Cardiovascular Disability Updating the Social Security Listings (2010) / Chapter Skim
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Pages 5-34
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From page 5... ...
SSA uses the Listings as a screening tool early in the disability determination process to identify applicants (referred to as claimants in this report) for benefits who are so severely impaired that further information about their vocational capacity or other factors, such as age, educational attainment, and work history, is not needed to rule favorably on their claims for disability benefits.
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From page 6... ...
program, a child is "considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months." The SSA disability standard is not based on a diagnosis or on degree of anatomical impairment alone. Rather, it focuses on the functional limitations imposed by one or more impairments and how they affect an individual's capacity to work given the limitations caused by the medical impairment or impairments and his or her age, education, and work history, or in the case of children, how the impairment or impairments limit ageappropriate activities at home, at school, and in the community.
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Step 1 The SSA field office determines whether the claimant is engaging in substantial gainful activity.3 If yes, the claimant is found not disabled. If no, the claim is forwarded to the disability determination services (DDS)
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Considering the individual's residual functional capacity (RFC) and Yes the physical and mental demands of the work he or she did in the past, is the Not individual able to perform past relevant work?
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CARDIOVASCULAR DISABILITY TRENDS Currently, there are eight adult cardiovascular system listings and five child-specific listings (Table O-1) .7 (If a child has a condition not included in the child-specific cardiovascular listings, e.g., an aortic aneurysm, he or 6 In general, RFC is what the individual can still do in a work setting despite the limitations from all of his or her medical impairments, including any impairments that are not severe.
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From page 10... ...
Chronic heart failure (CHF) accounted for 42 percent of the listings-based allowances in 2009, followed by chronic venous insufficiency (21 percent)
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2. If the diagnosis is not sufficient by itself to be a listing-level cri terion, determine if there is an accepted measure of impairment severity shown to have a high degree of association with incapac ity to work or with very serious functional limitations that would seem to preclude work.
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From page 12... ...
Maximizing the Use of Exercise Testing The introductory section of the cardiovascular system listings highlights the extensive use of exercise tests to determine functional capacity in patients with ischemic heart disease, CHF, and peripheral artery disease. The text also indicates that SSA might purchase an exercise test if needed to determine whether a claimant's impairment or impairments meet or equal a cardiovascular listing; however, the current Listings are based on an overly strict assessment of the risk associated with the performance of these tests.
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From page 13... ...
An objective cardiac abnormality demonstrated by a left ven tricular ejection fraction of 30 percent or less (or an ejection fraction of a systemic ventricle in congenital heart disease with out an anatomic, systemic left ventricle) , or a left ventricular diameter of 7 cm or greater, AND
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From page 14... ...
Three hospitalization-equivalent events in the past 12 months. Diastolic Heart Failure The criteria for diastolic heart failure should include: A
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From page 15... ...
RECOMMENDATION 5-3. Add an additional listing route in which the objective cardiac abnormality of a left ventricular ejection fraction of 20 percent or less, documented twice with at least 3 months inter vening, is sufficiently severe that demonstration of functional limitation is not needed to meet the listing.
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From page 16... ...
Ischemic means that an organ is not getting adequate blood and oxygen. Ischemic heart disease, also called coronary artery disease or coronary heart disease (CHD)
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From page 17... ...
Approximately every 34 seconds, an American has an MI, and in 15 percent of the cases it is fatal. In addition, in 2006, 1,115,000 inpatient diagnostic cardiac catheterizations were performed as well as 661,000 inpatient percutaneous coronary interventions (PCIs)
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From page 18... ...
: Ischemic re sponse defined by ST-segment depression of greater than or equal to 1 mm measured 0.08 seconds after the J-point that is horizontal or downsloping in configuration or ST-segment elevation greater than or equal to 1 mm in leads without q waves or fall in systolic blood pressure greater than or equal to 10 mm Hg below resting systolic blood pressure at a work load of less than or equal to 5 metabolic equivalents of tasks; OR 3. Stress-imaging test: Ischemic response with either exercise or pharmacologic vasodilator stress indicated by greater than or equal to two reversible and/or fixed regional myocardial per fusion defects during nuclear testing and transient ischemic dilation or resting left ventricular ejection fraction (LVEF)
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From page 19... ...
Exercise treadmill tests are used to provide objective evidence of the degree of the functional limitations of PAD, identify any non-PAD exercise limitations, and determine the safety of prescribing an exercise program, as well as to measure the response to therapy. Treadmill testing is not suitable for patients who, due to age or other reasons, are not able to exercise enough to allow reliable results.
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From page 20... ...
The recommendation for improving the PAD listing as an early screening tool is to supplement the medical diagnostic and severity requirements with evidence of severe functional limitations. Because the path to disability for PAD is functional limitation to mobility, the committee recommends using the same criteria for lower extremity disability used in the musculoskeletal listings.
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From page 21... ...
Current criteria B, C, and D in listing 4.12 should be replaced by a new criterion B that an appropriate test or tests be consistent with severe PAD, when the ABI is 0.50 or greater or there is evidence of medial calcification of the ankle arteries. These tests should include the toe-brachial index, Doppler wave forms, duplex ultrasonography, magnetic resonance angiography, computed tomography angiography, contrast angiography, and graded treadmill tests.
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From page 22... ...
Individuals with congenital heart disease may develop cardiac complications such as arrhythmias, heart failure, or valve insufficiency, even after surgical correction of the structural abnormalities. Surgery is the mainstay of treatment for congenital heart disease.
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Functional limitations may develop at any age, however, due to the development of arrhythmia, heart failure, endocarditis, or pulmonary hypertension, among other problems. The committee's recommendations for improving the congenital heart disease listings for adults and children (4.06 and 104.06)
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Symptomatic acyanotic heart disease interfering seriously with the ability to independently initiate, sustain, or complete activities; OR D Chronic heart failure manifested by: 1.
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RECOMMENDATION 10-5. Children age 12 and older should be considered disabled if they have congenital heart disease documented by appropriate medically acceptable imaging or cardiac catheterization, with one of the following criteria: A
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Single ventricle, including hypoplastic left heart syndrome, double inlet left ventricle, and Fontan operation for single ventricle; OR E Chronic heart failure manifested by: 1.
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Single ventricle including hypoplastic left heart syndrome, double inlet left ventricle, and Fontan operation for single ventricle; OR E Diagnosis of congenital heart disease and chronic heart failure manifested by: 1.
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OR B Evidence of moderate pulmonary hypertension, which imposes severe functional limitation on many but not all individuals, includes any of the following: • Recurrent syncope secondary to pulmonary hypertension; or • Right heart failure (same criteria as for heart failure list ing)
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From page 29... ...
Severe symptomatic mitral stenosis, aortic regurgitation, or mitral regurgitation may also warrant disability at the listing level, but these patients must demonstrate functional limitation in addition to an objective diagnosis of severity.
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From page 30... ...
Objective evidence is measured by one of the following: • Severe mitral stenosis characterized by mean gradient greater than 10 mm Hg, pulmonary artery systolic pressure greater than 50 mm Hg, and valve area less than 1.0 cm2; or • Severe aortic regurgitation characterized by regurgitant volume greater than or equal to 60 ml/beat, and regurgitant orifice area greater than or equal to 50 cm2, and increased left ven tricular size; or • Severe mitral regurgitation characterized by regurgitant volume greater than or equal to 60 ml/beat or regurgitant fraction greater than or equal to 50 percent, and regurgitant orifice area greater than or equal to 0.40 cm2, and enlarged left atrial size and enlarged left ventricular size. Functional limitation(s)
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From page 31... ...
RECOMMENDATION 13-1. Revise listing 4.05 to define arrhythmias as recurrent episodes of tachycardia or bradycardia documented by electrocardiography or other appropriate medically acceptable testing; that cause cardiac syncope, near syncope, or other debilitating symp toms; are not due to a reversible cause; do not respond to prescribed treatment; and very seriously limit the ability to independently initiate, sustain, or complete activities of daily living or instrumental activities of daily living.
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From page 32... ...
An aneurysm or dissection may com promise organ function and produce symptoms by the com pression of other structures in the tissue or body compartment or induce ischemia by compromising the flow of blood to the heart, kidneys, brain, or other organs; • Revise the effects of aneurysm or dissection to include: An aneurysm or dissection can cause heart failure, renal (kidney) failure, or neurological complications.
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From page 33... ...
Depression has a significant, negative impact on the overall functional capacity of affected individuals and increases morbidity and mortality. Other prevalent conditions that combine with cardiovascular disease to increase functional limitations include diabetes mellitus, chronic obstructive pulmonary disease and other respiratory diseases, and obesity.
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From page 34... ...
. disability evaluation under Social Security (blue book)
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