49 CFR 391.41(b)(4)

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

Regulations Versus Medical Guidelines (Guidance)

The fundamental question when deciding if a commercial driver should be medically certified is whether the driver has a cardiovascular disease (CVD) that increases the risk of sudden death or incapacitation and creates a danger to the health and safety of the driver, as well as the public sharing the road.

A number of concerns beyond the typical cardiac risk factors predispose commercial drivers to an increased risk of CVD.

• According to the Commercial Driver’s License Information System (CDLIS) in 2009, the average age of a driver is 39 years.
• Obesity and a sedentary lifestyle increase the risk of CVD. Both are more common in the commercial driving population than in the general population.
• Driving stressors such as traffic congestion, erratic shift work, a sense of responsibility for others, and emotional distress due to belligerent passengers can lead to increased neurosympathetic and adrenocortical catecholamine and cortisol release. This increases the likelihood of changes in arterial tone, myocardial excitability, and contractibility and thrombogenic propensity, particularly given the aging workforce in the United States.
• Drivers are exposed to other environmental stressors that may be detrimental to the cardiovascular system such as excessive noise, temperature extremes, air pollution, and whole body vibration.

The effect of CVD on the commercial driver is significant now and will increase in the future.

The major clinical manifestations of CVD are acute myocardial infarction, angina pectoris, sudden death, and congestive heart failure. Arrhythmia is the most likely cause of sudden driver incapacitation. However, coronary heart disease (CHD) is the most common etiology. Estimated frequencies of initial presentation of CHD are approximately 50% acute myocardial infarction, 30% angina, and 20% sudden death. Sudden cardiac dysfunction is particularly relevant to safety sensitive positions such as pilots, merchant marines, and commercial drivers. In these jobs, policies are expected to protect against sudden incapacitation on the job and harm to the public.

The effect of heart disease on driving must be viewed in relation to the general health of the driver. Other medical conditions may exacerbate a cardiovascular condition, thus, medical certification to drive depends on a comprehensive medical assessment of overall health and informed medical judgment about the impact of single or multiple conditions on the whole person.

Disqualification requires that the commercial motor vehicle (CMV) driver exhibits a higher than acceptable likelihood of acute incapacitation from a cardiac event resulting in an increased risk to self and others while driving.

The general purpose of the history and physical examination is to detect the presence of physical, mental, or organic conditions of such character and extent as to affect the driver ability to operate a CMV safely. This examination is for public safety determination and is considered by the Federal Motor Carrier Safety Administration (FMCSA) to be a “medical fitness for duty" examination.

As the medical examiner, your fundamental obligation during the cardiovascular assessment is to establish whether a driver has a cardiovascular disease or disorder that increases the risk for sudden death or incapacitation, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (physical examination), and additional testing requested by the medical examiner. Your assessment should reflect physical, psychological, and environmental factors.

Medical certification depends on a comprehensive medical assessment of overall health and informed medical judgment about the impact of single or multiple conditions on the whole person.

During the physical examination, you should ask the same questions as you would for any individual who is being assessed for cardiovascular concerns. The FMCSA Medical Examination Report Form includes health history questions and physical examination checklists. Additional questions should be asked to supplement information requested on the form. You should ask about and document cardiovascular symptoms.

  Regulations — You must review and discuss with the driver any "yes" answers

Does the driver have:

• A current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, or thrombosis?
• Syncope, dyspnea, or collapse?
• Heart failure?
• A history of heart disease or heart attack?
• A history of other heart condition?
• A history of heart surgery (valve replacement/bypass, angioplasty, implantable cardiac defibrillator, pacemaker)?
• And use cardiovascular medications that effectively control condition without side effects that interfere with safe driving?

Recommendations — Questions that you may ask include

Does the driver have:

• Chest pain?
• Chest pressure or ache with exertion?
• Pain, pressure, and/or dyspnea at rest or with exertion?
• Recurrent and/or severe palpitations?
• Pre-syncope (dizziness, light-headedness) and/or true syncope (loss of consciousness)?
• Medical therapy that requires monitoring?

 Regulations — You must evaluate

On examination, does the driver have:

• Murmurs, extra heart sounds, and/or arrhythmias?
• An enlarged heart?
• Abnormal pulse and amplitude, carotid or arterial bruits, and/or varicose veins?

  Regulations — You must document discussion with the driver about

• Any affirmative history, including if available:
  • Onset date, diagnosis.
  • Medication(s), dose, and frequency.
  • Any current limitation(s).
• Potential negative effects of medication use, including over-the-counter medications, while driving.
• Any abnormal finding(s), noting:
  • Effect on driver ability to operate a commercial vehicle safely.
  • Necessary steps to correct the condition as soon as possible, particularly if the untreated condition could result in more serious illness that might affect driving.
• Any additional cardiovascular tests and evaluation.

NOTE: If certifying the driver with an organic disease, document on the Medical Examination Report Form that the body has compensated for that organic disease. If not certifying, document that the body's compensation is not adequate to meet physical qualification requirements.

Medical fitness for duty includes the ability to perform strenuous labor. Overall requirements for commercial drivers as well as the specific requirements in the job description of the driver should be deciding factors in the certification process.

The following link to select cardiovascular guidance/advisory criteria key points: