BLOOD PRESSURE & HYPERTENSION

1. BLOOD PRESSURE&HYPERTENSION ALL ABOUT THE NUMBERS

2. 49 CFR 391.43(f) Blood Pressure (BP): "If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosed with Stage 1 hypertension (BP is 140/90–159/99) may be certified for one year. At recertification, an individual with a BP equal to or less than 140/90 may be certified for one year; however, if his or her BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued. An individual diagnosed with Stage 2 (BP is 160/100-179/109) should be treated and a one-time certificate for 3-month certification can be issued. Once the driver has reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter. An individual diagnosed with Stage 3 hypertension (BP equal to or greater than 180/110) should not be certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months."

3. SUMMARY: Initial certification: Stage 1 hypertension (BP is 140/90–159/99) may be certified for one year. At recert, an individual with a BP equal to or less than 140/90 may be certified for one year. At recert, if BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued. At Initial, stage 2 (BP is 160/100-179/109) should be treated and a one-time certificate for 3-month certification can be issued. At recert, once the driver has reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter. Stage 3 hypertension (BP equal to or greater than 180/110) should not be certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months."

4. Once on one year cycle for blood pressure, always on a one year cycle.(no return to 2 year card)

5. Page 2 of the form

6. CMV Drivers and risk: Percentage of drivers with hypertension increases from 29% in drivers with fewer than 10 years of driving experience, to 32% in drivers with 10-20 years of experience, and to 39% in drivers with more than 20 years of driving experience.* *The Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers includes data from Ragland, et al.

7. Regulation • Ask about if they have high BP or diagnosis of hypertension • Ask if they take medications • Measure BP • Repeat again later in examination for any BP 139/89 or greater • Check pulse rate and rhythm

8. Recommendation • Do a review of systems specific to cardiac if they mark “yes” for high BP • Ask about medication side effects • Lifestyle risk factors • Limitations • Medical examiner should confirm disqualifying BP if assistant measured it • Get a signed records release and obtain medical records for any questions/concerns

9. Regulation • You must document discussion with the driver regarding: • Decision to disqualify or limit card and why • Medications, compliance, and side effects • Current limitations • Abnormal findings • Further evaluation/testing/treatment needed

10. Remember: Medical fitness for duty includes the ability to perform strenuous labor.

11. Video of strenuous labor

12. Questions ?

13. CardiovascularModule

14. 49 CFR 391.41(b)(4) "A person is physically qualified to drive a commercial motor vehicle (CMV) if that person — Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease (CVD) of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure."

15. Higher Risk • Aging workforce • Driving stress • Emotional stress • Environmental stress • Road conditions • Deadlines • Obesity and sedentary lifestyle

16. Sudden incapacitation Most commonly from arrhythmia. Coronary heart disease Stroke or myocardial infarction

17. Regulation Review, discuss, and document findings regarding “yes” answers relevant to cardiac relevant questions.

18. Possibly relevant “yes” answers • “Any illness in the last 5 years” • Heart disease or heart attack; other cardiovascular condition • Heart surgery • High blood pressure • Muscular disease • Shortness of breath • Fainting, dizziness • Stroke or paralysis • Diabetes • Sleep disorders

19. Recommendation Do a cardiac review of systems and document

20. Regulation • Examination must evaluate: • Murmurs, extra heart sounds, arrhythmias • Enlarged heart • Pacemaker or Implantable Defibrillator • Abnormal pulse and amplitude • Carotid or arterial bruits • Varicose veins

21. Regulation • You must document discussion with the driver regarding: • Decision to disqualify or limit card and why • Medications, compliance, and side effects • Current limitations • Abnormal findings • Further evaluation/testing/treatment needed

22. Guidance/Advisory Criteria Various cardiovascular conditions

23. NOTE: If more than one “waiting period” is applicable due to multiple conditions or disease, examine the driver after completion of the longest waiting period.

24. NOTE: Obtain medical records for all cardiovascular conditions. Require clearance from a cardiologist who understands the functions and demands of commercial driving.

25. Abdominal aortic aneurism • Waiting Period: Minimum of three months for post surgical repair of aneurism • Decision: Max certification is one year • Recommend to certify if • The AAA is: • Less than 4 cm and the driver is asymptomatic. • Greater than 4 cm but less than 5 cm and the driver is asymptomatic and has clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. • Surgically repaired and the driver meets post surgical repair guidelines above for waiting period. • Recommend not to certify if: • The driver has: 1.) Symptoms, regardless of AAA size. 2.) Recommendation for surgical repair, regardless of AAA size, from a cardiovascular specialist who understands the functions and demands of commercial driving. • The AAA: • Is greater than 4 cm but less than 5 cm and driver does not have medical clearance for commercial driving from a cardiovascular specialist. • Is greater than or equal to 5 cm. • Has increased more than 0.5 cm during a 6 month period, regardless of size.

26. Abdominal aortic aneurism Monitoring/Testing: Ultrasound Follow-up: Annually

27. Thoracic aneurysm • Waiting period: Minimum — three months post-surgical repair • Decision: Maximum certification period — one year • Recommend to certify if: • The driver: • Has a thoracic aneurysm less than 3.5 cm. • Has a surgically repaired thoracic aneurysm and the driver meets post-surgical repair of aneurysm guidelines, including: • Has completed surgical repair waiting period. • Has medical clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. • Recommend not to certify if: • The driver has a thoracic aneurysm greater than 3.5 cm.

28. Thoracic aneurysm Monitoring/Testing: You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Follow-up: The driver should have an annual medical examination.

29. Other aneurysms • Waiting period: Minimum — three months post-surgical repair of an aneurysm • Decision: Maximum certification — one year • Recommend to certify if: • The driver has: • Surgical repair of the aneurysm and meets post-surgical repair of aneurism guidelines. • Clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. • Recommend not to certify if: • The driver has: • Recommendation for surgical repair of an aneurysm, from a cardiovascular specialist who understands the functions and demands of commercial driving, but has not had surgical repair.

30. Other aneurysms Monitoring/testing: You may, on a case-by-case basis, obtain additional tests and consultations to adequately assess driver medical fitness for duty. Follow-up: The driver should have an annual medical examination.

31. Post surgical repair of aneurysm Waiting period: Minimum — three months post-surgical repair Decision: Maximum certification period — one year Recommend to certify if: The driver: Is asymptomatic. Has clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. Recommend not to certify if: The driver has: Recommendation for surgical repair of an aneurysm from a cardiovascular specialist who understands the functions and demands of commercial driving, but has not had surgical repair.

32. Post surgical repair of aneurysm Monitoring/Testing: When post-surgical treatment includes anticoagulant therapy, the driver should meet monitoring guidelines. See Venous Disease Recommendation Table- Coumadin Follow-up: The driver should have an annual medical examination.

33. Acute deep vein thrombosis Drivers are at increased risk due to prolonged periods of sitting May have other risk factors for DVT such a tobacco abuse Can be incapacitated by DVT which becomes pulmonary or cerebral emboli

34. Acute deep vein thrombosis Waiting period: No recommended time frame You should not certify the driver until etiology is confirmed, and treatment has been shown to be adequate/effective, safe, and stable. Decision: Maximum certification period — one year Recommend to certify if: The driver has no residual, acute DVT. Recommend not to certify if: The driver has DVT ineffectively treated. Monitoring/Testing: When DVT treatment includes anticoagulation therapy, the driver should meet monitoring guidelines. Follow-up: The driver should have an annual medical examination.

35. Chronic Thrombotic Venous Disease Waiting period: No recommended time frame You should not certify the driver until etiology is confirmed and treatment has been shown to be adequate/effective, safe, and stable. Decision: Maximum certification period — 2 years Recommend to certify if: The driver has no symptoms. Recommend not to certify if: As the medical examiner, you believe that the nature and severity of the medical condition of the driver endangers the health and safety of the driver and the public. Monitoring/Testing: You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Follow-up: The driver should have a biennial medical examination.

36. Intermittent Claudication Waiting period: Minimum — three months for post-surgical repair You should not certify the driver until etiology is confirmed and treatment has been shown to be adequate/effective, safe, and stable. Decision: Maximum certification — one year Recommend to certify if: The driver, following surgery has: Relief of symptoms. No other disqualifying cardiovascular disease. Recommend not to certify if: The driver has pain at rest. Monitoring/Testing: You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Follow-up: The driver should have an annual medical examination.

37. Peripheral Vascular Disease Waiting period: Minimum — 3 months post-surgical repair Decision: Maximum certification period — 1 year Recommend to certify if: The driver has no other disqualifying cardiovascular disease. Recommend not to certify if: The driver has pain at rest. Monitoring/Testing: You may, on a case-by-case basis, obtain additional tests and consultations to adequately assess driver medical fitness for duty. Follow-up: The driver should have an annual medical examination.

38. Superficial phlebitis Waiting period: No recommended time frame You should not certify the driver until etiology is confirmed and treatment has been shown to be adequate/effective, safe, and stable. Decision: Maximum certification period— two years Recommend to certify if: The driver is otherwise medically qualified. Recommend not to certify if: The driver has coexisting DVT and does not meet the DVT guideline as previously noted Monitoring/Testing: You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Follow-up: The driver should have a biennial medical examination.

39. Varicose veins Waiting period: No recommended time frame You should not certify the driver until etiology is confirmed and treatment has been shown to be adequate/effective, safe, and stable. Decision: Maximum certification period — two years Recommend to certify if: The driver has no complications. Recommend not to certify if: As the medical examiner, you believe that the nature and severity of the medical condition of the driver endangers the health and safety of the driver and the public. Monitoring/Testing: You may on a case-by-case basis obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Follow-up: The driver should have a biennial medical examination.

40. Pulmonary emboli • Waiting period: Minimum — three months with no pulmonary embolism • Decision: Maximum certification period — one year • Recommend to certify if: • The driver has: • Appropriate long-term treatment. • No other disqualifying cardiovascular disease. • Recommend not to certify if: • The driver has symptoms. • Monitoring/testing: • When PE treatment includes anticoagulant therapy, the driver should meet monitoring guidelines. • Follow-up: • The driver should have an annual medical examination.

41. Implantable defibrillator DISQUALIFY

42. Pacemaker • Waiting period: • Minimum — 1 month post-pacemaker implantation if underlying disease is: • Sinus node dysfunction. • AV block. • Minimum — 3 months post-pacemaker implantation if underlying disease is: • Neurocardiogenic syncope. • Hypersensitive carotid sinus with syncope. • Decision: Maximum certification period — 1 year • Recommend to certify if: • The driver has: • Documentation indicating the presence of a functioning pacemaker. • Documentation indicating completion of routine pacemaker checks. • No disqualifying underlying disease. • Recommend not to certify if: • The driver has: • An implantable cardiac defibrillator/pacemaker combination device. • A disqualifying underlying disease.

43. Pacemaker • Monitoring/Testing: • The driver should: • Comply with pacemaker center scheduled function checks. • Provide documentation of pacemaker function checks at examination. • Follow-up: • The driver should have an annual medical examination.

44. Supraventricular Arrhythmias Supraventricular Tachycardia Atrial Fibrillation

45. Supraventricular Arrhythmias • Waiting Period: • Minimum — one month anticoagulated adequately and diagnosis is atrial fibrillation • As cause of stroke or risk for stroke. • Following thoracic surgery. • Minimum — one month post-isthmus ablation and diagnosis is atrial flutter • Minimum — one month asymptomatic/treated asymptomatic and diagnosis is: • Atrioventricular nodal reentrant tachycardia. • Atrioventricular reentrant tachycardia and Wolff-Parkinson-White syndrome. • Atrial tachycardia. • Junctional tachycardia.

46. Supraventricular Arrhythmias • Decision: Maximum certification period — 1 year • Recommend to certify if: • The driver has: • Heart rate that is controlled. • Treatment for prevention of emboli that is effective and tolerated. • No underlying disease that is disqualifying. • Clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. • Recommend not to certify if: • The condition causes: • Loss of consciousness. • Compromised cerebral function. • Sudden death resuscitation.

47. Supraventricular Arrhythmias • Monitoring/Testing: • The driver should: • Comply with anticoagulation guidelines, when appropriate. • Have annual evaluation by a cardiovascular specialist who understands the functions and demands of commercial driving. • Follow-up: • The driver should have an annual medical examination.

48. Anticoagulation Guidelines: Waiting period: Minimum — 1 month stabilized NOTE: If more than one waiting period applies (because of multiple cardiac conditions or other comorbid diseases), examine the driver for certification after the completion of the longest waiting period. Decision: Maximum certification period — 1 year Recommend to certify if: The driver: Is stabilized on medication for at least 1 month. Provides a copy of the international normalized ratio (INR) results at the examination. Has at least monthly INR monitoring. Recommend not to certify if: INR is not being monitored. INR is not therapeutic. Underlying disease is disqualifying. Monitoring/Testing: The driver should obtain INR monitoring at least monthly. Follow-up: The driver should bring results of INR monitoring to the examination. NOTE SEE: Venous Disease Recommendation Tables (PDF) — Coumadin

49. Ventricular Arrhythmias Majority of instances of cardiac sudden death

50. Ventricular Arrhythmias • Waiting period: Minimum — one month after drug or other therapy and diagnosis is: • Coronary heart disease. • Right ventricular outflow VT. • Idiopathic left ventricular VT. • Decision: Maximum certification period — one year • Recommend to certify if: • Is asymptomatic. • Has an identified non-disqualifying cardiac cause. • Clearance from cardiovascular specialist understands function/demand of CVM driving. • Recommend not to certify if: • Is symptomatic. • Has sustained VT. • Has NSVT, LVEF less than 0.40. • Has a diagnosis of: • Hypertrophic cardiomyopathy. • Long QT interval syndrome. • Brugada syndrome.