Are there any driving limitations for a patient with a history of myocardial infarction (MI), low normal left ventricular ejection fraction (LVEF), and mild to moderate aortic stenosis (AS), who is asymptomatic?

Driving Limitations for a 92-Year-Old Patient with Cardiac History

There are no specific driving limitations for this asymptomatic 92-year-old patient with a history of MI, fixed defects on nuclear stress test, and mild-moderate aortic stenosis with preserved LVEF of 45-50%, as current guidelines do not restrict driving in asymptomatic cardiac patients with preserved or mildly reduced LVEF.

Assessment of Cardiac Status and Driving Risk

The patient's cardiac status includes:

• History of myocardial infarction (MI)
• Fixed defects on nuclear stress test (indicating old infarction without active ischemia)
• Low-normal LVEF (45-50%)
• Mild to moderate aortic stenosis (AS)
• No cardiac symptoms (chest pain, syncope)

Key Considerations for Driving Safety

1. Symptom Status:

   • The patient denies chest pain, syncope, or any cardiac symptoms
   • Asymptomatic status is the most important factor supporting continued driving

2. Left Ventricular Function:

   • LVEF 45-50% represents low-normal or mildly reduced function
   • According to ACC/AHA guidelines, this level of cardiac function does not warrant driving restrictions in asymptomatic patients 1

3. Aortic Stenosis Severity:

   • Mild to moderate AS does not typically cause hemodynamic compromise during daily activities
   • Guidelines do not recommend driving restrictions for asymptomatic mild-moderate AS 1

4. Absence of Ischemia:

   • Nuclear stress test showed fixed defects but no active ischemia
   • Absence of inducible ischemia significantly reduces risk of cardiac events while driving

Guideline-Based Recommendations

The ACC/AHA guidelines for heart failure management and aortic stenosis do not specify driving restrictions for:

• Patients with asymptomatic mild-moderate AS 1
• Patients with history of MI but no active ischemia 1
• Patients with mildly reduced LVEF who are asymptomatic 1

Monitoring Considerations

While driving is not restricted, the following monitoring approach is recommended:

1. Regular Follow-up:

   • Monitor for development of symptoms (especially syncope, which would warrant driving restriction)
   • Serial echocardiograms to assess progression of AS and LVEF

2. Warning Signs That Would Change Recommendations:

   • Development of syncope or pre-syncope (absolute contraindication to driving)
   • Progression to severe AS (would require reassessment)
   • Development of symptoms of heart failure
   • Decline in LVEF to <35%

3. Medication Considerations:

   • Avoid nondihydropyridine calcium channel blockers which may have negative inotropic effects in patients with reduced LVEF 1, 2
   • Optimize guideline-directed medical therapy for post-MI and reduced LVEF

Conclusion

This 92-year-old patient can continue to drive without specific restrictions based on their cardiac status. The absence of symptoms (particularly syncope), absence of active ischemia, and only mild-moderate AS with preserved LVEF do not warrant driving limitations according to current cardiovascular guidelines.