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High Blood Pressure Regulation Reference Guidance

FMCSA guidance on hypertension has recently changed, again!  Until 2020, hypertension guidance described hypertension stages – Stage 1, 2, and 3 – with specific recommendations for each stage. In 2021 the FMCSA described alternative hypertension guidance which did not refer to these stages, but also included the prior guidance referencing stages. In 2022, the references to hypertension stages were eliminated, and only the new alternative guidance was referenced. Now, in the 2024 Medical Examiner Handbook, and in the recently updated  Medical Advisory Criteria found in 49 CFR 391 Appendix A, only the original guidance describing hypertension stages is referenced. Hypertension stages it is!

High Blood Pressure Regulation - 49 CFR 391.41(b)(6)

4.6.1 Regulation: “A person is physically qualified to drive a commercial motor vehicle if that person- Has no current clinical diagnosis of high blood pressure likely to interfere with his/her ability to operate a commercial motor vehicle safely.”

4.6.2 Medical Advisory Criteria for 49 CFR 391.41(b)(6):

  1. Hypertension alone is unlikely to interfere with the ability to control and drive a commercial motor vehicle safely; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. These criteria are based on the October 2002 Federal Motor Carrier Safety Administration's Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers, which used the three stages of hypertension established by the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (November 1997).
  2. Stage 1 hypertension corresponds to a systolic blood pressure of 140-159 mmHg and/or a diastolic blood pressure of 90-99 mmHg. The driver with a blood pressure in this range is at low risk for hypertension-related acute incapacitation and may be medically certified to drive for a 1-year period. Physical qualification examinations should be done annually thereafter. The blood pressure should be at or less than 140/90 mmHg at these annual examinations. However, if blood pressure is greater than 140/90 mmHg but less than 160/100 mmHg at an examination, a driver may be certified for another 3 months.
  3. A blood pressure of 160-179 mmHg systolic and/or 100-109 mmHg diastolic is considered Stage 2 hypertension. A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. However, a blood pressure in this range does not necessarily preclude medical certification during evaluation and institution of treatment. The driver may be given a one-time certification of 3 months to reduce blood pressure to less than or equal to 140/90 mmHg. Provided treatment is well tolerated and the driver demonstrates a blood pressure value of 140/90 mmHg or less, the driver may be certified for another 9 months from the date of the initial examination. The driver is certified annually thereafter.
  4. A blood pressure at or greater than 180 mmHg (systolic) and 110 mmHg (diastolic) is considered Stage 3, and carries a high risk for an acute blood pressure-related event. The driver may not be qualified, even temporarily, until blood pressure is reduced to 140/90 mmHg or less and treatment is well tolerated. The driver may be certified for 6 months and biannually (every 6 months) thereafter if at recheck blood pressure is 140/90 mmHg or less.
  5. Annual certification is recommended if the medical examiner does not know the severity of hypertension prior to treatment. An elevated blood pressure finding should be confirmed by at least two subsequent measurements on different days. This could be done using the “determination pending” status.
  6. Treatment includes non-pharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors for hypertension. Most antihypertensive medications also have side effects, such as somnolence or syncope. The importance of side effects must be evaluated on an individual basis and considering the underlying hypertension. Individuals should be alerted to the possibility that antihypertensive medications may interfere with the ability to control and drive a commercial motor vehicle
  7. Medical certification for secondary hypertension is based on the above stages. Evaluation is warranted if an individual is persistently hypertensive on maximal or near-maximal doses of two to three pharmacologic agents. Some causes of secondary hypertension may be amenable to surgical intervention or specific pharmacologic disease. The Physical Examination

Blood Pressure (BP)

  • BP readings taken during the driver physical qualification examination should be used for certification decisions.
  • BP greater than 139/89 should be confirmed with a second measurement taken later during the examination.
  • Record additional BP measurements in the “Second reading” space or in your comments on the Medical Examination Report Form, MCSA-5875.
  • The driver may be certified for up to 2 years if the driver’s hypertension has resolved without blood pressure medications according to documentation from the medical provider.

An ME’s fundamental task is to establish whether a driver has high BP that is likely to interfere with the ability to operate a CMV safely. The physical qualification examination is based on information provided by the driver (history), objective data (physical examination), and if necessary, additional testing requested by the ME. The ME’s 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. 

With respect to blood pressure, the FMCSRs do not include any specific requirements for waiting periods, maximum certification periods, specific diagnostic procedures or treatment, or specific diagnostic results. The table below is the basis for the guidance in the Medical Advisory Criteria listed above


FMCSA Stages of Hypertension

Blog entry discussing Hypertrophic Cardiomyopathy on the exam:

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