Recommended Changes to Cardiovascular Disease Guidelines
Following are the existing guidelines, with the MRBs recommended changes in bold.
Section 1: Drivers without known heart disease
- The Medical Expert Panel (MEP) recommends that the currently used definition for abnormal exercise tolerance testing (ETT) should be revised so that it is defined as an inability to exceed 6 METS (metabolic equivalents) on ETT.
Section 2: CMV drivers with known chronic heart disease
- The MEP recommends that it be made clear that for all guidelines in this section, there is an expectation that individuals with known CHD will have had all of their medications titrated to the optimal dose.
- The current FMCSA guideline states that individuals with angina pectoris may be qualified for certification if they are rendered asymptomatic. The MEP recommended that CMV drivers with angina pectoris may be qualified for certification to drive a CMV if the pattern of angina is stable.
- 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 all the following conditions:
- At least one week has passed since the procedure
- The treating cardiologist provides approval
- The individual has demonstrated tolerance to medictions
- The individual has a normal ETT 3 to 6 months following PCI
- Current FMCSA guidelines state that individuals who have undergone coronary artery bypass surgery that meet the requirements for certification should be recertified on an annual basis for five years. After this time, such individuals should undergo an exercise tolerance test annually. The MEP recommended extending the time between exercise tolerance tests to two years.
Section 3: CMV drivers with hypertension
The MEP recommended several changes to the guideline statements in Section 3.
- The MEP recommends that a series of statements explaining the general principles of certification of individuals with hypertension be added to the current CVD guidelines. These general principles are as follows:
- Certification and recertification of individuals with hypertension should be based on a combination of factors: blood pressure, the presence of target organ damage, and co-morbidities.
- 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.
- All CMV drivers should be referred to their personal physician for therapy, education, and long-term management.
- The MEP recommends that text be added to the current FMCSA guidelines in this section noting that there is an expectation throughout this section that blood pressure has been measured appropriately.
- The MEP recommends that text be added to the current FMCSA guidelines in this section noting that there is an expectation throughout this section that blood pressure medication has been titrated appropriately. The target blood pressure for titration should be <140/<90.
- The MEP recommends that text be added to the current FMCSA guidelines included in this section noting that medical examiners should ensure that individuals with hypertension are properly educated about the importance of making appropriate changes in lifestyle and proper compliance with medication.
- The MEP recommends the current guidelines be clarified so that current ambiguity about thresholds that define hypertension stage in the existing guidelines be eliminated. The panel recommends that updated guidelines note that the hypertension stages used in updated guidelines are consistent with those recommended by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Section 4: CMV drivers with supraventricular tachycardias
- The MEP recommends that the current ambiguity associated with lone atrial fibrillation be resolved 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.
- The MEP recommends that FMCSA provide details of how risk for stroke from embolization among individuals with atrial fibrillation should be determined. The panel recommends that the most appropriate risk stratification model currently available is CHADS2 (Cardiac Failure, Hypertension, Age, Diabetes, Stroke and transient ischemic attack (TIA). The CHADS2 risk index is based on a point system in which two points are assigned for a history of stroke or TIA and 1 point each is assigned for age over 75 years, a history of hypertension, diabetes, or recent heart failure (HF).
- FMCSA requested clarification of the relative role of aspirin and vitamin K inhibitors in reducing stroke risk in individuals with atrial fibrillation. The MEP referred FMCSA to the current ACC/AHA/European Society of Cardiology (ESC) guidelines for appropriate antithrombotic treatment of individuals with atrial fibrillation. The MEP noted that the current FMCSA guideline for the certification of individuals with atrial fibrillation is applicable to individuals undergoing antithrombotic therapy who have at least one moderate-risk factor for stroke, any high-risk factor for stroke, or more than one moderate-risk factor for stroke.
- The MEP recommends that individuals with atrial fibrillation at moderate to high risk for a stroke be recertified annually. Furthermore, the members recommend that the guidelines make it clear that in order to be recertified the individual must have his or her anticoagulation monitored by at least monthly International Normalized Ratio (INR) and demonstrate adequate rate/rhythm control.
Section 5: CMV drivers with pacemakers
- The MEP recommends that the current guideline pertaining to the use of pacemakers in individuals with neurocardiogenic syncope be revised. Current guidelines state that individuals with recurrent neurocardiogenic syncope who have received a pacemaker as a treatment for the condition may be certified three months following implantation. The MEP no longer accepts a pacemaker as definitive treatment for neurocardiogenic syncope.
- The MEP recommends that text be added to documentation accompanying the cardiovascular disease (CVD) guideline update that describes the appropriate evaluation of an individual who presents with syncope. The purpose of this new text will be to ensure that efforts are made to distinguish individuals with cardiogenic syncope from those with syncope from other causes.
Section 6: CMV drivers and implantable cardioverter defibrillators
The MEP made a single recommendation on the guideline statements in Section 6.
- The MEP recommends that the current FMCSA CVD guidelines, which preclude any individual with an implanted cardioverter defibrillator (ICD) from being certified to drive a CMV, be upheld.
Section 7: CMV drivers with abdominal or thoracic aortic aneurysms
The MEP made several recommendations for changes to the guideline statements in Section 7.
- The MEP recommends that the upper limit for the abdominal aortic aneurysm (AAA) diameter below which an asymptomatic individual may be certified to drive a CMV be increased to 5.5 cm for men and that an upper limit of 5.0 cm be set for women.
- The MEP recommends that FMCSA make changes to some of the wording of the current guidelines on certification of individuals with AAAs. The recommended changes are presented below.
- Individuals with an AAA 4.0 to 5.4 cm in diameter can be certified if they are asymptomatic AND they are cleared by a vascular specialist. (The word AND is not included in the current guidelines.)
- Individuals with an AAA 4.0 to 5.4 cm in diameter cannot be certified if they are either symptomatic OR a vascular specialist has recommended that they undergo surgery. (The word OR is not included in the current guidelines.)
- The MEP recommends that FMCSA add guidance to the current guideline on certification of individuals who have undergone endovascular AAA repair (EVAR). It recommends that text be added to the current guideline that ensures that recertification of individuals who have undergone EVAR comply with the follow-up protocol required following such an intervention. Compliance with the follow-up protocol is necessary following EVAR because the implanted stent may become dislodged. This in turn may result in endovascular leak that, in some cases, can result in aneurysm rupture.
- The MEP recommends that the upper limit for the thoracic aortic aneurysm (TAA) diameter below which an asymptomatic individual may be certified to drive a CMV be increased from 3.0 cm to 5.0 cm.
Section 8: CMV drivers with peripheral vascular disease
- The current guidelines for certification of individuals with intermittent claudication state that an individual who is symptomatic should not be certified to drive a CMV. The MEP recommends that this be changed to disqualification from driving a CMV when pain occurs at rest.
Section 9: CMV drivers with venous disease
- Active DVT should disqualify an individual from driving a CMV.
- 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 6 months) following resolution.
- If on a Vitamin K antagonist such as warfarin (Coumadin), drivers need to be regulated for at least 1 month prior to certification (or recertification) and have their INR monitored at least monthly thereafter.
- INR should be maintained within the target range: 2.03.0.
- 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 10: CMV drivers with cardiomyopathy
- Since the development of the CVD guidelines published in 2002, changes have occurred in the classification of the cardiomyopathies. Consequently, the MEP recommends that the current guidelines for cardiomyopathies be updated to reflect this.
- The current guidelines state that an individual with hypertrophic cardiomyopathy should not be certified to drive a CMV. The MEP recommends that the guideline be changed to reflect the fact that not all individuals with hypertrophic cardiomyopathy are at risk for sudden incapacitation or death. Specifically the panel recommends that individuals who meet all the following criteria are at low risk and may be certified to drive:
- No history of cardiac arrest
- No spontaneous sustained VT
- Normal exercise BP (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
- The MEP noted that low-risk individuals must be followed closely for changes in risk status.
- The MEP recommends changes to the text explaining the criteria that defines who should not be certified to drive a CMV, relative to those individuals with idiopathic dilated cardiomyopathy who do not have symptomatic HF. The current guidelines state that individuals with ventricular arrhythmia who present an LVEF<50% be precluded from certification. The MEP recommends that these criteria be changed to the following:
- Sustained ventricular arrhythmia for 30 seconds or more OR requiring intervention
- LVEF ≤40%