49 CFR 391.41(b)(6)

"Has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability to operate a commercial motor vehicle safely."

49 CFR 391.43(f) Blood Pressure (BP)

"If a driver has hypertension and/or is being medicated for hypertension, he or she should be recertified more frequently. An individual diagnosed with Stage 1 hypertension (BP is 140/90–159/99) may be certified for one year. At recertification, an individual with a BP equal to or less than 140/90 may be certified for one year; however, if his or her BP is greater than 140/90 but less than 160/100, a one-time certificate for 3 months can be issued. An individual diagnosed with Stage 2 (BP is 160/100-179/109) should be treated and a one-time certificate for 3-month certification can be issued. Once the driver has reduced his or her BP to equal to or less than 140/90, he or she may be recertified annually thereafter. An individual diagnosed with Stage 3 hypertension (BP equal to or greater than 180/110) should not be certified until his or her BP is reduced to 140/90 or less, and may be recertified every 6 months."

Regulations Versus Medical Guidelines (Guidance)

Americans With Hypertension

According to the Third National Health and Nutrition Examination Survey, 29% of all U.S. adults 18 years and older have BP greater than or equal to 140/90 or are taking medication for hypertension. The prevalence of hypertension is nearly equal for men and women. Among adults with hypertension, 78% are aware of their condition, 68% are treated with antihypertensive medication, and 64% achieve BP less than 140/90 with treatment.

Risks Associated With Hypertension

Hypertension alone is unlikely to cause sudden collapse; however, hypertension is a potent risk factor for the development of more serious cardiovascular disease (CVD), peripheral vascular disease, and chronic renal insufficiency. BP greater than or equal to 140/90 is deemed high for most individuals without other significant cardiovascular risk factors.

In individuals ranging from 40 to 89 years of age, for every 20 mm Hg systolic or 10 mm Hg diastolic increase in BP, there is a doubling of mortality from both ischemic heart disease and stroke. The relationship between BP and risk of a CVD event is continuous, consistent, and independent of other risk factors. Both elevated systolic and diastolic BP are risk factors for coronary heart disease (CHD).

Commercial Drivers at Greater Risk for Developing Hypertension

Once in the profession, commercial motor vehicle (CMV) drivers have a greater propensity to develop hypertension than their peers in other professions. The Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers includes data from Ragland, et al., demonstrating that the percentage of drivers with hypertension increased from 29% in drivers with fewer than 10 years of driving experience, to 32% in drivers with 10-20 years of experience, and to 39% in drivers with more than 20 years of driving experience. As the years of experience rise, part of the increase in hypertension may relate to accompanying aging, increase in body mass, or decline in physical activity.

Effective Treatment Reduces Risk

High BP can be a modifiable CVD risk factor. Lifestyle modification and pharmacotherapy are the mainstays of antihypertensive treatment regimens. Effective hypertension management reduces cardiovascular morbidity and mortality. The Chicago Heart Association Detection Project in Industry found that antihypertensive therapy reduces the incidence of stroke, myocardial infarction, and heart failure.

Contemporary medical therapies are effective in lowering BP, reducing complications, and are generally regarded as safe.

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 ability of the driver 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 “fitness for duty" examination.

As the medical examiner, your fundamental obligation is to establish whether a driver has high BP that is likely to interfere with the ability to operate a CMV safely, thus endangering public safety.

The examination is based on information provided by the driver (history), objective data (measuring BP and 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 that you would for any individual who is being assessed for high BP and/or with a current clinical diagnosis of hypertension.

A current diagnosis of hypertension exists when one or more antihypertensive agents are used to control high BP. When antihypertensive medication is used to treat an underlying condition other than high BP, certification is based on the underlying condition and tolerance to the medication.

The FMCSA Medical Examination Report Form includes questions about the health history of the driver and requires measuring BP. Additional questions should be asked to supplement the information requested on the Medical Examination Report Form. You may ask about symptoms of hypertension and use of antihypertensive medications. It is generally not the role of the medical examiner to determine treatment for the disease.

You should evaluate for other clinical cardiovascular diseases, including CHD, heart failure, and left ventricular hypertrophy, as well as stroke or transient ischemic attack, peripheral artery disease, retinopathy, nephropathy, and other target organ damage.

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

Does the driver:

• Have high BP?
• Take medication?

Recommendations — Questions that you may ask include

Does the driver have:

• Contact information for the treating provider and a medical release form?
• Symptoms related to or caused by high BP?
• Limitations resulting from the disease or treatment?
• Lifestyle risk factors, particularly modifiable behaviors and conditions (e.g., smoking, obesity, and/or lack of exercise)?
• Uncontrolled hypertension while using three or more antihypertensive medications at close to maximum dosages? If the response is “yes,” an evaluation for secondary hypertension may be appropriate.

  Regulations — You must evaluate

For every certification and recertification examination you must:

• Measure BP.
• Confirm BP greater than 139/89 with a second measurement taken later during the examination.
• Check pulse rate, strength, and rhythm.

NOTE: Under the supervision of the medical examiner, trained assistive personnel may measure and record the BP; however, it is prudent for the medical examiner to confirm disqualifying BP personally.

Record BP and pulse in Section 5 of the Medical Examination Report Form.

NOTE: The table on the right side of Section 5 summarizes certification decisions based on the stages of hypertension. The first column shows the BP ranges and the second column reflects the corresponding stage of hypertension. When the systolic and diastolic readings are in different stages of hypertension, classify BP as the higher stage (e.g., BP of 164/96 or 154/104 is classified as stage 2 hypertension).

  Regulations — You must document discussion with the driver about

• Any affirmative history, including if available:
  • Onset date and diagnosis.
  • Medication(s), dose, and frequency.
  • Any current limitation(s).
• Potential negative effects of medication used while driving, including over-the-counter medications.
• Any abnormal finding(s), noting:
  • Effect on driver ability to operate a CMV 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 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 hypertension guidance/advisory criteria key points: