Question Answers quoted from "Medico-Legal and Ethical Issues in Cardiology and General Medicine" by Leslie Tay, Catherine Tay.

" A 40-year-old gentleman experienced a sudden onset of chest pain and diaphoresis whilst shopping.
He is admitted to hospital and a diagnosis of an acute myocardial infarction is made on his ECG. He has primary angioplasty performed with good results.
After five days, he is clinically stable and is discharged from hospital.

(a) When is he allowed to drive legally if he is driving a private car?

(b) When is he allowed to drive legally if he drives public service vehicles such as taxis and buses?

(c) When is he allowed to drive legally if he drives contracted transport service vehicles?

(d) If the patient continues to drive despite your advice, what should you do?

Can you inform the relevant authorities or his insurance company?

(e) Is this ethical or appropriate?

(f) Is his insurance invalid if he drives against medical advice?

Answers
(a) When is he allowed to drive legally if he is driving a private car?
A person driving a private car will have a group 1 licence (holders of Class 1, 2 and 3 driving licences).

After any acute coronary syndrome (unstable angina, ST-elevation myocardial infarction and non-ST elevation myocardial infarction), a person will not be fit to drive for at least one month after the episode. However, if it is successfully treated by coronary angioplasty, then driving may recommence after one week. Further, if the doctor can reasonably foresee that there may be accidents, because he is not really fit to drive (objective test), he can be sued for negligence in any case.

(b) When is he allowed to drive legally if he drives public service vehicles such as taxis and buses?

Drivers of public transport vehicles are classed as group 2 (holders of Class 4, 5 and vocational licences). The Singapore Medical Association (SMA) Medical Guidelines for Fitness to Drive specify that he must stop driving for two months. He can return to driving only if he is symptom-free and able to complete the exercise stress test to the required standard. The United Kingdom Driving and Vehicle Licensing Agency (DVLA) allows for an exercise stress test or some other functional assessment such as a stress myocardial perfusion scan or a stress echocardiography in the assessment for fitness to drive (see below). Annual review is required.

The United Kingdom guidelines will only be indirectly relevant, as it may offer direction in cases without local guidelines. Clinical Considerations Exercise Stress Testing Drivers should be able to complete three stages of the standard Bruce protocol, without anti-anginal* medication for 24 hours, and should remain symptom-free from signs of cardiovascular dysfunction, angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/ or ischaemic ECG changes (> 2mm ST depression horizontal or down-sloping).

Functional Assessment: Stress Myocardial Perfusion Scan or Stress Echocardiogram The UK DVLA licensing standard requires that
(a) The LVEF is 40% or more: (b) (i) no more than 10% of the myocardium is affected by reversible ischaemic change on myocardial perfusion scan or (ii) no more than one segment is affected by reversible ischaemic change on stress echocardiography.

*Anti-anginal medication includes the use of nitrates, β-blockers, calcium channel blockers and ivabradine. If any of the above medication is prescribed purely for the control of hypertension or an arrhythmia, then discontinuation prior to exercise testing is not required.

(c) When is he allowed to drive legally if he drives contracted transport service vehicles? Same answer as (b) above.
(d) If the patient continues to drive despite your advice, what should you do?

Can you inform the relevant authorities or his insurance company? The examining doctor may inform the Traffic Police Department or Land Transport Authority (LTA) of the medical condition of his patient who, in his opinion, is not fit to drive. The source of such information forwarded will be kept strictly confidential. You do not need to inform his insurance company.
(e) Is this ethical or appropriate?

According to SMA Medical Guidelines for Fitness to Drive, you may inform the Traffic Police Department or LTA. It is not appropriate to inform his insurance company. (f ) Is his insurance invalid if he drives against medical advice? Yes. There is usually a clause in the insurance contract stating that the insurance is invalid if one drives against medical advice."