The number that matters is 140/90. At or below it, and with no hypertension history, blood pressure does not shorten your certificate (a driver on treatment may still get one year). Above that, up to 159/99 (Stage 1), the guidance allows a one-year card; 160/100 to 179/109 (Stage 2) allows a one-time three-month card to get treatment working; 180/110 and above (Stage 3) means no card until the pressure is 140/90 or lower on tolerated treatment, then six-month cards. These figures come from FMCSA's Medical Advisory Criteria, which are guidance: the rule itself, 49 CFR 391.41(b)(6), has no number, and the certified medical examiner decides.
What the rule says
49 CFR 391.41(b)(6) is one line: a person is physically qualified if the person has no current clinical diagnosis of high blood pressure likely to interfere with the ability to operate a commercial motor vehicle safely. It sets a judgement, not a threshold. The thresholds sit in Appendix A to Part 391, the Medical Advisory Criteria, which FMCSA revised on 19 January 2024 (89 FR 3577). The appendix introduction says they are strictly advisory and do not have the force and effect of law. They are still the reference examiners work from: 391.43(c)(1) requires examiners to be knowledgeable of those advisory criteria.
The stages, from paragraph E of the Medical Advisory Criteria
| Reading | Stage | What the guidance says |
|---|---|---|
| 140/90 or lower | Within the target | With no hypertension history, no blood pressure limit on the certificate: the ordinary maximum is 24 months (391.45(b)). A driver on treatment whose earlier severity the examiner does not know: annual certification recommended (E.6). |
| Systolic 140 to 159 and/or diastolic 90 to 99 | Stage 1 | Low risk. May be certified for 1 year. At later annual exams the reading should be 140/90 or lower; if it is above 140/90 but below 160/100, a one-time 3-month certificate to bring it down to 140/90 or lower. |
| Systolic 160 to 179 and/or diastolic 100 to 109 | Stage 2 | An absolute indication for drug treatment. One-time 3-month certificate to start or adjust treatment and reach 140/90 or lower. If treatment is tolerated and the reading is 140/90 or lower, certify for 1 year. |
| 180 systolic and 110 diastolic or higher | Stage 3 | High risk. Not qualified, even briefly, until reduced to 140/90 or lower with treatment well tolerated. Then 6 months, and every 6 months after that if the recheck is 140/90 or lower. |
The wording is worth reading exactly. Stages 1 and 2 are defined by systolic "and/or" diastolic, so either number alone can put you in the stage. The Stage 3 sentence in the appendix reads "at or greater than 180 (systolic) and 110 (diastolic)".
The other paragraphs of E that decide cases
- E.1, confirmation. An elevated reading should be confirmed by at least two subsequent measurements. The MCSA-5875 form has room for a second reading, which the instructions call optional and to be recorded when found necessary.
- E.2, what actually matters. Hypertension alone is unlikely to interfere with safe driving, but the likelihood rises with target organ damage, particularly cerebrovascular disease. The stages are based on FMCSA's 2002 Cardiovascular Advisory Panel guidelines, which adopted the sixth Joint National Committee report of 1997.
- E.6, unknown history. Annual certification is recommended if the examiner does not know how severe the hypertension was before treatment. This is why a driver on blood pressure medicine with a good reading often still gets a one-year card.
- E.7, the medicines themselves. Treatment includes drug and non-drug measures. Most blood pressure drugs have side effects such as somnolence or syncope, which must be weighed individually, and drivers should be told the drugs may affect their driving.
- E.8, secondary hypertension. Certified on the same stages. Evaluation is warranted if a person stays hypertensive on maximal or near-maximal doses of two or three drugs.
The examiner may always certify for less than the maximum when closer monitoring is needed; the form offers 3 months, 6 months, 1 year or another period under "meets standards, but periodic monitoring required".
Why you may have heard different numbers
Older articles quote a table from a 2013 expert panel report. FMCSA's January 2024 notice on the Medical Examiner's Handbook (89 FR 3892) says commenters found that table vague and confusing, that FMCSA agreed, removed it from the Handbook, and continued the guidance in the Medical Advisory Criteria. The same notice says FMCSA is researching the topic and will update the Handbook if the final report warrants it. So the table above is the current guidance as published; if you read something else, check its date.
Guidance, not a formula
Drivers sometimes treat the stage table as a scoring sheet. FMCSA describes it differently. Its January 2024 notice on the Medical Examiner's Handbook (89 FR 3892) says the Handbook tells examiners they are free to choose whether to use guidance and recommendations as a basis for decisions, and that words such as "recommend", "consider", "may", "should" and "could" are used in a recommendatory or permissive sense. The binding part is 391.41(b)(6) and the examiner's duty under 391.43 to decide. The stages are still the published guidance, and 391.43(c)(1) requires examiners to know it, but an examiner who certifies a controlled Stage 1 driver for less than a year, or who wants more information before deciding, is within the rule.
Blood pressure is only part of the heart exam
High blood pressure has its own standard, but the cardiovascular standard in 391.41(b)(4) is separate: no current clinical diagnosis of myocardial infarction, angina, coronary insufficiency, thrombosis or other cardiovascular disease known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure. Paragraph C of the Medical Advisory Criteria adds three points that often come up alongside blood pressure:
- C.1: "current clinical diagnosis" is meant to cover a current condition or one that has not fully stabilized.
- C.2: coronary artery bypass surgery and pacemaker implantation are remedial procedures and do not preclude certification; implantable cardioverter-defibrillators address an ongoing condition and are likely to cause syncope or collapse.
- C.3: anticoagulation should not by its use alone preclude certification.
A driver with well-controlled blood pressure but a recent cardiac event is therefore judged under (b)(4), not under the stage table.
Blood pressure and the length of your card
Putting paragraph E together with the interval rule in 391.45:
- No hypertension diagnosis, reading 140/90 or lower: up to 24 months.
- Treated hypertension, reading 140/90 or lower, severity before treatment unknown to the examiner: 1 year recommended (E.6).
- Stage 1 at the exam: 1 year (E.3).
- Stage 2: 3 months, once, then 1 year if controlled (E.4).
- Stage 3: no certificate until controlled, then 6 months at a time (E.5).
How the certificate interval works more generally, including when a new exam is needed early, is on the certificate validity page.
Worked examples
These apply the published guidance to invented readings. They are illustrations, not predictions; the examiner decides every case.
Example 1: first-time high reading
A new applicant with no history of hypertension reads 152/94, then 150/92 and 148/93 on two rechecks later in the visit. Confirmed Stage 1 under E.1 and E.3. The guidance allows a 1-year certificate. At next year's exam she should be at or below 140/90; if she reads, say, 146/94, the guidance allows a one-time 3-month certificate to bring it down.
Example 2: Stage 2 at renewal
A driver reads 168/102, confirmed. Under E.4 he may receive one 3-month certificate to start or adjust treatment. He returns within the three months at 136/86, tolerating his medicine. The guidance allows a 1-year certificate from there.
Example 3: Stage 3
A driver reads 186/114. Under E.5 he should not be qualified at all, even for a short period. The examiner may place the exam in pending status for up to 45 days under 391.43(g)(4) or find him not qualified; a not-qualified finding ends any earlier certificate under 391.43(g)(3). Once treatment brings him to 140/90 or lower and is well tolerated, he may be certified for 6 months at a time.
What examiners look at besides the number
- The health history: question 7 of the MCSA-5875 asks about high blood pressure, and questions 5 and 6 ask about heart disease and heart procedures, which fall under the separate cardiovascular standard in 391.41(b)(4).
- Your medication list and whether the drugs cause drowsiness or fainting (E.7).
- Signs of target organ damage (E.2).
- Whether the reading is confirmed (E.1).
- The urinalysis. The form records protein, blood and sugar and notes that their presence may be a reason for further testing to rule out an underlying problem, which is one of the ways an examiner looks beyond the cuff reading.
- The body-systems exam, which includes the cardiovascular and vascular systems as separate items, each marked normal or abnormal with an explanation of any abnormal finding.
After a short card
- Book the recheck early. A three-month card is designed as a window to get treatment working. If you return on the last day and the examiner needs more information, the pending status allowed by 391.43(g)(4) does not extend your current certificate, according to FMCSA's 2024 Handbook notice.
- Bring the evidence. The name of the drug, the dose, when it started, and any readings your doctor has taken.
- Another examiner is allowed, with the same information. The same notice says a driver may seek a second opinion and examination from another examiner, but is expected to give both the same medical information.
- A not-qualified finding ends the old card. Under 391.43(g)(3), all previously issued certificates stop being valid.
Intrastate drivers
The MCSA-5875 has a second determination block, "Medical Examiner Determination (State)", for exams performed under 391.41 to 391.49 with any variances a state has adopted. The form says those determinations are valid only for intrastate operations. If you drive only within one state, your state may apply different rules, including on blood pressure; this page covers the federal guidance only.
"How do I lower my blood pressure for the DOT physical?"
This page cannot give medical advice, and the rules do not reward a one-day fix: the guidance asks for confirmed readings and looks at history and treatment. What the rules do make clear is practical. Take your prescribed medicine as your doctor directed, list it on the form, bring any home readings or records your doctor has, and do not leave the exam to the last day on your card, because a Stage 2 or 3 reading can mean a short certificate or none. Talk to the doctor who treats you, before the exam, about any change to treatment.
Common mistakes
- Stopping blood pressure medicine to avoid questions. The form asks about both the condition and the drugs, and a false answer falls under 390.35.
- Treating 140/90 as a pass mark for everyone. A treated driver at 138/88 may still get one year under E.6.
- Ignoring the three-month card. In Stages 1 and 2 it is described as one-time.
- Reading an old table. The 2013 table was removed from the Handbook in 2024.
To find a certified examiner near you, use the DOT physical directory. The full list of physical standards is on the DOT physical requirements page, and the visit itself is described on what happens at a DOT physical.