49 CFR 391.43 and the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers

Background:

Effective September 30, 2003, the Federal Motor Carrier Safety Administration (FMCSA) published revised blood pressure guidelines that medical examiners may follow for the evaluation, certification, and follow-up testing of commercial drivers when performing Department of Transportation (DOT) physical examinations pursuant to 49 CFR Part 391.41.  These changes are based on the advisory criteria for blood pressure contained in the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers that were published in October 2002.  These are, in turn, based on the 1997 Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 6).

The revised blood pressure guidelines represent the current medical consensus for evaluating and treating hypertension.  They are not, however, part of FMCSA’s medical standard for blood pressure, Part 391.41(b)(6), which remains unchanged: “A person is physically qualified to drive a commercial motor vehicle if that person has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability to operate a commercial motor vehicle safely.”

According to the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers:

An estimated 50 million Americans have hypertension. Commercial drivers have an increased propensity for the development of hypertension that exceeds the risk seen in other professions. Long-term data show increased rates of cerebral, cardiac, and renal complications in patients with elevated blood pressure. Hypertension is progressive in nature if uncontrolled and requires regular follow- up. The effect of hypertension on target organs also increases the risk of sudden incapacitation.

New Guidelines and Medical Examiner Report

As of September 30, 2004, the FMCSA requires the use of the new form, Medical Examiner Report for Commercial Driver Fitness Determination, which reflects the revised blood pressure guidelines.

Physicians do have some latitude regarding drivers and blood pressure, for example to rule out “blood pressure’s physiologic variations and measurement errors” or “white coat” hypertension.  The diagnosis of hypertension should be based on the average of 2 or more readings taken at each of 2 or more visits after an initial screening.  A single elevated blood pressure level is not sufficient for a diagnosis of hypertension.  If deciding not to use the recommended blood pressure guidelines, the medical examiner should document other best practice guidelines and/or data to support his or her decision.

The Cardiovascular Advisory Panel Guidelines identify normal or controlled blood pressure for DOT medical certification as a systolic value of less than 140 and a diastolic value of less than 90 mmHg (less than 140/90).  This is a decrease from the 1987 guideline of less than 160/90.  An individual with a blood pressure (BP) equal to or less than 140/90 may be certified for up to two years providing no medications are being used to control blood pressure and there is no other medical condition for which a shorter certification period would be appropriate.  If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently.  To meet qualification standards, commercial drivers on antihypertensive medications must also be free of any side effects that could impair their job performance.

Beginning Sept. 30, 2003, the Medical Examiner Report form contained the following instructions for the three stages of hypertension:

• Stage 1:  BP range of 140-159/90-99.  The driver is certified for one year. The driver with a BP in this range is usually without symptoms and at low risk for hypertension-related acute incapacitation.  To obtain a one-year recertification, the individual should have a BP equal to or less than 140/90, and should receive a DOT certification exam each year thereafter.  At recertification, if a driver’s BP is greater than 140/90 but less than 160/100 (141-159/91-99), a one-time certificate for three-months can be issued to allow time for the driver to be evaluated and treated.
• Stage 2:  BP range of 160-179/100-109.  The driver is issued a one-time, 3-month certificate and should be treated.  Once the driver has been treated and the BP is equal to or less than 140/90, s/he can receive a one-year certification from the date of the initial exam (when the three month certification was given) and should receive a DOT certification exam each year thereafter.
• Stage 3:  BP at or above 180/110.  The driver is medically disqualified.  Drivers with Stage 3 hypertension are at high risk for developing acute hypertension-related symptoms.  Once the BP is equal to or less than 140/90, s/he will be given a six-month certificate from the date of the initial disqualifying examination and will require recertification every six months thereafter.

The commercial driver with multiple risk factors for heart disease or target organ damage may be required to meet more intensive blood pressure control by his or her primary care physician.  All hypertensive drivers are strongly encouraged to consult with their personal physicians to ensure appropriate therapy for optimal BP control and education and management to lower other risk factors for cardiovascular disease.

Medical Examination Report for Commercial Driver Fitness Determination*

Medical Examiner should take at least two readings to confirm BP.

*Based on the “Medical Examination Report for Commercial Driver Fitness Determination,” published in the Federal Register, September 30, 2003, Vol. 68, No. 189.