National Academies Press: OpenBook
Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
×

CARDIOVASCULAR DISABILITY

Updating the Social Security Listings

Committee on Social Security Cardiovascular Disability Criteria

Board on the Health of Select Populations

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
×

THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. SS-00-08-60149 between the National Academy of Sciences and the Social Security Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

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Copyright 2010 by the National Academy of Sciences. All rights reserved.

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Suggested citation: IOM (Institute of Medicine). 2010. Cardiovascular disability: Updating the Social Security listings. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES


Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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COMMITTEE ON SOCIAL SECURITY CARDIOVASCULAR DISABILITY CRITERIA

NANETTE K. WENGER (Chair),

Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia

WILLIAM E. BODEN,

University at Buffalo Schools of Medicine and Public Health and Kaleida Health, New York

BLASE A. CARABELLO,

Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas

ROBERT M. CARNEY,

Washington University School of Medicine, St. Louis, Missouri

MANUEL D. CERQUEIRA,

Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio

MICHAEL H. CRIQUI,

University of California, San Diego

ANDREW E. EPSTEIN,

University of Pennsylvania and Philadelphia Veterans Affairs Medical Center

ERIKA S. FROELICHER,

University of California, San Francisco

GARY H. GIBBONS,

Morehouse School of Medicine, Atlanta, Georgia

MARK A. HLATKY,

Stanford University, California

ALICE K. JACOBS,

Boston University School of Medicine and Boston Medical Center, Massachusetts

KAREN S. KUEHL,

George Washington University, Children’s National Medical Center, and Washington Hospital Center, Washington, DC

TODD D. MILLER,

Mayo Clinic, Rochester, Minnesota

LYNNE W. STEVENSON,

Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts

Consultant

HOWARD H. GOLDMAN,

University of Maryland School of Medicine, Baltimore

Study Staff

FREDERICK (RICK) ERDTMANN, Director,

Board on the Health of Select Populations

MICHAEL McGEARY, Study Director

SUSAN R. McCUTCHEN, Senior Program Associate

ERIN E. WILHELM, Research Associate

LAVITA D. COATES-FOGLE, Senior Program Assistant

PAMELA RAMEY-McCRAY, Administrative Assistant

SAMANTHA CHAO, Program Officer

JOI WASHINGTON, Senior Program Assistant

ANDREA COHEN, Financial Associate

WILLIAM McLEOD, Senior Librarian

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Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

James A. Blumenthal, Duke University Medical Center, Durham, North Carolina

Robert O. Bonow, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois

Deborah Chyun, New York University

David P. Faxon, Brigham and Women’s Hospital, Boston, Massachusetts

Gary S. Francis, Cleveland Clinic and Case Western Reserve University, Minneapolis, Minnesota

William L. Henrich, University of Texas Health Science at San Antonio

William R. Hiatt, University of Colorado, Denver

Stuart Rich, University of Chicago Medical Center, Illinois

Roberta G. Williams, University of Southern California and Childrens Hospital, Los Angeles

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Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Harlan M. Krumholz, Yale University, and Johanna T. Dwyer, Tufts University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Preface

The Committee on Social Security Cardiovascular Disability Criteria, an ad hoc committee of medical experts appointed by the Institute of Medicine (IOM), was charged to conduct a study to assist the Social Security Administration (SSA) with revising its criteria for cardiovascular disability in its Listing of Impairments (“the Listings”). The committee reviewed the current cardiovascular disability criteria in the Listings and identified areas in which the committee believed the cardiovascular listings should be revised and updated based on current medical knowledge and practice. Specifically, the committee (1) conducted a comprehensive review of the relevant research literature and current professional practice guidelines developed jointly by the American Heart Association and the American College of Cardiology; (2) assessed the current cardiovascular listings in light of current research knowledge and evidence-based medical practice; and (3) produced a concise report with specific recommendations for revision of the cardiovascular listings based on evidence (to the extent possible) and on professional judgment (where evidence was lacking). SSA uses the Listings to expedite the approval of claims from individuals who are so obviously disabled that they have a high probability of being found disabled if SSA went through the full disability determination process. The primary purpose of the consensus committee was to make concrete recommendations designed to improve the utility of the cardiovascular listings for evaluating disability claims by improving the sensitivity and specificity of the listing criteria to identify individuals who meet SSA’s definition of disability, that is, those who are no longer able to engage in substantial work activities.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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The contemporary approach to patient-centered care is designed to achieve optimal outcomes, including disease outcomes. This is the approach that the committee extended to tailor a process for disability evaluation that would ensure optimal outcomes.

The committee is grateful for the contributions of many individuals who expanded our knowledge and understanding of cardiovascular disability and suggested improvements in the disability evaluation process. They are listed in the Acknowledgments section of this report. The committee acknowledges with deepest appreciation the expert support and collegial relationship of the IOM staff. They are Michael McGeary (study director), Susan McCutchen (senior program associate), Erin Wilhelm (research associate), LaVita Coates-Fogle (senior program assistant), and Frederick (Rick) Erdtmann (director, Board on the Health of Select Populations).

The cardiovascular community has a tradition of evidence-based clinical practice guidelines that address a number of cardiovascular disease states. These guidelines are updated periodically to reflect current knowledge. A specific and uniform grading system identifies the level of evidence and the robustness of the database supporting this evidence. However, a review of the currently applicable clinical practice guidelines, although with abundant recommendations for diagnostic and prognostic testing, clinical management, and resultant outcomes, clearly shows (as viewed by the committee) an unmet need for a research base for the evaluation of cardiovascular disability.

The approach of the committee is its unique contribution. Careful review of the scientific literature from both primary and secondary sources was undertaken to identify tests or procedures that would quantify functional capacity and, furthermore, be generally available either in the claimants’ medical records or for purchase in the assessment of potential claimants. With this in mind, we sought to apply the best available knowledge and to recommend new practices and perspectives to ensure the optimal outcomes for disability claimants who meet SSA’s definition of disability.

Highlighted in the committee deliberations was that a large number of recently available cardiovascular test procedures precisely delineate anatomy or pathoanatomy, but that there is no consistent relationship between anatomy and functional capacity. The committee therefore concluded that the tests delineating anatomy should be used to define the presence and severity of disease, but that the disability process usually requires additional information on the functional limitations imposed by the disease. The committee recommended revisions in most of the current listings and suggested new listings for certain cardiovascular problems, including hypertrophic cardiomyopathy, right heart failure, and pulmonary hypertension. We developed flowcharts for decision making for most of the cardiovascular listings to assist the adjudicator in the definition of disease and levels

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
×

of functional limitations required to meet those listings. We also reviewed important comorbidities that the adjudicator should consider in assessing whether a claimant’s cardiovascular condition equals a listing. Finally, we delineated four areas of research that SSA could pursue to improve the disability decision process, including the listings.

The committee first met in December 2009, with three subsequent formal sessions in February, April, and June 2010 (and numerous conference calls), during which we categorized and evaluated cardiovascular medically determinable physical and mental impairments that could be expected to result in death or that have lasted or can be expected to last for a continuous period of not less than 12 months.

I would like to express my personal gratitude for the skills and dedication of the individual committee members and for their expertise, enthusiasm, and energy. On behalf of the committee, I would also like to thank Howard Goldman, who chairs IOM’s standing committee of medical experts to assist SSA, for his participation and advice.

The intellectual content is evidence based and objective. The conclusions were reached by consensus and are the combined judgment of the committee. Our emphasis in this report is on consistency, quality, and appropriateness criteria.

Future covariables that should influence disability determination and guide its research agenda include the impact of changes in the national and regional economy, changes in health insurance and access to health care and disease evaluation, and the expansion of the evidence base enabled by open government, among others. All are likely to alter cardiovascular disease outcomes and inform consequent cardiovascular disability determinations.


Nanette K. Wenger

Chair, Committee on Social Security Cardiovascular Disability Criteria

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Acknowledgments

Many individuals and organizations contributed to the study. In particular, the committee and staff would like to thank:

ROBYN BARST, Columbia University College of Physicians and Surgeons

AMY BASKEN, National Congenital Heart Association

MARGARET BEARDSWORTH, Pulmonary Hypertension Association

WILLIAM R. DAVIDSON, JR., Penn State Milton S. Hershey Medical Center

CHRISTINE DEHAAN, Social Security Administration

LAURENCE DESI, SR., Social Security Administration

ROBIN DOYLE, Social Security Administration

SHEILA EVERETT, Social Security Administration

HARRISON FARBER, Boston University

JAMES W. FASULES, American College of Cardiology

JOSEPHINE GRIMA, National Marfan Foundation

LARRY F. HAMM, American Association of Cardiovascular and Pulmonary Rehabilitation

MONTE HETLAND, Social Security Administration

JAMILLAH JACKSON, Social Security Administration

KATHERINE KRONER, Pulmonary Hypertension Association

VANESSA LEVINE, Alliance of Community Health Plans

GAVIN LINDBERG, Health and Medicine Council of Washington

JOANNA MARASHLIAN, Social Security Administration

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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PATRICK E. MCBRIDE, American Association of Cardiovascular and Pulmonary Rehabilitation

GREGORY L. MONETA, Oregon Health and Science University

MICHELLE J. NICKOLAUS, Penn State Milton S. Hershey Medical Center

MIKE O’CONNOR, Social Security Administration

RONALD J. OUDIZ, University of California, Los Angeles

KEVIN PARMER, Social Security Administration

JEFFREY PRICE, National Association of Disability Examiners (NADE) and North Carolina Disability Determination Services

J. SCOTT PRITCHARD, NADE and Oregon Disability Determination Services

FRANK SCHUSTER, Social Security Administration

PAUL SCOTT, Social Security Administration

ARTHUR R. SPENCER, Social Security Administration

SHIRLEETA STANTON, Social Security Administration

STEVEN STEINBERG, Social Security Administration

JANET TRUHE, Social Security Administration

AMY VERSTAPPEN, Adult Congenital Heart Association

CHERYL WILLIAMS, Social Security Administration

ROBERTA G. WILLIAMS, University of Southern California

In addition, the committee would like to thank those at the Social Security Administration headquarters and regional offices who helped arrange the visits of committee members to state disability determination services (DDS) offices and the staff in the DDSs who took the time to explain the disability determination process and how the Listings are used in that process, and to discuss practical problems encountered in using them.

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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Tables, Figures, and Boxes

TABLES

O-1

 

Current Adult and Child Cardiovascular Listings,

 

10

2-1

 

Numbers of Disability Program Beneficiaries and Benefit Amounts, 2008,

 

43

6-1

 

Survival Rates After Heart Transplantation, by Sex,

 

98

7-1

 

Canadian Cardiovascular Society Functional Classification of Angina,

 

103

7-2

 

Other Variables Associated with Multivessel CHD or Worse Prognosis,

 

106

7-3

 

Criteria to Meet a Listing Through the Use of an Exercise Stress Test,

 

108

7-4

 

Optimal Pharmacologic Therapy Based on the COURAGE Trial,

 

121

9-1

 

Clinical Classification of Chronic Venous Disease (CVD),

 

159

12-1

 

Characterization of Severe Valve Disease,

 

193

14-1

 

Normal Adult Thoracic Aortic Diameters,

 

215

B-1

 

Literature Table of Cardiovascular Employment and Disability Articles,

 

250

FIGURES

O-1

 

Five-step sequential evaluation process for adults,

 

8

2-1

 

Five-step sequential evaluation process for adults,

 

41

2-2

 

Disability evaluation process for Supplemental Security Income children,

 

45

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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3-1

 

Annual number of initial adult cardiovascular claims, 1990–2008,

 

56

3-2

 

Annual allowance rate for initial adult cardiovascular claims, 1990–2008,

 

57

3-3

 

Annual percentage of initial adult allowances made on the basis of the cardiovascular listings, 1990–2008,

 

58

3-4

 

Annual number of initial adult allowances based on the cardiovascular listings, 1999–2009,

 

59

3-5

 

Percentage of adult initial allowances based on the cardiovascular listings, by selected impairment code, 1989–2008,

 

60

5-1

 

Recommended listing-level criteria for systolic and diastolic heart failure,

 

89

5-2

 

Recommended listing-level criteria for hypertrophic cardiomyopathy,

 

91

5-3

 

Recommended listing-level criteria for right heart failure,

 

92

7-1

 

Coronary heart disease listings,

 

122

7-2

 

Coronary heart disease listings: Ischemic heart disease ladder flow diagram,

 

123

10-1

 

Documentation of congenital heart defect likely to require surgery, diagnosis of significant heart disease in infancy or childhood,

 

171

10-2

 

Documentation of congenital heart defect likely to require surgery, disabled by Groups A and B, birth to age 12,

 

171

10-3

 

Documentation of congenital heart defect, disabled by Group C, ages 12 to 18,

 

172

10-4

 

Documentation of congenital heart defect disabled as adults, ages 18 and over,

 

173

11-1

 

Meeting criteria for disability due to pulmonary hypertension,

 

187

12-1

 

Determining listing-level disability for claimants with valvular heart disease,

 

192

BOXES

1-1

 

Cardiovascular Committee’s Statement of Work,

 

37

4-1

 

Committee’s Approach to Revising the Listings,

 

65

5-1

 

Current Listing for Chronic Heart Failure,

 

86

6-1

 

Current Listing for Heart Transplant,

 

98

7-1

 

Current Adult Listing for Ischemic Heart Disease,

 

118

7-2

 

Current Childhood Listing for Ischemic Heart Disease,

 

119

8-1

 

Current Listing for Peripheral Arterial Disease,

 

144

8-2

 

1.00 Musculoskeletal System,

 

150

9-1

 

Current Listing for Chronic Venous Insufficiency,

 

160

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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10-1

 

Current Congenital Heart Disease Listing for Children,

 

174

10-2

 

Current Congenital Heart Disease Listing for Adults,

 

175

13-1

 

Current Listing for Recurrent Arrhythmias,

 

204

14-1

 

Current Listing for Aneurysm of Aorta or Major Branches,

 

215

B-1

 

Definition of Tiers,

 

249

C-1

 

American College of Cardiology/American Heart Association (ACC/AHA Guidelines),

 

271

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Abbreviations and Acronyms

AAA abdominal aortic aneurysm

ABI ankle-brachial index

ACC American College of Cardiology

ACE angiotensin-converting enzyme

ACS acute coronary syndrome

ADLs activities of daily living

AHA American Heart Association

ALJ administrative law judge

AR aortic regurgitation

AVNRT atrioventricular nodal reentrant tachycardia

AVRT atrioventricular reentrant tachycardia

BMI body mass index

BMS bare metal stents

BNP brain natriuretic peptide

BP blood pressure

BRFSS Behavioral Risk Factor Surveillance System

CABG coronary artery bypass graft

CAD coronary artery disease

CCB calcium channel blocker

CCS Canadian Cardiovascular Society

CDC Centers for Disease Control and Prevention

CDR continuing disability review

CE consultative examination

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Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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CHD chronic heart disease

cm centimeter

COPD chronic obstructive pulmonary disease

CPX cardiopulmonary exercise

CT computed tomography

CTA computed tomography angiography

CVD cardiovascular disease; chronic venous disease

CVI chronic venous insufficiency

CXR chest x-ray

DDS disability determination services

DES drug-eluting stent

DM diabetes mellitus

Dx diagnosis

ECG electrocardiogram

EECP enhanced external counterpulsation

EF ejection fraction

ESV end systolic volume

ETT exercise tolerance test

EVAR endovascular aneurysm repair

FDA Food and Drug Administration

HDL high-density lipoprotein cholesterol

HF heart failure

HFpEF heart failure with preserved ejection fraction

IADLs instrumental activities of daily living

ICD implantable cardioverter-defibrillator

ICD International Classification of Diseases

IHD ischemic heart disease

IOM Institute of Medicine

kg kilogram

LA left atrial/atrium

LDL low-density lipoprotein cholesterol

LED lower extremity disease

LV left ventricle

LVDD left ventricular diastolic dysfunction

LVEF left ventricular ejection fraction

LVOT left ventricular outflow tract

Suggested Citation:"Front Matter." Institute of Medicine. 2010. Cardiovascular Disability: Updating the Social Security Listings. Washington, DC: The National Academies Press. doi: 10.17226/12940.
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m meter

MER medical evidence of record

MESA Multi-Ethnic Study of Atherosclerosis

METs metabolic equivalents of task

MI myocardial infarction

MIE medical improvement expected

min minute

MINE medical improvement not expected

MIP medical improvement possible

ml milliliter

mm millimeter

mm Hg millimeters of mercury

mph miles per hour

MR mitral regurgitation

MRA magnetic resonance angiography

MRI magnetic resonance imaging

NHANES National Health and Nutrition Examination Survey

NHLBI National Heart, Lung, and Blood Institute

NPRM Notice of Proposed Rulemaking

NRC National Research Council

NT-proBNP N-terminal prohormone brain natriuretic peptide

O2 oxygen

PAD peripheral artery disease

PCI percutaneous coronary intervention

PET positron emission tomography

PO2 partial pressure of oxygen

POMS Program Operations Manual System

proBNP prohormone brain natriuretic peptide

PVC premature ventricular contraction

PVD peripheral vascular disease

RER respiratory exchange ratio

RFC residual functional capacity

SD standard deviation

sec second

SGA substantial gainful activity

SIP Sickness Impact Profile

SPECT single-photon emission computerized tomography

SRS summed reversibility score

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SSA Social Security Administration

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

SSS summed stress score

TA thoracic aorta

TBI toe-brachial index

TG triglycerides

TID transient ischemic dilatation

Torr Torricelli

U.S. United States

VHD valvular heart disease

VO2 oxygen consumption

WHO World Health Organization

WMA wall motion abnormality

WMI wall motion index

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The Social Security Administration (SSA) uses a screening tool called the Listing of Impairments to identify claimants who are so severely impaired that they cannot work at all and thus immediately qualify for benefits. In this report, the IOM makes several recommendations for improving SSA's capacity to determine disability benefits more quickly and efficiently using the Listings.

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