Cardiovascular Disability Updating the Social Security Listings (2010) / Chapter Skim
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7 Ischemic Heart Disease
7 Ischemic Heart Disease
Pages 101-132
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From page 101... ...
a flow diagram has been introduced that depicts five pathways to meet listings, including clinical, standard exercise testing, stress imaging, and angiographic anatomic criteria, with one pathway specific for patients with prior coronary artery bypass graft and severe Chd. because many patients with ischemic heart disease are unable to exercise, standard stress electrocardiographic criteria for ischemia (the sole determinant of objective ischemia assessment in prior cardiovascular disability listings)
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From page 102... ...
Ischemic heart disease, also called coronary heart disease (CHD) or coronary artery disease, is the term given to heart problems caused by narrowed heart (coronary)
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From page 103... ...
Class III is defined by marked limitation of ordinary physical activity such that angina is precipitated by walking one or two blocks on level ground, climbing one flight of stairs in normal conditions and at normal pace, playing a musical instrument, performing household chores, gardening, vacuuming, walking a dog, or taking out the trash. Class IV is defined by inability to carry on any physical activity without discomfort; anginal syndrome may be present at rest (Campeau, 1976, 2002; Goldman et al., 1981)
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From page 104... ...
However, this test is an invasive and relatively costly procedure associated with a low, yet definite, risk of an adverse event. Coronary angiography is most often performed following an abnormal stress test or in the setting of an acute coronary syndrome (unstable angina or heart attack)
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From page 105... ...
. Additionally, a more severely abnormal test result is associated with an increased likelihood of multivessel CHD and a worse prognosis.
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From page 106... ...
NOTE: BP = blood pressure; CHD = coronary heart disease; ESV = end systolic volume; ETT = exercise tolerance test; LVEF = left ventricular ejection fraction; SPECT = single-photon emission computerized tomography; SRS = summed reversibility score; SSS = summed stress score; TID = transient ischemic dilatation; WMA = wall motion abnormality; WMI = wall motion index. SOURCES: Dubach et al., 1988; Gibbons et al., 2002a,b; Klocke et al., 2003; McNeer, 1978; Pellikka et al., 2007.
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From page 107... ...
In addition to multiple coronary artery territories, other markers shown by imaging usually represent extensive ischemia. For nuclear imaging this marker is transient ischemic dilatation, or poststress dilatation of the left ventricle.
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From page 108... ...
Fixed/reversible regional wall motion abnormality Echocardiography ≥ 2 coronary territories Decrease in LVEF between rest and exercise Echocardiography Increase in ESV between rest and exercise NOTE: BP = blood pressure; ECG = electrocardiogram; ESV = end systolic volume; LVEF = left ventricular ejection fraction; METs = metabolic equivalents of task; PET = positron emission tomography; SPECT = single-photon emission computerized tomography. exercise or unable to achieve at least 85 percent of the age-predicted maximal heart rate with exercise, which is the effort level required to achieve adequate sensitivity to detect coronary artery stenosis capable of causing angina (Klocke et al., 2003; Pellikka et al., 2007)
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From page 109... ...
It is most useful in patients with an intermediate risk of coronary heart disease. In patients with extensive calcium deposits or prior coronary artery stents, detection of stenosis is difficult (Budoff et al., 2006)
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From page 110... ...
Clinical practice guidelines for the diagnosis and treatment of chronic stable angina (Fraker et al., 2007; Gibbons et al., 2002a) , unstable angina/ non-ST-segment elevation myocardial infarction (Anderson et al., 2007)
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From page 111... ...
EECP was shown to increase the time to ST-segment depression during exercise testing, reduce angina, and improve healthrelated quality of life for at least 1 year in a randomized, double-blind study of patients with chronic stable angina (Soran et al., 2006)
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From page 112... ...
. An analysis of NHANES CHD mortality data between 1980 and 2000 revealed that approximately 47 percent of the decline in mortality could be explained by the use of medical and surgical treatment (including secondary prevention therapies after myocardial infarction or revascularization, initial treatment of MI or unstable angina, treatment of heart failure, revascularization for chronic angina, and other therapies, including antihypertensive and lipid-lowering primary prevention strategies)
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From page 113... ...
. Although treatments are usually successful in decreasing symptoms and improving exercise tolerance, they do not necessarily result in a return to premorbid activities such as work.
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From page 114... ...
Persons who have been unemployed for an extended period of time have a more difficult time integrating into the workforce. Cardiac rehabilitation programs can address the physical and psychosocial matters necessary to return to work (Wenger et al., 1995)
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From page 115... ...
ISChEmIC hEaRt dISEaSE Occupational work evaluation programs that use simulated work conditions to identify physical and psychological workplace stresses may have a role for disability evaluations, but others suggest that standard clinical testing is sufficient to identify ability to work (Dennis, 1990; Mital et al., 2004)
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From page 116... ...
Disability and Functional Limitation Function with respect to cardiac disease is optimally assessed when the cardiovascular system is subjected to either physical or emotional stress testing; hence, numerous well-known stress-testing methods (both physical and emotional) have been developed, such as the step, bicycle ergometer, and exercise tolerance tests.
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From page 117... ...
. See Boxes 7-1 and 7-2 for the current adult and children ischemic heart disease listings.
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From page 118... ...
CaRdIoVaSCUlaR dISabIlIty BOX 7-1 Current Adult Listing for Ischemic Heart Disease 4.04 Ischemic heart disease, with symptoms due to myocardial ischemia, as described in 4.00E3–4.00E7, while on a regimen of prescribed treatment (see 4.00B3 if there is no regimen of prescribed treatment) , with one of the following: A. ign- or symptom-limited exercise tolerance test demonstrating at least one of S the following manifestations at a workload equivalent to 5 METs or less: 1. orizontal or downsloping depression, in the absence of digitalis glycoside H treatment or hypokalemia, of the ST segment of at least –0.10 millivolts (–1.0 mm)
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From page 119... ...
whenever the stress-testing information and symptom criteria are discrepant. For instance, if the records indicate that a claimant has functional Class IV symptoms, but he or she then performs a stress test and exer cises for 10 minutes, the results of the stress test should apply.
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From page 120... ...
procedures or two PCI and one coronary artery bypass graft [CABG] procedure)
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From page 121... ...
NOTE: ACE = angiotensin-converting enzyme; BMS = bare metal stents; DES = drug-eluting stent; HDL = high-density lipoprotein cholesterol; LDL = low-density lipoprotein cholesterol; LV = left ventricle; MI/ACS = myocardial infarction/acute coronary syndrome; PCI = percutaneous coronary intervention; TG = triglycerides. a Subject to modification, pending finalization and subsequent changes to American College of Cardiology/American Heart Association (ACC/AHA)
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From page 122... ...
+ LVEF < 5 0 % and/ or bypass graf ts + Prior CABG Listing Listing FIGURE 7-1 Coronary heart disease listings. NOTE: CABG = coronary artery bypass graft; CCS = Canadian Cardiovascular Society; Dx = diagnosis; LVEF = left igure 7-1.ejection fraction; METs = metabolic F ventricular eps equivalents of task; MI = myocardial infarction.
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From page 123... ...
No No No listing No listing No listing FIGURE 7-2 Coronary heart disease listings: Ischemic heart disease ladder flow diagram. NOTE: CABG = coronary artery bypass graft; CCS = Canadian Cardiovascular Society; ETT = exercise tolerance test; LVEF = left ventricular ejection fraction; Figure 7-2 new METs = metabolic equivalents of task.
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From page 124... ...
RECOMMENDATION 7-3. The committee recommends that patients with prior coronary artery bypass graft and either severe disease in native coronary arteries that have not been bypassed (greater than or equal to 50 percent stenosis in the left main artery or greater than or equal to 70 percent stenosis in the proximal or midportion of greater than or equal to two major native coronary arteries)
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From page 125... ...
2008. 2007 focused update of the ACC/AHA 2004 guidelines for the man agement of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 Writing Group to Review New Evi dence and Update the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction, writing on behalf of the 2004 writing committee.
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From page 126... ...
2006. Assessment of coronary artery disease by cardiac computed tomography: A scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology.
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From page 127... ...
2004. ACC/AHA 2004 guideline update for coro nary artery bypass graft surgery: Summary article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery)
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From page 128... ...
and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) : A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
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From page 129... ...
2010. Intensive multifactorial intervention for stable coronary artery disease: Optimal medical therapy in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation)
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From page 130... ...
2008. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting tech niques.
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From page 131... ...
1996. Return to work and quality of life measurement in coronary artery bypass grafting.
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