Cardiovascular Issues in DOT Commercial Drivers

Cardiovascular questions that come up on DOT exams:

With history of unrepaired aortic aneurysm or thoracic aneurysm, am I to require ultrasound at the yearly recert? what about echocardiogram every 2-3 years with aortic valve replacement?

With an unrepaired aortic aneurysm you will need to monitor and re-certify annually. The driver is disqualified if a thoracic aneurysm is greater than 3.5 cm, so you will need to see the cardiologists’ consult letter and ECHO that shows the aneurysm is asymptomatic and smaller than 3.5 cm.
There should be a 3 month waiting period after aortic valve replacement in an asymptomatic driver with a cardiology clearance and a post discharge ECHO cardiogram. The guidelines do not specify frequency of ECHO post surgically, this would be at the discretion of the medical examiner in consultation with the treating cardiologist. An ECHO every 2-3 years is recommended for those with mild to moderate aortic valve disease/regurgitation, so this would seem to be a reasonable interval for a stable post-surgical patient.

With history of coronary artery disease, do I order yearly EKG or just go with the letter from the cardiologist consult?

As the medical examiner, you are responsible for appropriate certification of the driver. If you feel the cardiology consultation addresses satisfactory monitoring of the cardiac condition, that is your discretion. There should be at least a baseline copy of an EKG in the chart which can be requested from the cardiologist or the PCP if already performed.

If the driver is on anticoag treatment, I know I recert based on the INR results I am given, but I can’t ensure the driver will continue to check them. I am thinking this is not my role and the problem would show up at the next recert?

The issue here is whether you feel the driver is compliant with treatment or just coming under control before the DOT exam. If I feel the driver is non-compliant, I will generally use my discretion as the medical examiner to require a shorter time period for re-certification. With INRs, I’ll want to see that the driver is being monitored on a regular basis, monthly according to current FMCSA guidelines. If at the yearly recertification exam I see that there are only 6 or 7 monthly results over the previous year, I will issue a 3 mo certificate. If I get all 3 months’ INR’s on the next re-cert exam, I’ll extend to 6 mos, then a year. If the driver knows he is just going to have to come back in more often for recertifications, he/she may as well go in for their monthly INRs !

Could you please clarify a Coumadin/CVA question for me? One section states if a driver in on anticoagulant therapy, their can be if they are having monthly INR’s & results are within range. But the CVA quidelines state anticoagulant’s are automatic disqualifiers due to the increased bleeding risk. Here are my questions:

1) Why is Coumadin (with good theraputic control) qualified to safely drive in one situation but not another
2) Which situations, on anticoagulants, are and are not qualifiers for DOT clearance. Please clarify reasoning.
3) What about the other anticoagulants (Plavix, Xarelto, Pradaxa, etc) usage that does not have monitoring parameters (ie, INR monitoring)?

As with many medications, you have to consider the underlying condition. After CVA it is disqualifying, but other conditions that are currently stable, e.g. Atrial Fibrillation, DVT, the driver may be qualified with proper clearance from the treating physician(s) and monitored INRs. The other anticoagulants aren’t specifically addressed by FMCSA. The medical examiner will need to assess based on the underlying condition and supporting documentation from the treating physicians.

Is there a brief course of study for cardiologists so that they can be documented to “understand the functions and demands of commercial driving”?

No, but you can send them the cardiovascular section from the ME Handbook (you can send the specific section) and you may also want to send them the cardiovascular tables.