DVLA’s current medical guidelines for professionals – Cardiovascular appendix
Group 1 and 2 entitlement
If drug treatment for any cardiovascular condition is required, any adverse effect which is likely to affect driver performance will disqualify.
Group 2 entitlement only
An applicant or driver who has, after cardiac assessment, (usually for ischaemic or untreated heart valve disease) been permitted to hold either a LGV or PCV licence will usually be issued with a short term licence (maximum duration 3 years) renewable on receipt of satisfactory medical reports.
Exercise evaluation shall be performed on a bicycle* or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol or equivalent safely, without anti-anginal** medication for 48 hours and should remain free from signs of cardiovascular dysfunction, viz. angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which accredited medical opinion interprets as being indicative of myocardial ischaemia (usually >2mm horizontal or down-sloping) during exercise or the recovery period. In the presence of established coronary heart disease, exercise evaluation shall be required at regular intervals not to exceed 3 years.
*Cycling for 10 minutes with 20 watt increments/minute to a total of 200W
**Anti-anginal medication refers to the use of Nitrates, B-blockers, Calcium channel blockers, Nicorandil, Ivabradine and Ranolazine prescribed for anti-anginal purposes or for other reasons eg cardio-protection.
NB: When any of the above drugs are being prescribed purely for the control of hypertension or an arrhythmia then discontinuation prior to exercise testing is not required.
Should Atrial Fibrillation develop de novo during exercise testing, provided the individual meets all the DVLA exercise tolerance test criteria, the individual will be required to undergo an echocardiogram and meet the licensing criteria, just as any individual with a pre-existing Atrial Fibrillation.
Chest pain of uncertain cause
Exercise testing should be carried out as above. Those with a locomotor disability who cannot comply will require either a gated Myocardial Perfusion Scan, Stress Echo study and/or specialised cardiological opinion.
Stress Myocardial Perusion Scan/Stress Echocardiography
The licensing standard requires that:
- The LVEF is 40% or more.
- (a) no more than 10% of the Myocardium is affected by reversible ischaemic change on Myocardial Perfusion Imaging, or
(b) no more than one segment is affected by reversible ischaemic change on Stress Echocardiography.
NB: Full details of DVLA protocol requirements for such tests can be obtained on request.
The functional implication of coronary heart disease is considered to be more predictive for licensing purposes than the anatomical findings. For this reason the Exercise Tolerance Test and where necessary, Myocardial Perfusion Imaging or Stress Echocardiography are the investigations of relevance for licensing purposes and it is the normal requirement that the standard of one or other of these must be met. Angiography is therefore not commissioned for (re-) licensing purposes. When there remains conflict between the outcome of a functional test and the results of recent angiography, such cases can be considered on an individual basis. However, (re-) licensing will not normally be considered unless the coronary arteries are unobstructed or the stenosis is not flow limiting and the left ventricular ejection fraction is = to or > 40%.
‘Predictive’ refers to the risk of an infarct within one year. Grafts are considered as ‘Coronary Arteries’.
ETT and Hypertrophic Cardiomyopathy
For the purpose of assessment of Hypertrophic Cardiomyopathy cases, an Exercise Test falling short of 9 minutes would be acceptable provided:
- There is no obvious cardiac cause for stopping the test in less than 9 minutes, and
- There is at least a 25mm Hg rise in Systolic blood pressure during exercise testing.
- Meets all other requirements as mentioned in HCM section.
Marfan’s syndrome: Aortic root replacement - Group 2 licence
Debarred if: emergency aortic root surgery; elective aortic root surgery associated with complications/high risk factors eg aortic root, valve and Arch (including de branching) surgery; external aortic root support operation.
Annual review: Group 2 licence to be allowed in elective aortic root replacement surgery – if uncomplicated, successful surgery with satisfactory regular specialist follow-up – valve sparing surgery, root replacement + valve replacement with no post-operative evidence of suture line aneurysm and on 2 yearly MRI/CT surveillance.
Definition of severe aortic stenosis (as per the European Society of Cardiology guidelines, August 2012)
- Aortic valve area < 1 cm2 or < 0.6 cm2 per m2 BSA (body surface area)
- Mean aortic pressure gradient > 40 mmH/g
- Maximum jet velocity > 4 m/s