The Medical Examiner’s Handbook represents the FMCSA’s most current recommendations. There have been 5 versions of the Handbook to date: a pre-2015 version, which is now labeled by the FMCSA as “NO LONGER IN USE”, and subsequent versions 2019, 2020, 2021, and 2022 all marked as “DRAFT”.
FMCSA recommendations in these various versions of the Medical Examiner’s Handbook show the subtle and not-so-subtle changes in the FMCSA guidance on hypertrophic cardiomyopathy, changes which reflect the general direction of the FMCSA from 2014 to now. These changes show how the FMCSA guidance has shifted from recommendations to disqualify based on diagnosis alone to indicating that the ME should make a case-by-case evaluation.
- Pre-2015 Handbook (available versions now marked as “NO LONGER IN USE”): If you note an enlarged heart in a driver, you should not certify the driver until evaluation by a cardiovascular specialist who understands the functions and demands of commercial driving to confirm or rule out a diagnosis of hypertrophic cardiomyopathy. Recommend not to certify if: The driver has a diagnosis of hypertrophic cardiomyopathy. So this guidance suggests obtaining cardiovascular specialist evaluation but for the purpose of determining if the driver has a diagnosis of hypertrophic cardiomyopathy, and elsewhere in the same Handbook version a diagnosis of hypertrophic cardiomyopathy is noted as disqualifying.
- 2019 Handbook (marked as “DRAFT”): The confirmed diagnosis of hypertrophic cardiomyopathy is disqualifying in that federal regulation 391.41(b)(4) states that a driver “has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive heart failure.” This guidance still specifically states that a diagnosis of hypertrophic cardiomyopathy is disqualifying, but by specific reference to regulatory qualification language.
- 2020 Handbook (marked as “DRAFT”): The confirmed diagnosis of hypertrophic cardiomyopathy should be considered to be a cardiovascular disease known to be accompanied by symptoms of palpitations; shortness of breath, especially during exercise; chest pain, especially during exercise; syncope and collapse, especially during or just after exercise or exertion. This guidance still implicitly recommends disqualification, but this time by referring to symptoms that are themselves disqualifying.
- 2021 Handbook (marked as “DRAFT”): MEs should evaluate, on a case-by-case basis, whether the driver meets the physical qualification standards. An ME could consider obtaining an evaluation by a cardiologist. See https://www.emedicinehealth.com/hypertrophic_cardiomyopathy/article_em.htm. This is the first time the FMCSA makes no implicit or explicit reference to hypertrophic cardiomyopathy as disqualifying, and the referenced article has no specific recommendations related to fitness-for-duty.
- 2022 Handbook (marked as “DRAFT”): MEs should evaluate, on a case-by-case basis, whether the driver meets the physical qualification standards. An ME could consider obtaining an evaluation by a cardiologist. With respect to cardiomyopathies, the FMCSRs do not include any specific requirements for waiting periods, maximum certification periods, specific diagnostic procedures or treatment, or specific diagnostic results. One source MEs could consider (is) the table from the July 5, 2013, Expert Panel Recommendations titled “Medical Examiner Physical Qualification Standards and Clinical Guidelines for Cardiovascular Disease and Commercial Motor Vehicle Driver Safety”. The table lists various conditions that should be met to consider certification for hypertrophic cardiomyopathy but never indicates that the condition is in-and-of-itself disqualifying.
2024 Handbook (marked as a final copy, not draft): The prognosis for hypertrophic cardiomyopathy is very specific to an individual and their particular anatomy. The majority of individuals with hypertrophic cardiomyopathy have no symptoms and most have a near-normal life expectancy. MEs should evaluate, on a case-by-case basis, whether the individual meets the physical qualification standards. An ME could consider obtaining an evaluation by a cardiologist.
So, there you have it: FMCSA guidance recommendations for hypertrophic cardiomyopathy over the years. The guidance shifts from hypertrophic cardiomyopathy as disqualifying based on the diagnosis alone to a condition that should be evaluated on a case-by-case basis to assess certification. This reflects the FMCSA direction from 2014 to present, which is to move from conditions and diagnoses being disqualifying based on diagnosis alone to recommending case-by-case evaluation of drivers with any and all conditions.
Blog entry discussing Hypertension on the exam:
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