Cardiovascular Conditions

Category B

  1. Cardiovascular disease may affect a driver's ability in a variety of ways.  For this reason, safety assessment level guidelines and standards are shown for four of the more common circumstances.  Although an individual may have more than one abnormality, the one which causes the most limitation is the one under which they should be assessed for this category.  It is essential that all aspects of their condition be evaluated at an appropriate safety assessment level.
  2. GENERAL HEART DISEASE: This safety assessment level is made for any patient having had any diagnosis of heart disease.  The levels are based on the functional classification of the American Heart Association.
    1. Class I. Patients with heart disease but with no limitations of physical activity: Ordinary physical activity causes no undue dyspnea, anginal pain, fatigue, or palpitation.
    2. Class II. Patients with slight limitations of physical activity: They are comfortable at rest and with mild exertion.  They experience symptoms only with the more strenuous grades of ordinary activity.
    3. Class Ill. Patients with marked limitation of physical activity: They are comfortable at rest, but experience symptoms even with the milder forms of ordinary activity.
    4. Class IV. Patients with the inability to carry on any physical activity without discomfort: Symptoms of cardiac insufficiency or of the anginal syndrome may be present, even at rest, and are intensified by activity.
  3. RHYTHM: Patients with rhythm disturbances should not be given safety assessment levels 2 or 3, except when the arrhythmia has been so remote and well controlled, or of such a minor nature, that the patient is expected to drive without presenting a risk to the public.
  4. AFTER MYOCARDIAL INFARCTION OR CARDIAC SURGERY: No patient in these categories should drive until six weeks after the event or until the condition is stable, as determined by a health care professional.  Because of the risk of infarction, recurrence, or other cardiovascular events such as arrhythmia, after infarction, or surgery, if the health care professional believes a patient has an unusually mild condition, a Safety Assessment Level 3 may be given on his/her recommendation.  A treadmill stress test should be repeated after six months.
  5. HYPERTENSION: Apart from its complications, hypertension is largely an asymptomatic condition and in itself does not impair fitness to drive.  Medications that may have sedative side effects or cause unexpected orthostatic hypotension must be assessed by the health care professional as to their effect on the safety assessment.  Visual, neurological, or cardiovascular complications should also be assessed under other categories.
  6. Other less common cardiovascular conditions, such as fistula, coarctation, cardiogenic syncope, severe peripheral arterial or venous vascular disease etc., should be assessed in a fashion comparable to those listed, based upon anticipated functional ability while driving.
  7. COMMERCIAL INTRASTATE DRIVERS: Commercial drivers who have had LVAD or ICD are disqualified from driving any commercial vehicle.  New applicants for the K restriction program are not accepted.  Drivers currently on the K restriction program who are given the same safety assessment level are subject to periodic reviews and MAB approval.  Functional Ability Medical Report Forms submitted with a different safety assessment level, for drivers currently on the K restriction program, must be submitted to the MAB for approval.
    1. ICD - Disqualifying for FMCSA Medical Card.  If a driver wishes to apply for a renewal of the Intrastate Waiver (K restriction), they must submit the following to be reviewed by the Medical Advisory Board: Relevant factors which the committee will need to consider for qualification of a driver of commercial vehicles with an implanted cardioverter and/or cardiac defibrillator (ICD) are as follows and must be addressed in the letter from the treating cardiologist:
      1. Cardiac diagnosis and NYHA classification.
      2. Reason for implantation: primary prevention or treatment of recurrent arrhythmia.
        1. If treatment: what is the arrhythmia being treated, and what is the efficacy of treatment?
        2. Was there ever loss of consciousness, syncope, or near-syncope?
        3. Date and results of last electro-physiologic testing.
        4. Type of device inserted.
      3. When was device inserted, when was the last time the device activated to treat arrhythmia, and were there associated symptoms; i.e.; syncope, distraction, etc.?
      4. What is the Left Ventricular Ejection Fraction and date last estimated?
      5. Is coronary artery disease/CABG present? Has there been recent assessment of patency?
      6. Is the patient on beta-blocker therapy?
      7. Statement that the cardiologist understands the duties of commercial drivers and believes this driver is safe to drive a commercial vehicle.
  1. CARDOVASCULAR ASSESSMENT LEVEL: Most antihypertensive agents have potential side effects which may affect driving capability.  The examining health care professional should be alert to the following potential problems which may be more prominent or likely with certain antihypertensives as listed.  Each hypertensive applicant who is receiving antihypertensive medication should be specifically questioned for these side effects:
    1. ORTHOSTATIC HYPOTENSION
      Virtually any antihypertensive, especially when used in combinations including diuretics, ACE inhibitors, calcium channel blockers, alpha blockers, clonidine, especially Guanethidine and Guanadrel.
    2. SYNCOPE
      Alpha Blockers
    3. DROWSINESS/SEDATION
      Methyldopa, Guanabenz, Guanadrel, Resperine, Clonidine
    4. DIZZINESS
      Most beta blockers, alpha blockers, calcium channel blockers.  Also, apresoline may aggravate angina symptoms in individuals with pre-existing clinically significant coronary artery disease.
    5. OTHER AGENTS AFFECTING DRIVING SAFETY
      Because of their greater tendency to produce side effects, the following agents are even more likely to affect driving safety: Guanethidine, Methyldopa, Reserpine, Guanabenz, and Guanadrel.
PRIVATE VEHICLES
Safety Assessment Level General Heart Disease Rhythm After Myocardial Infarct or Surgery Medical Report Required Interval for Review Class/Restrictions
1 No history, past heart disease fully recovered No history or transient arrhythmia in childhood No history No N/A Private vehicles
2 Heart disease AHA class I, no limits, no symptoms on ordinary activity Transient isolated arrhythmia without recurrence in past five years Unusually mild condition *(b) No N/A Private vehicles
3 AHA class I, no undue symptoms on ordinary activity Past arrhythmia, normal rhythm; stable with pacemaker for six months One year minimum; symptoms only with strenuous activity *(a) Yes 1 Year Private vehicles
4 AHA class II, slight limit on activity; comfortable on mild exertion *(d) Arrhythmias controlled or stable for three months Three months minimum; no symptoms at rest *(a) Yes 1 Year Private vehicles
5 Class III, limited activity with symptoms on activity; anticipated aggravation by unlimited driving *(d) N/A N/A Yes 1 Year Private vehicles
6 Class III, limited activity with fluctuation in symptoms on exertion Unstable rhythm profile; supraventricular tachycardia which is hemodynamically unstable; recurring ventricular arrhythmias proven by Holter monitor; driving limitations & health care professionals recommendation should be based upon anticipated degree of instability of rhythm *(cde) Recovery time frame & restrictions TBD by health care professional & appropriate safety assessment level determined, see narrative paragraph 4 *(b) Yes 6 Months Private vehicles; recommended speed, area, and daylight only restrictions
7 Special circumstances not listed above or under evaluation Yes 6 Months *(ab) Private vehicles, special restrictions as recommended by Health Care Professional
8 AHA Class IV, limitations with any activity, symptoms at rest Arrhythmias with history of loss of consciousness in past Recovery not sufficient to drive Yes N/A No driving

a - Or as recommended by health care professional, up to a maximum period of five years
b - See narrative for consideration of mild or stable cases
c - If  medication does not interfere with alertness or coordination
d - Or profile level 5, with long term stability
e - Level 6, Type II second degree heart block or trivascular block

COMMERCIAL VEHICLES
Safety Assessment Level General Heart Disease Rhythm After Myocardial Infarct or Surgery Medical Report Required Interval for Review Class/Restrictions
1 No history, past heart disease fully recovered No history or transient arrhythmia in childhood No history No N/A Commercial unrestricted
2 Heart disease AHA class I, no limits, no symptoms on ordinary activity Transient isolated arrhythmia without recurrence in past five years Unusually mild condition *(b) No N/A Commercial Unrestricted
3 AHA class I, no undue symptoms on ordinary activity Past arrhythmia, normal rhythm; stable with pacemaker for six months One year minimum; symptoms only with strenuous activity *(a) Yes 1 Year Commercial Unrestricted
4 AHA class II, slight limit on activity; comfortable on mild exertion *(b) Arrhythmias controlled or stable for three months Three months minimum; no symptoms at rest *(a) Yes 1 Year Commercial unrestricted
5 Class III, limited activity with symptoms; anticipated aggravation by unlimited driving *(b) Unstable rhythm profile; supraventricular tachycardia which is hemodynamically unstable; recurring ventricular arrhythmias proven by Holter monitor; driving limitations & health care professional's recommendation should be based upon anticipated degree of instability of rhythm *(c) Recovery time frame & restrictions TBD by health care professional & appropriate safety assessment level determined *(b) Yes 1 Year No commercial driving
6 Class III, limited activity with fluctuation in symptoms on exertion Unstable rhythm profile; supraventricular tachycardia which is hemodynamically unstable; recurring ventricular arrhythmias proven by Holter monitor; driving limitations & health care professional's recommendation should be based upon anticipated degree of instability of rhythm *(c) Recovery time frame & restrictions TBD by health care professional & appropriate safety assessment level determined *(b) Yes 6 Months No commercial driving
7 Special circumstances not covered above or patient under evaluation Yes 6 Months *(ab) Possible commercial driving, with Health Care Professional recommendation
8 Heart disease; AHA Class IV, limitations with any activity, symptoms at rest Arrhythmias with history of loss of consciousness in past Recovery not sufficient to drive Yes N/A No driving

a - Or as recommended by health care professional, longer or shorter interval according to stability, up to a maximum period of five years
b - See narrative for consideration of mild or stable cases
c - If  medication does not interfere with alertness or coordination