In the practice of clinical cardiology, when is your primary responsibility not to your patient? When asked to approve a patient’s commercial driver’s license, our primary responsibility is to public safety. Since the Commercial Motor Vehicle Safety Act of 1986 was signed into law, it has been a requirement that truck drivers and bus drivers need to obtain a Commercial Driver’s License (CDL) in order to operate these vehicles. Truck driving is a high-risk occupation and physicians are asked to evaluate drivers in order to decide whether they are medically stable enough to drive large trucks, trucks carrying hazardous materials, as well as driving public transportation buses or school buses.
The US Department of Transportation has established general qualifications for physicians to use when evaluating drivers. The current guidelines pertaining to cardiovascular disease require that the driver “has no current clinical diagnosis of myocardial infarction, angina pectoralis, coronary insufficiency, thrombosis, or any other cardiovascular disease known to be accompanied by syncope, dyspnea, collapse, or congestive heart failure.” It is important for cardiologists in the US to understand the guidelines in order for them to determine whether it is safe for their patients to obtain and maintain their CDL. I am currently on the Medical Panel of the Motor Vehicle Commission in New Jersey, and each year I review the medical histories of hundreds of drivers. The purpose of this editorial is briefly to review the handling of common diagnoses. After a myocardial infarction, the driver must wait two months before returning to driving and must have their cardiologist’s approval. These patients should be on optimal medical therapy.
They may not drive if they have an ischemic stress test, their ejection fraction is <40 %, or if they have recurrent angina. The stress test requirements include a normal blood pressure response to exercise, no angina or clinically significant arrhythmias, and the ability to exercise more than six minutes on a Bruce protocol. If there are significant areas of ischemia noted on imaging, the patient is to be excluded. If they underwent percutaneous coronary intervention, driving is allowed after one week. In the case of a patient who is post-bypass surgery, they must wait three months before driving, and their ejection fraction must be >40 %. It is also important to try to identify high-risk individuals. In patients older than 45 years old with cornary artery disease (CAD) equivalents (such as diabetes, peripheral vascular disease, or high Framingham risk scores), a stress test is suggested. Implantable defibrillator is an exclusion criteria to a CDL. For syncope, there are variations in the guidelines from state to state.
For example, in New Jersey, recurrent syncope with no identifiable cause needs to be reported, and the patient may not drive until he or she is event-free for six months. In Pennsylvania, a patient with recurrent syncope would need to be event-free for one year before driving. In the case of chronic heart failure (CHF), one must be New York Heart Association Functional Class I to drive. If the driver is Class II, III, or IV, they need to be maximally treated until the patient is back to Functional Class I, and, at that point, they can resume their commercial driving activities.
The physician must be an advocate for public safety, more than an advocate for the patient, when determining a person’s suitablility for driving. Certainly, patients who have significant cardiovascular disease should be excluded from driving school buses or trucks, particularly carrying hazardous material. The current standards can be obtained from the US Department of Transportation, Federal Motor Carrier Safety Administration. The title of the document is Federal Motor Carrier Safety Regulations Handbook, which is available at www.jjkeller.com. Making physicians aware of the federal government’s guidelines that aim to protect the public has been a challenge. This edition of US Cardiology comprehensively addresses many more salient issues on which the cardiology professional—either in general of specialist practice—should be aware. I hope that this edition proves a fascinating and informative read.