Cardiovascular Advisory Panel Guidelines for the Medical ...
U.S. Department Of Transportation
Federal Motor Carrier Safety Administration
Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers
Authored by
Roger Blumenthal, MD Heidi Connolly, MD Bernard J. Gersh, MD
Joel Braunstein, MD Andrew Epstein, MD Ellison H. Wittels, MD
FMCSA-MCP-02-002
October 2002
TABLE OF CONTENTS
TABLE OF CONTENTS
EXECUTIVE SUMMARY
i
INTRODUCTION
1
Background
1
FMCSR Guidelines
1
2001 Cardiovascular Medical Advisory Panel and Topics
2
FMCSA Directives to the Cardiovascular Advisory Panel
2
Resources used in the Development of the Guidelines
3
Process Used by the Panel
3
Format of Papers
3
Guidelines Versus Standards
4
Guideline Limitations
4
Overview of Medical Illness and Motor Vehicle Crashes
5
Establishing Risk for Commercial Drivers
5
Qualifications and Duties of Medical Examiners
5
Consideration of Job Demands
6
Medical Evaluation
6
Consideration of Non-cardiovascular Factors
7
The New DOT Medical Examination Form
7
Medical History and Physical Examination
7
Required Testing
8
Additional Tests Available to the Medical Examiner
8
Interpretation of Test Results
8
Consultation
8
Review of Results with Applicant
8
Completing the Form
9
Waiting Period
9
Frequency of Re-certification Examinations
9
References
10
ISCHEMIC HEART DISEASE
13
Background
14
Prevalence of Coronary Heart Disease
14
CHD and Motor Vehicle Crashes
14
Sudden Death and the Incidence of Crashes
15
Sudden Death and Instantaneous Death
15
Need for Early Identification of Coronary Heart Disease
16
ISCHEMIC HEART DISEASE (Continued)
Sudden Death as the First Sign of Coronary Disease
16
Strategies to Detect Coronary Heart Disease
17
Strategy 1: Risk Factor Identification and Treatment
17
Tobacco Smoking
18
Hypercholesterolemia
18
Diabetes Mellitus
19
Overweight/Obesity and Physical Inactivity
19
Age and Coronary Heart Disease
20
Hypertension (See Hypertension Section)
20
Commercial Drivers and Cardiovascular Disease
20
Cardiac Risk Factors Among Commercial Drivers
21
Commercial Driver Specific Risk Factors
21
Examiner Access to Risk Factor Data
22
Driving and Electrocardiogram Changes
22
The Risk of Physical Exertion in the Presence of
Coronary Heart Disease
22
The Relationship Between Risk Factors and Driver
Certification
23
Strategy 2: Early Identification and Treatment of CHD
23
Limitations of the Exercise Tolerance Test
24
The Exercise Tolerance Test in Asymptomatic Persons
with No Risk Factors
24
Exercise Tolerance Test in Commercial Drivers With
Risk Factors and No known CHD
25
Additional Tests to Detect CHD
26
Certification of Drivers with Clinical Coronary Heart Disease 26
Risk Factors in Established Coronary Heart Disease
27
The Exercise Tolerance Test and Work Capacity in Drivers
with Coronary Heart Disease
27
Commercial Driver Certification After Myocardial Infarction 28
Certification of Commercial Drivers with Stable Angina Pectoris 29
Certification of Commercial Drivers After Percutaneous
Coronary Intervention
30
Certification of Commercial Drivers After Coronary Artery
Bypass Grafting
32
Target Organ Damage
34
Recommendation Tables
35
References
38
HYPERTENSION
48
Epidemiology and Impact on Public Health
49
Causes of Hypertension Among Commercial Drivers
50
The Effect of Hypertension on Driver Safety
52
Defining Medically Acceptable Blood Pressure in
the Commercial Driver
52
Stage 1 Hypertension
52
Stage 2 Hypertension
52
Stage 3 Hypertension
53
Risk of Acute Incapacitation from Hypertension
53
Treatment
54
The Need for Blood Pressure Control to Prevent
Target Organ Damage
54
Secondary Hypertension
54
Recommendation Table
55
References
56
VALVULAR HEART DISEASE, MYOCARDIAL DISEASE
59
VALVULAR HEART DISEASE
60
General Recommendations
60
Mitral Stenosis
60
Mitral Regurgitation
62
Mitral Valve Prolapse
64
Aortic Stenosis
65
Aortic Regurgitation
66
Tricuspid Valve Regurgitation
69
Tricuspid Valve Stenosis
69
Pulmonary Valve Stenosis and Regurgitation
69
Percutaneous Balloon Valvotomy or
Surgical Commissurotomy for Mitral Stenosis
69
Mitral Valve Repair for Mitral Regurgitation
70
Aortic Valve Repair
70
Prosthetic Valves
70
MYOCARDIAL DISEASE
72
Hypertrophic Cardiomyopathy
72
Congestive Heart Failure and Idiopathic Dilated Cardiomyopathy 73
Restrictive Cardiomyopathy
75
Recommendation Tables
76
References
83
CARDIAC ARRHYTHMIAS, PACEMAKERS,
90
IMPLANTABLE CARDIOVERTER-DEFIBRALLATORS
Background
91
Risk of Arrhythmia
91
Driving and Electrocardiographic Changes
91
Supraventricular Arrhythmias
92
Ventricular Arrhythmias
93
Bundle Branch Blocks and Hemiblocks
94
Pacemakers
94
Implantable Cardioverter-Defibrillators
94
Arrhythmias and Syncope
95
Recommendation Tables
96
References
105
CONGENITAL HEART DISEASE
108
Introduction
109
Diagnostic Evaluation
109
Overview of Certification Guidelines
110
Bicuspid Aortic Valve
110
Marfan Syndrome
110
Subvalvular Aortic Stenosis
111
Discrete Supravalvular Aortic Stenosis
111
Atrial Septal Defect
112
Atrial Septal Defect: Ostium Secundum
112
Atrial Septal Defect: Ostium Primum
112
Atrial Septal Defect: Sinus Venosus Defect
113
Ventricular Septal Defect
114
Patent Ductus Arteriosus
115
Coarctation of the Aorta
115
Pulmonary Valve Stenosis
116
Ebstein Anomaly
117
Tetralogy of Fallot
117
Transposition of the Great Vessels
119
Congenitally Corrected Transposition of the Great Arteries
120
Pulmonary Hypertension
120
Complex Congenital Heart Disease with Prior Fontan Operation 121
Recommendation Tables
122
References
133
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