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DOT Exam Oakstone Course > Coronary Heart Disease > Flashcards

Coronary Heart Disease Flashcards

1
Q

drivers with coronary heart disease must be medically stable. From whom should you obtain medical clearance regarding the patient?

A

Treating provider, usually cardiologist or cardiac surgeon for post-CABG

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2
Q

What symptoms do you have to specifically make sure a patient on cardiovascular medication is not experiencing?

A

-Orthostatic hypotension
-dizziness
-hypotension
-bradycardia

Driver should be knowledgeable about medications; free from side effects the compromise driving ability; and compliant with the treatment plan.

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3
Q

The presence of risk factors for coronary heart disease does not mean the driver will develop CHD, only that there is an _________ risk. However, the absence of risk factors does not mean that the driver will not have CHD event.

A

increased

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4
Q

When is a driver considered high risk for CHD?

A

Whenever one or more of the following conditions is present:
-diabetes
-peripheral vascular disease
-Framingham risk score predicting a 20% CHD event risk over the next 10 years
-over 45 years old with multiple risk factors

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5
Q

Suppose the driver has no known CHD, low risk, and is asymptomatic and healthy. Can you certify; how often would you recertify?

A

-If the Framingham risk score is less than 10, certify if asymptomatic
-recertify biennially
-decision to not certify should not be based solely on the presence of multiple risk factors

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6
Q

Suppose the driver has no known CHD, is asymptomatic but high risk. Under what circumstances can you certify? How often must the patient be re-examined?

A

-Certify if asymptomatic
-re-examined annually
-recertify annually
-needs close physician follow-up and aggressive comprehensive risk management

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7
Q

Suppose the driver has no known CHD, is asymptomatic but high risk. Under what circumstances is the driver ineligible to be certified? How often must the patient be re-examined?

A

-Don’t certify if exercise tolerance test is abnormal
-don’t certify if ischemic changes are on the EKG

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8
Q

Suppose the driver has multiple CHD risk factors. Can you certify this driver?

A

-Can certify for maximum of one year if you believe the medical condition does not endanger health and safety of the driver in public
-multiple risk factors do not automatically disqualify a driver
-annual medical exam suggested

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9
Q

Suppose the driver has multiple CHD risk factors. When are you unable certify that this driver?

A

-Do not certify if you believe the medical condition endangers the health and safety of the driver in public

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10
Q

Which drivers need an ETT every two years?

A

Drivers who are post MI, post angioplasty, or who have stable angina pectoris need an ETT every two years

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11
Q

Which drivers need an ETT every five years?

A

Every year post-CABG surgery, starting at five years.

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12
Q

Which drivers should be referred for radionuclide stress testing or echocardiography myocardial imaging?

A

-Driver has an unsatisfactory exercise tolerance test result
-dysrhythmia
-significant EKG changes
sometimes, the medical insurer will not pay for these tests because they say they aren’t medically necessary. This puts the driver in the DOT examiner in a difficult position.

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13
Q

What is the major predictor of CHD?

A

Left ventricular function.
Additional prognostic indicators:
-age
-coexisting vascular disease
-angina pectoris
-dysrhythmia or arrhythmia
-general health
-severity of CHD

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14
Q

When is the greatest risk for mortality after acute MI?

A

-First few months after the event
-most post MI deaths are sudden deaths

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15
Q

When can a post myocardial infarction patient return to work?

A

-When there is no exercise-induced myocardial ischemia and no left ventricular dysfunction

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16
Q

What is the minimum required left ventricular ejection fraction?

A

Must be greater than or equal to 40%
-echo (cardiac ultrasound) is used to assess ejection fraction
-radionuclide imaging can be used if more precise ejection fraction measurements are needed
-in-hospital post MI echo results are adequate for purposes of DOT evaluation

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17
Q

What numbers are required to say that a driver has satisfactory post MI exercise tolerance test results?

A

-Heart rate is greater than 85% of the predicted maximum heart rate unless on beta blockers
-no significant ST segment depression
-no ventricular dysrhythmia
-SBP rise is greater than 20 mmHg without angina
-workload capacity > 6 METs

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18
Q

When all the criteria that a driver who has had an MI must meet in order to return to work?

A

-Asymptomatic
-more than two months post MI
-no myocardial imaging ischemic changes
-satisfactory exercise tolerance test, meaning greater than six metabolic equivalents
-tolerates medication
-examine approval from cardiologist
-must have an annual exam
-must have biennial exercise tolerance test
-can be certified for one year

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19
Q

A post-MI driver reports angina at rest or change in anginal pattern within three months of the exam. Can they be certified?

A

No. Pt must be asymptomatic.

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20
Q

A post-MI driver is complying with the medication. They say sometimes medicines make them sleepy or dizzy. They scored > 6 METS on their ETT, are 4 months post MI, and have no ischemic changes on EKG. Can they be certified?

A

No. Patient must be tolerating their cardiovascular therapy. Even if they mean all the other criteria, they still have to also be able to tolerate the medications.

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21
Q

What causes angina pectoris?

A

-Deficit and oxygen supply to the heart muscle in relation to the demand for oxygen
-condition is progressive
-can be stable or unstable
-presence of angina means at least one coronary vessel has hemodynamically significant narrowing

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22
Q

Suppose the patient has angina. What constitutes satisfactory stable angina exercise tolerance test results?

A

-Heart rate is greater than 85% of the predicted maximum heart rate unless on beta blockers
-no significant ST segment depression or ST segment elevation
-no ventricular dysrhythmia
-SBP rise is greater than 20 mmHg without angina
-workload capacity > 6 METs

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23
Q

Compare stable angina to unstable angina with regards to what causes symptoms.

A

Stable angina: provoked by four specific things
-ecstasy (sex)
-exercise
-exertion
-extreme weather

VERSUS

Unstable angina: doesn’t have to be provoked in order for the patient have symptoms. Patient has decreased response to medication.

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24
Q

Compare stable angina to unstable angina with regards to frequency of symptoms.

A

Stable angina: predictable pattern. Patient is usually able to identify what things will cause them to get symptomatic.
Lower risk for adverse clinical outcomes compared to other CHD

Vs

Unstable angina: chest pain occurs even at rest. Duration of chest pain is longer than with stable angina.

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25
Q

______ angina means there’s usually significant narrowing in at least one coronary artery.

A

Stable

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26
Q

______ angina has an unpredictable course.

A

Unstable

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27
Q

How is stable angina treated?

A

Rest, medications, revascularization

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28
Q

How is unstable angina treated?

A

Medications and revascularization

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29
Q

Do not certify a driver who has had unstable angina pectoris car occurring within the past ______ months.

A

three

30
Q

Presence of unstable angina means patient is at risk for what additional cardiovascular events?

A

-Syncope
-dyspnea
-collapse
-congestive cardiac failure

31
Q

Patient with stable angina cannot be certified until they have a minimum of _____ months with no rest angina and no change in angina pattern.

A

three

32
Q

You can certify patient was stable angina for what period of time? What are the criteria they must meet in order to become certified?

A

-One year
-angina is truly stable; no change in angina pattern or angina at rest in the past three months
- asymptomatic
-tolerates medication and treatment
-satisfactory exercise tolerance test
-examine approval from a cardiologist

33
Q

In order for patient with stable angina to be certified, they must have evaluation from a_______ .

A

Cardiovascular specialist

34
Q

How often must a driver who has stable angina have an exercise tolerance test? How often must the driver have a medical exam?

A

-ETT must occur every two years
-must have imaging stress test if ETT is inconclusive
-requires an annual medical exam

35
Q

If a driver with stable angina is certified, how often must the driver have a medical exam?

A

Annually

36
Q

For what period of time can a patient with stable angina be certified?

A

Certify for one year

37
Q

How often must a patient with stable angina who is certified have an exercise tolerance test?

A

-Biennially (every two years)
-obtain imaging stress test if exercise tolerance test is inconclusive

38
Q

What affects prognosis of patient with heart failure?

A

Prognosis depends on underlying disease; driving risks are independent of underlying disease
-can be caused by ischemia
-if not caused by ischemia, hypertension is the most common cause

39
Q

____________ is the most frequent diagnosis of individuals with heart failure who present with systolic dysfunction, but have no evidence of significant underlying coronary artery disease.

A

idiopathic dilated cardiomyopathy

40
Q

Heart failure is a major cause of ________ dysfunction.

A

Systolic

41
Q

Heart failure accounts for _______ % of cases of sudden death.

A

10-30%

42
Q

If driver is diagnosed with heart failure, what constitutes satisfactory exercise tolerance test results?

A

-Heart rate more than 85% of maximum heart rate unless on beta blockers
-no significant ST segment depression
-no ventricular dysrhythmia
-SBP rise greater than 20 mmHg without angina
-workload capacity greater than six metabolic equivalents

43
Q

What criteria must the patient with heart failure meet in order to be certified?

A

-Asymptomatic stable
-ejection fraction 40% or greater
-etiology confirmed - you have to identify what is causing the heart failure; it cannot be a case of heart failure of unknown cause
-treatment is safe, adequate, effective
-metabolic equivalent of six or greater

44
Q

Under what circumstances might a driver with heart failure whose ejection fraction is less than 40% be recertified?

A

If the driver has an ejection fraction less than 40% but they are asymptomatic, they can be recertified if yearly evaluation shows improvement.

45
Q

What kind of medical monitoring and follow-up is required for a driver who has a diagnosis of heart failure?

A

-Must have annual evaluation and clearance from cardiovascular specialist
-annual evaluation from the cardiologist must include:
* Echocardiogram
* Holter monitor
-annual medical exam

46
Q

Percutaneous coronary intervention (PCI) is also called what?

A

Percutaneous transluminal coronary arthroplasty (PTCA)

47
Q

What is the basic procedure of PCI (Percutaneous coronary intervention), also called PTCA (Percutaneous transluminal coronary arthroplasty)?

A

-Catheter passes through the skin into the femoral artery or some other artery
-catheter is threaded into the coronary arteries
-operator takes a look at arteries
-clots are cleared by inflating a balloon, inserting a stent, or using a rotor

48
Q

What constitutes satisfactory post PCI exercise tolerance test results?

A

-Heart rate more than 85% of maximum heart rate unless on beta blockers
-no significant ST segment depression or elevation
-no ventricular dysrhythmia
-SBP rise greater than 20 mmHg without angina
-workload capacity greater than six metabolic equivalents

49
Q

What is the recommended waiting period for certification after the patient has had PCI?

A

-Recertify after one week post PCI if the procedure was done for stable angina
-procedure was done for MI or unstable angina, you can’t certify until patient completes the waiting period for the underlying condition that led to PCI.

50
Q

What all the criteria that a driver who has had an MI must meet in order to return to work?

A

-Asymptomatic
-more than two months post MI
-no myocardial imaging ischemic changes
-satisfactory exercise tolerance test, meaning greater than six metabolic equivalents
-tolerates medication
-examine approval from cardiologist
-must have an annual exam
-must have biennial exercise tolerance test
-can be certified for one year

51
Q

A driver who is post-MI must wait at least ____ months before returning to work.

A

two

52
Q

Do not certify a driver who has had unstable angina pectoris car occurring within the past ______ months.

A

three

53
Q

If a driver who received PCI is certified, how frequently must they be re-examined?

A

Must have an annual medical exam

54
Q

What criteria must a driver who has had PCI meet in order to become certified?

A

-Must be at least one week post PCI what if the procedure was done for stable angina; must complete the waiting period for underlying condition when PCI was done for MI or unstable angina
-annual medical exam
-asymptomatic
negative exercise tolerance test 3 to 6 months post PCI and every other year
-no injury, such as bruising, hematoma, swelling at the vascular insertion site
-tolerates medication
-drivers been examined and approved by cardiologist

55
Q

Can you certify driver who had PCI three weeks ago if they still have bruising, hematoma, swelling, or other injury the vascular insertion site?

A

No

56
Q

How often must a driver who has had PCI receive exercise tolerance testing?

A

-Must complete this 3 to 6 months post PCI and every other year
-may recertify the driver as long as the exercise tolerance test results are negative
-do not certify if the patient has a positive exercise tolerance test 3 to 6 months post PCI or when they complete the required every other year exercise tolerance testing

57
Q

What is the initial certification after a driver has had PCI/angioplasty ?

A

Six months; after six months have passed, the driver must come for follow-up exam
-Certify for up to one year ONCE THE DRIVER HAS A SATISFACTORY stress test

58
Q

Driver who has had angioplasty must have ETT between ____ months and ___ years after angioplasty. ETT results must be brought to the ____ month follow up exam.

A

Driver must have exercise tolerance testing between six months and three years after angioplasty. Must result to the six-month follow-up exam.

59
Q

If ETT results are good after PCI, for how long can the driver be certified? How often size tolerance testing need to be repeated?

A

-Certify for up to one year ONCE THE DRIVER HAS A SATISFACTORY stress test
-repeat exercise tolerance testing every two years
-requires annual evaluation and clearance from cardiovascular specialist and an annual exam

60
Q

What might post-PCI angina suggests is happening? What studies need to be done?

A

-Restenosis
-driver needs reevaluation with stress imaging study or repeat angiography

61
Q

What is coronary artery bypass grafting, or CABG ?

A

-Clot in the coronary artery is bypassed by grafting a vessel from somewhere else in the body, frequently the saphenous vein or the left internal mammary artery
-CABG patients have a high risk of reocclusion, but have less risk of sudden death compared to those who are treated medically

62
Q

When can most patients who have had CABG return to work?

A

When the sternum is healed

Patient must be at least three months post CABG before they can be certified

63
Q

For which patient is CABG the preferred treatment?

A

-Extensive atherosclerosis with left ventricular dysfunction or debilitating angina
-multi-vessel coronary heart disease
-narrowing of the proximal left main coronary artery or the left main coronary artery

64
Q

Describe satisfactory post CABG exercise tolerance testing results.

A

-Heart rate more than 85% of maximum heart rate unless on beta blockers
-no significant ST segment depression or elevation
-no ventricular dysrhythmia
-SBP rise greater than 20 mmHg without angina
-workload capacity greater than six metabolic equivalents

65
Q

What is the minimum waiting period for certification after CABG?

A

Three months

66
Q

For what period of time can you certify a post CABG driver who meets requirements?

A

-One year

67
Q

How often must a post-CABG driver have a medical exam?

A

-Annually

68
Q

What requirements must the post CABG driver meet in order to become certified?

A

-At least three months post CABG
-asymptomatic
-ejection fraction equal to or greater than 40%
-sternal wound healed
-tolerates medications and has no orthostatic symptoms
-examined and approved by treating cardiologist

maximal certification period is one year

69
Q

There is a high rate of long-term reocclusion. Therefore, how frequently must a patient who has had CABG have an exercise tolerance test?

A

-ETT must be done yearly once the driver is five or more years post CABG
-must also do radionuclide stress testing or myocardial imaging if:
* stress test results are unsatisfactory
* dysrhythmia
* abnormal EKG
-annual medical exam

70
Q

Which regulation describes a cardiovascular standard?

A

49 CFR 391.41 (b) (4)

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