Electrophysiology Studies in the Assessment and Management of Patients Involved in High Risk Occupations and Activities

Abstract

The term “high risk activity” is ill-defined but is often used in reference to daily work or recreational activities of individuals that may trigger a serious medical event (for example, athletes) or where the occurrence of a serious medical emergency during the course of those activities could cause serious bodily injury or death to the individual as well as members of the general public (for example, commercial airline pilots or truck drivers). Cardiac arrhythmias may cause temporary or protracted impairment of consciousness or physical function and constitute a serious concern for individuals engaged in high risk activities. Often, such arrhythmias are potentially life-threatening and warrant aggressive management. The incidence of arrhythmia-induced incapacitation while engaged in activities such as commercial or personal driving, aviation or athletic competition appears to be rare but the consequences of impaired function may be tragic. As a result, physicians must not only deal with the assessment and management of the arrhythmia problem but also address issues pertaining to the patient’s continued participation in work, athletic or recreational activities. The management of individuals engaged in highrisk occupations is also a concern to those organizations responsible for regulating those high risk activities, setting public policy or safeguarding the public. Unfortunately, optimal treatment of an arrhythmia may not guarantee that the person involved will be permitted to resume unrestricted activity [1,2]. In a previous edition of this Journal, we reviewed the role of EPS as it pertains to individuals engaged in high-risk activities based upon the published literature at that time. This report provides an update, incorporating knowledge gained from studies completed in the interim. As before, conclusions in this report continue to be extrapolated from studies involving heterogeneous sample populations since there is no new data to indicate that individuals engaged in high-risk activities differ fundamentally from the general population in their physiologic response to arrhythmias. The usefulness of intracardiac electrophysiologic studies (EPS) has been extensively reviewed and updated guidelines of the joint ACC/AHA Task Force concerning the role of EPS have been published [3,4]. In general, EPS has several potential uses. It can be used to determine the precise mechanism of a patient’s spontaneous arrhythmia. This is of particular importance for patients with bundle branch reentrant VT where catheter ablation constitutes effective therapy for the arrhythmia. EPS also serves as a risk stratification tool to identify individuals who may be susceptible to a particular cardiac arrhythmia. Thirdly, EPS has been used to assess the efficacy with antiarrhythmic drug therapy where there is evidence that drug suppression of an EPS-inducible tachyarrhythmia confers a good prognosis. Finally, EPS can be used in support of surgical or catheter based arrhythmia substrate ablation strategies.