.7%-5.4%) in the general population.

Conclusions and Relevance  Prior hospitalization for syncope was associated with increased risk of motor vehicle crashes throughout the follow-up period. This study suggests that syncope should be considered as one of several factors in a broad assessment of fitness to drive.

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Figure 1.
Motor Vehicle Crash Risk Following Syncope by Age and Sex

Poisson regression model with the general Danish population as reference, with adjustment for sex, cardiovascular disease, cardiac pacemaker, implantable cardioverter-defibrillator, diabetes, alcohol abuse, use of anxiolytics or antipsychotics, socioeconomic status, and calendar year and stratified by age. IR indicates incidence rate; PY, person-years.

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Figure 2.
Time Elapsed From Syncope and Risk of Motor Vehicle Crashes

Poisson regression model with the general Danish population as reference, with adjustment for age, sex, socioeconomic status, calendar year, cardiac pacemaker, implantable cardioverter-defibrillator, cardiovascular disease, diabetes, alcohol abuse, and use of anxiolytics or antipsychotics. Crash events per person-year (PY) are reported for the syncope population. RR indicates rate ratio.

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Figure 3.
Elevated Cumulative Incidence for Motor Vehicle Crashes Following Syncope

Illustrated incidence is compared with an age- and sex-matched control population, accounting for competing risk of death from other causes.

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