Okay, so this is one of the places that actually have a recommendation, which is kind of fun. Not taking this easily, but they decided that if there's a more than that, their cutoff for cardiovascular things is a 20% cardiac event risk in the next 10 years. So that's where their cutoff is. Okay. If you've ever used the Framingham does have an online calculator where you can put in the person's weight and blood pressure and age and stuff like that, and actually calculate these numbers. A lot of primary care people do that to decide how much they want to scare one of their patients. So this is something you can look at for that person's combination of conditions to kind of estimate where they're at 20% 10 year risk is the intention intended cutoff. With the understanding that you could never make a chart that will accurately reflect all those cutoffs, since some of them, you might more hypertension and more less weight or less more weight and less hypertension will get you different answers. So you can't really do it all in one thing. So if there's a waiting period, use the longest one. The cardiovascular disease report, unfortunately, is old, but the table from 2009 is old, but it is still the, you can look at that the 2013 update is the one you want to focus on there because it's a big, big long table. It's like 60 something pages long, you know, look at it, get kind of the gestalt, figure out what the way I think about it is, what are the 10 most likely things that patient's going to come in with, like, they're going to come in with cabbages and stents and bypass surgery and, you know, pacemakers, and maybe an AD, those things, I would look those up, you know, the person that had, you know, an ASD repair, when they were four, I'll go look that up on the chart, because there just aren't that many of them. Right. But I want to know the ones that are common, because that's what's gonna be on the test. The guidebook references you back to the 2013 table. And I said this, that actually is, that's the guidance that takes you back to the table. So just go to that 2013 table from the medical expert panel. That's the one you want to focus on for cardiovascular diseases. If they need exercise testing, the FMCSA number is six mats. Okay. For all conditions. And if they don't have, so they can do six mats, which is apparently six minutes on a Bruce protocol, then they're, that's adequate for driving purposes. Now the cardiologist may want them to do more, that's a different question, but they can do six mats, they can do the driving tasks. So that's enough to put chains on a tire and to walk back and deal with emergency situations and strap their loads and all that kind of stuff. They, the FMCSA has their own definition of a positive stress test of a one millimeter of ST depression or elevation in two or more leagues. That's their definition of an abnormal test. So just, you know, just be mindful of that because sometimes cardiologists use slightly different cutoffs. So remember it's, it's one millimeter is an, is FMCSA is abnormality and, or a marked T wave abnormality. Those are like key words. Does that mean T wave inversions on something other than three and B1 or? Well, this is with exercise. Remember this is, so we're doing exercise. So if, if their T wave changes with exercise, that's concerning. Okay. So across all of everything you're going to hear about in this test, 40 is the number, the number shall be 40. It shall not be 39. It should not be 41. The number for everything we're going to talk about is 40. If there's some number you can't remember, the number is probably 40 on this test. So the ejection fraction shall be greater than or equal to 40%. That's a normal ejection fraction for drivers. You know, we've already done vision where you got to be 20, 40 or better, right? Hearing conservation, 40 decibels, right? The number shall always be 40. So there's a bunch of diseases I recommend. And this is, this is the beginning of the table of contents keeps going. There's three more pages of all the things they thought of as cardiovascular diseases, all these degenerative heart diseases, and you know, bundle branch blocks, and I'm not going to look that one up because that's a common one too. That would be in my top 10. When you look through them, like what are the ones that I, that I see all the time? And look at what their recommendation is for those things that you see on a regular basis in our patients. This is just a sample. I just went and chopped out a little piece of their chart just to kind of see. So it's kind of like certification approved, not approved, recertification. And then some things to have, like, this is the aortic stenosis, they've got these centimeter numbers. Remember, chiropractors don't do centimeters, so we don't have to worry about that. Specific diseases. These are the ones that we're going to talk about today. So left ventricular ejection fraction must be greater than or equal to 40, because that's the number for everything. They can't have pulmonary hypertension if it's known. And they want to have, if they have an echo, you might do other testing. Remember that a MUGA is still the best way to tell what their EF really is. So and you can do, you can use echo, cath, MUGA, whatever it is, but something that reflects their ejection fraction. And that's like, if they're like post MI, I want to know that. If they've had heart failure, I want to know that. Now if they're 55, that's awesome. And it's difficult for somebody with like an MI to get out of the hospital without something that tells you an EF. It's not never, but it's hard to get out. We do worry right after they've had an MI, that's the biggest risk for sudden death. And we want to make sure that they don't have exercise-induced myocardial ischemia. The protocols for this keep changing. I don't even know what the cardiologists are doing this week. When I was an intern, they were doing, and if you had an MI, you would do like a six met stress test before they let you leave the hospital. And then now I think they discharge, I think they discharge you with your MI, and then they have you come back a week later and do your stress test. I mean, there's some, but they're, they still do a stress test after MI so they can figure out if they're going to let you go back to work or not. Most cardiologists do. I don't know what that is this week. So waiting period after an MI, minimum two months, recertification after the two months is done, maximum one year, because it's a weirdness. They're not, they're not the absolute stone cold normal 17 year old or 21 year old. So they have to be asymptomatic, tolerating their meds. You do have to have an exercise stress test after their MI. You know, ischemic changes and an LV ejection fraction of 40% or greater. And we just did that. So don't certify if they've got angina at rest. Now this has to do with, we'll talk about angina in just a second. This is right after their MI, okay. Ischemic changes or they don't tolerate cardiovascular therapy. Like if they can't do, like you try to get them to cardiac rehab and they can't do it, they probably shouldn't be driving. They're going to need to, a cardiovascular specialist is going to have to certify them at least from a cardiac perspective. And the recommendation was a biannual every two year exercise tolerance test. This is a bit of a conflict right now, but it is what is currently in the guidelines. I don't know where your pressure is, of course. I understand that. So then that they did address that in their pressure course, you're right. They didn't change the rule. So this is where we've got, this is getting Carl's head's trying to like, I don't know what's on the task. So the current recommendation for all these things is get testing per the cardiologist. They have to see the, be actively seeing the cardiologist and get the testing that the cardiologist wants them to get. That's the current recommendation. So if the cardiologist says, I want you to get a stress test, then you get the stress test. If the cardiologist doesn't say that, then you follow the cardiologist lead. That's what the update says. I mean, he's completely correct. This is where, this is the part that's very like, I just want to pick something and write it down and tell us. Like I can follow their rule. They said, you know, that's, it's not part of the rules anymore. You're going to see a lot of lines through things and X's because what I do is because I can't tell what they're going to test us on. I'll give you the old version and I'll give you the new version. I'm trying to do them both. That's why we're going a little slower than I would like. So if they have angina, I don't, if they're asymptomatic, that's fine. If they have angina at rest, I don't certify. And if their angina is changing, I don't certify. This is one of the ones where I a hundred percent want a letter from the cardiologist that says that they don't anticipate any problems and their cardiologist, if somebody's got ongoing angina, the cardiologist will have tested them because that's how they make money. So I went to research, the biennial stress test was, was in there and maybe imaging. And now we're back to the cardiologist examination recommendations have to be compliant with their cardiologist recommendations. That is the requirement because this has changed a lot. And what the cardiologists want to do has changed a lot. And the one that I can't, I can't fault the cardiologist because they're one of the very few medical specialties that is actually evidence-based. They said, we used to do it this way, we compared to doing it this other way and this other way made no difference. So let's stop doing it. And they actually do. They'll back off from treatment interventions because it doesn't help. I congratulate them for that. They're way different than their orthopedics colleagues. So minimum waiting period after they've had a stent, minimum is one week. And that's just for healing of the puncture site. Okay. I don't want somebody to start having an arterial bleed while they're driving down the road that will not make the world better. They have to be released by their cardiologist, tolerating the medicines and following their cardiologist testing recommendations. The exercise testing requirement is, has evaporated. One of the problems with a lot of these, these exercise tolerance test requirements is nobody was going to pay for them because it's not standard care. So the insurance companies go, we're not paying for that. And an exercise tolerance test is at least a couple hundred dollars, a bare minimum. And well, if you just do a stress test on a treadmill and a cardiologist, you might get it out under $500. If they do any imaging, it ain't, it ain't that you're not in the neighborhood, you're way more. PCI recertification, one year that I'm okay with that, follow the recommendation by their cardiologist. The specific recommendation for stress testing has evaporated. Post-CABG, three month waiting period, mostly so that they recover fully from their surgery. Their sternum's gotta be well enough healed that they can move their arms against resistance like this on their big steering wheel, or to strap down their load. That's what this is mostly about, the three month waiting period, okay? I know they're now doing CABGs in other surgical ways, minimally invasive, I'm waiting for them to do, waiting for them to follow one and be doing the way that the gynecology, the hysterectomy, they'll just get a longer thing and just do everything transvaginally and just do the CABG that way, but they're not quite there yet. We still have to have, so post-CABG, I wanna make sure their ejection fraction's over 40. The cardiologists typically do that before they release, the cardiothoracic surgeons typically do that before they release the person. An inpatient EF on day, not one, but day five after the surgery is okay, as long as their EF's over 40. Cardiologist says they're okay to come back, they're asymptomatic and they're doing well. Recertification period would be annual because they have a potential problem. And then the five year exercise tolerance test has evaporated, we're back to do what your cardiologist, see the cardiologist and follow the recommendations. So my personal cutoff here is, if I've got somebody who hasn't seen their cardiologist in three years or five years, and they've had bypass or a stent, I'm probably gonna send, they're gonna get a short card to go see their cardiologist. Because they need to, if they're following up and they're doing what the cardiologist wants, I'm fine with that. Since we're now 100% relying on the cardiologist to decide when testing is necessary, I want them to see the cardiologist, like once a year is fine. And if the cardiologist wants to go to every other year, I'm not gonna fight with them. But if it's less than every other year, I want them to go see them. Last time I saw him was in 2015, you need to go back, it's 2023. And if he wants more testing, I want, since he's the call for the testing, I want him to be seen so he can make that call. QDVT, increased risk in drivers because they sit way too long. Anticoagulants can decrease this risk by about 80%, which is good. DVT can be a source of pulmonary emboli, which could be bad. So we want to avoid this. You can do this a lot. I talked to all the drivers about, stopping every two hours, the car and walking or the truck and walking around. And most of them actually do that because you got to, eventually you got to pay. And the people driving with the little urinals in the truck is probably not ideal. I know it's the army way of doing that, but it's not ideal for commercial truck drivers. Waiting period, there's no waiting period after a DVT once I know what's going on. The one time, so if you start getting DVTs, especially not leg DVTs in somebody, think about that first. Like, what else is going on? Why are they, where's their cancer? Or where's their other disease that might be a problem? I'm going to certify them for not more than a year and make sure that they continue to follow up with whoever's treating their DVT. Annual certification, there's no, there is a venous disease recommendation table. I would look at that very quickly. It is not, there's a lot of recommendations that are very specific, but I think it's uncommon, beyond DVT, I think it's uncommon enough you're not going to see it really on the test. And abdominal aortic aneurysm. Remember that our theme is nothing can be more than 40. So as long as they're less than 40 millimeters or four centimeters, right, we can certify them. The, if they get over 40 millimeters, we want, I want the opinion of a vascular surgeon. Now they, the vascular surgeon can just stand back, say you're still 43, I don't, 4.3 centimeters, we don't need to do surgery yet, that's fine. But when the vascular surgeon recommends surgery, then that's not fine. And then they, they need to get that fixed. Okay. So don't certify if you ever see somebody that's over 5.5 for a guy or five millimeters, five centimeters for a young lady, or whenever the vascular surgeon recommends surgery. So those are at 40, at 40, you start worrying and then at 55 or 50, then you don't certify. This one actually still has numbers that I think still hold. Now make sure you understand that's abdominal. That's abdominal. Thoracic is five centimeters now. That actually overtly changed in the new book. So thoracic, it used to be four, now it's five. So if they're over five, the guys, if they have one at all, they just see the vascular surgeon. And if they are asymptomatic and no surgery is recommended and they're less than five, you can certify. Don't certify five or greater. It doesn't matter if it's ascending or descending. Correct. It's thoracic. That is completely correct. Doesn't matter. The question was, does it matter ascending or descending? And the answer is, it does not matter. Okay. So I'm going back a little bit. If a cardiologist says they're okay to drive, can you certify someone with chronic stable angina, taking nitroglycerin once a week for angina that doesn't occur at rest? The answer to your question is yes. For somebody who's using infrequent nitroglycerin that doesn't occur at rest, that is actually okay to certify that person, again, with the cardiologist's blessing. And the other thing that I would do is I would talk with the driver. And this is, I want more, my goal is to figure out, is there a way we can get this person to drive safely? I want to talk to them about how they deal with their angina and their nitroglycerin. You might not want somebody driving. Some people, when they take their nitro, get this horrible pounding headache, which will make it harder to drive. Some people get visual changes with nitro that will, again, make it harder to drive. And so maybe what you do, I mean, I want to know if they're getting, if they're using the nitro when they're driving, actively going down the road, that worries me a bit. If they're getting, if they have this episode where they need the nitro while they're tarping the load, I'm less worried about that. I mean, because that's a pretty high level of exertion. They've got to climb up on the truck and deal with this big canvas thing and strap it down. It's a lot of work. And if that's what, they need the nitro after that, then they can just sit there for a little while with their truck before they go anywhere. I think that's fine. So I'd want to know a little bit more before I approve somebody that's using nitro on a regular basis. Okay, for all the aneurysms of the aorta, three months post-surgery, just to make sure that they're truly healed, because usually they've got big openings in their body, cleared by the cardiovascular surgeon, and then there would be a annual recertification. So what about AFib? So there are many ways to assess AFib risk. CHADS-2 is one of the ways, there are others. So you need to figure out if they're being adequately controlled. And this is one of the cases where use of an anticoagulant decreases the risk of an event while driving. So I actually want this person, I'm sorry, let me say it differently. I want them to be following up with their treating provider. And if they put them on anticoagulation from aspirin all the way up through warfarin or Heliquis or any of those things, that's all good. Okay, hypertrophic cardiomyopathy. So if somebody's got HOCUM and they're young, I worry a lot, right? If somebody's got HOCUM and they're old, they've lived through it, I don't need to worry about this. I would want them to see a cardiovascular specialist. I do a lot of young pilot applicants. I do a lot of teenagers that are wanting to go to pilot training programs. And I do make them Valsalva for me to make sure they don't at least have the murmur changes that would go with HOCUM. And if they do, I'd rather they go see somebody about that than I send them up to a flying airplane and see what happens. Same thing for truck drivers. If I saw a very young driver, I would include that in my exam. There are some specific cutoffs for like left ventricular thickness and things like that that I would want to make sure are the way they're supposed to be before I certify somebody. And apparently, and I don't even know what this means, but if they have a provocable resting peak gradient, 50 or higher, you don't certify them. I think the cardiologist gonna have to tell me that. But if they do, that would be a cutoff. And that's actually in the guidebook. So for cardiovascular diseases, remember the EF must always be 40. And they're to follow the cardiovascular recs as far as clinical evaluations like tests. And if they've got a waiting period, it usually relates to the procedures, then you would follow the waiting periods. Any questions on cardiovascular? The one things that I'll throw in because it's apparently not in the text right now is pacemakers are just fine of any sort, assuming a appropriate post-surgical period and IEDs are not okay. Okay, so let me see if we have a, maybe we'll try the pretest. Yes, go ahead. Okay, so on the cardiology consult thing, the old guidelines, you didn't need a cardiologist recommendation or opinion, but now with most of those, like for angina, for all the other stuff, you do need a cardiology opinion, is that right? At a bare minimum, a treating physician opinion. It doesn't always have to be a cardiologist, but whoever's treating that condition. So yeah, because now instead of saying, I mean, in the distant past, theoretically, you could say, I want them to have a exercise tolerance test to six meds every so often, but I don't do that anymore. I just say, you need to get the cardiologist recommendation for when you need testing. Okay, and only- And keep seeing your cardiologist. And the only reason I was asking that was because like question 17 on the pretest, it was as directed by the cardiologist and I just wanted to make sure that was the right answer for the current testing. Yeah, pretty much for all the cardiac testing, they need to stay, all the cardiac conditions, they need to stay in contact with their cardiologist or their treating provider and follow their recommendations for testing. Okay. And getting some sort of a note from them is not a bad thing. It doesn't need to necessarily, like their last clinic note is fine. If they're seeing the cardiologist every year, just get a copy of the clinic note where they said, I don't recommend testing or I want them to have this test or whatever they do. As long as they follow through, they're fine. Okay, thank you.

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