Recommendations of the Medical Expert Panel

At the April 2007 meeting, the Medical Review Board (MRB) reviewed and discussed the evidence report and expert panel recommendations for cardiovascular disease and commercial driving. The MRB unanimously voted to recommend an emendation of the current standards while asking for clarification on the acceptable rate of expansion of thoracic and abdominal aneurisms (1 cm or .5 cm). The MRB recommended using the terms “medical doctor (MD)" or "doctor of osteopathy (DO) vascular surgeon” rather than “vascular specialist” as recommended by the Medical Expert Panel (MEP).

The recommendations for change are:

Recommended Cardiovascular Changes

Section 1: Commercial Motor Vehicle (CMV) drivers without known heart disease

1. Revise the current definition for abnormal exercise tolerance testing (ETT) to "an inability to exceed 6 METS (metabolic equivalents) on ETT."

Section 2: CMV drivers with known chronic heart disease

1. Clarify that for all guidelines in this section, the expectation is that drivers with known coronary heart disease will have had all of their medications titrated to the optimal dose.
2. CMV drivers with angina pectoris may be qualified if the pattern of angina is stable.
3. Current FMCSA guidelines state that an individual with angina pectoris who has undergone a percutaneous coronary intervention (PCI) may be qualified to drive if he or she meets four conditions. The panel recommends removing the requirement for a normal ETT 3 to 6 months following PCI.
4. Current FMCSA guidelines require individuals who have undergone coronary artery bypass surgery to be recertified every year for 5 years, then undergo an ETT annually. The MEP recommends an ETT every 2 years.

Section 3: CMV drivers with hypertension

1. Add statements explaining the general principles of certification of individuals with hypertension. These are:
   1. Certification and recertification of individuals with hypertension should be based on a combination of factors: blood pressure, the presence of target organ damage, and comorbidities.
   2. To provide consistency in certification, blood pressure recorded at the certification (or recertification) examination should be used to determine blood pressure stage. The certifying examiner may decide on the length of certification for drivers with elevated blood pressure despite treatment.
   3. All CMV drivers should be referred to their personal physicians for therapy, education, and long-term management.
   4. Add an expectation throughout this section that blood pressure be measured appropriately.
2. Add an expectation throughout this section that blood pressure medication be titrated appropriately. Target blood pressure for titration should be <140/<90.
3. Add text that medical examiners should ensure that individuals with hypertension are properly educated about making appropriate lifestyle changes and complying with medication.

Section 4: CMV drivers with supraventricular tachycardias

1. Resolve the ambiguity associated with “lone atrial fibrillation” by making it clear that the diagnosis refers to individuals with atrial fibrillation with no identifiable underlying disease. This is usually diagnosed in younger persons.
2. Provide details of how risk for stroke from embolization among individuals with atrial fibrillation should be determined.
3. FMCSA requested clarification of the role of aspirin and vitamin K inhibitors in reducing stroke risk in individuals with atrial fibrillation. The MEP referred FMCSA to the current American College of Cardiology/American Heart Association/European Society of Cardiology guidelines for appropriate antithrombotic treatment of those with atrial fibrillation.
4. Individuals with atrial fibrillation at moderate to high risk for a stroke should be recertified annually. In order to be recertified, the individual must have his or her anticoagulation monitored at least monthly and demonstrate adequate rate/rhythm control.

Section 5: CMV drivers with pacemakers

1. Revise current guidelines. The MEP no longer accepts a pacemaker as definitive treatment for neurocardiogenic syncope.
2. Add text documentation accompanying the CVD guideline update that describes the appropriate evaluation of an individual who presents with syncope to ensure that efforts are made to distinguish individuals with cardiogenic syncope from those with syncope from other causes.

Section 6: CMV drivers with abdominal or thoracic aortic aneurysms

1. The upper limit for the abdominal aortic aneurysm (AAA) diameter below which an asymptomatic individual may be certified should be increased to 5.5 cm for men and 5.0 cm for women.
2. Change the current guidelines to read: individuals with an AAA 4.0 cm to 5.4 cm in diameter can be certified if they are asymptomatic AND are cleared by a vascular specialist. Individuals with an AAA 4.0 cm to 5.4 cm in diameter cannot be certified if they are either symptomatic OR a vascular specialist has recommended they undergo surgery.
3. Add guidance to the current guideline for individuals who have undergone endovascular AAA repair (EVAR), ensuring that recertification after EVAR requires compliance with the follow-up protocol.
4. Increase the upper limit for the thoracic aortic aneurysm (TAA) diameter below which an asymptomatic individual may be certified from 3.0 cm to 5.0 cm.

Section 7: CMV drivers with peripheral vascular disease

Amend the current guidelines for certification of individuals with intermittent claudication to disqualify CMV drivers only when pain occurs at rest.

Section 8: CMV drivers with venous disease

1. Active deep vein thrombosis (DVT) should disqualify an individual from driving a CMV.
2. Individuals who have experienced DVT that has resolved should be maintained on anticoagulation with a Vitamin K antagonist for a minimum of three months (preferably six months) following resolution.
3. If on a Vitamin K antagonist such as warfarin (Coumadin), drivers need to be regulated at least 1 month prior to certification (or recertification) and have their International Normalized Ration (INR) monitored at least monthly thereafter.
4. INR should be maintained within the target range: 2.0–3.0.
5. Individuals treated with subcutaneous heparin or low molecular weight heparin may be certified (or recertified) to drive a CMV as soon as the DVT has resolved.

Section 9: CMV drivers with cardiomyopathy

1. Change the prohibition against individuals with hypertrophic cardiomyopathy to reflect the fact that not all individuals with hypertrophic cardiomyopathy are at risk for sudden incapacitation or death. Permit those who meet all the following criteria to be certified to drive:
   • No history of cardiac arrest.
   • No spontaneous sustained ventricular tachycardia (VT).
   • Normal exercise blood pressure (e.g., no decrease at maximal exercise).
   • No non-sustained VT.
   • No family history of premature sudden death.
   • No syncope.
   • Left ventricular (LV) septum thickness <30mm.
   Low-risk individuals must be followed closely for changes in risk status.
    
2. Change the criteria for individuals with idiopathic dilated cardiomyopathy who do not have symptomatic heart failure to:
   • Sustained ventricular arrhythmia for 30 seconds or more OR requiring intervention
   • LVEF ≤40%