Cardiovascular Disability Updating the Social Security Listings (2010) / Chapter Skim
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5 Heart Failure, Cardiomyopathy,and Right Heart Failure
5 Heart Failure, Cardiomyopathy,and Right Heart Failure
Pages 77-96
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From page 77... ...
the recommendations are cognizant of the safety and utility of exercise testing, particularly if the exercise testing is combined with the determination of peak oxygen consumption. the recom mendations would also allow the functional limitation requirement to be met by repeated hospitalizations.
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From page 78... ...
The type of heart muscle weakness is often described by the pumping strength of the heart, measured by the left ventricular ejection fraction (EF)
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From page 79... ...
The most common causes are cardiomyopathy, which means weakness of the heart muscle not resulting from another cardiac diagnosis, and coronary artery disease, which causes irreversible damage to the heart muscle and has usually been preceded by a myocardial infarction (heart attack) , although these often occur silently.
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From page 80... ...
This condition is usually diagnosed by echocardiography, which reveals both abnormal thickness of the heart muscle and abnormal diastolic function. Hypertrophic cardiomyopathy is sometimes considered a type of diastolic heart failure, but it is often considered a separate diagnosis due to unique aspects of therapy and prognosis.
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From page 81... ...
This may be due in some cases to congenital underdevelopment of the right side of the heart, but more commonly develops later from chronic excess load on the right ventricle. Other conditions that can lead to the syndrome of right heart failure include tricuspid valve disease, pulmonary hypertension, pericardial disease, and atypical right heart response to left ventricular dysfunction, with less severe abnormality of left ventricular EF or diastolic dysfunction than required to meet criteria for systolic or diastolic heart failure as described above.
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From page 82... ...
. Medical therapy for patients with symptoms of systolic heart failure includes angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, beta adrenergic blocking agents, and diuretics as needed to control fluid retention, which may entail multiple changes and use of more than one diuretic.
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From page 83... ...
The recommended regimens for systolic heart failure may improve heart function as measured by increase in the EF and/or decrease in left ventricular enlargement. In general, the maximal impact of these therapies to improve objective cardiac function and exercise capacity may not be realized for 6 months or longer.
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From page 84... ...
. Exercise testing has been consistently demonstrated and widely accepted to be practical and safe for most patients with chronic heart failure (Balady et al., 2010)
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From page 85... ...
. For patients performing symptom-limited exercise testing without gas exchange to measure peak VO2, the level is defined by the estimated MET level of the exercise.
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From page 86... ...
CaRdIoVaSCUlaR dISabIlIty BOX 5-1 Current Listing for Chronic Heart Failure 4.02 Chronic heart failure while on a regimen of prescribed treatment, with symptoms and signs described in 4.00D2. The required level of severity for this impairment is met when the requirements in both A and B are satisfied. A. Medically documented presence of one of the following: 1. ystolic failure (see 4.00D1a(i)
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From page 87... ...
Functional assessment in the current listing is severely limited by the previous position that exercise testing posed significant risk to patients with heart failure. The assessment of clinical limitation without exercise testing thus has been highly subjective.
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From page 88... ...
Information regarding the frequency with which individual functional limitations are used as criteria is not currently accessible. CONCLUSIONS AND RECOMMENDATIONS After review of the current medical literature and related treatment and practice guidelines from ACC and AHA, the committee determined the chronic heart failure listing should be revised to include separate evaluation criteria for the following related conditions: chronic heart failure (both systolic and diastolic heart failure)
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From page 89... ...
: Moderate to severe diastolic dysfunction B (functional limitation) Any 1 of 3 Exercise Limitation Three < 15 ml/kg/min hospitalizations peak VO2 Cardiologist assessed: in 12 months with ≥ 1.1 RER Excess risk of exercise for hear t failure OR AND requiring < 5 METs with Cardiac limit to intravenous documented signs activities of daily living therapy or symptoms FIGURE 5-1 Recommended listing-level criteria for systolic and diastolic heart failure.
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From page 90... ...
An objective cardiac abnormality demonstrated by a left ven tricular or septal wall thickness greater than 15 mm in the ab sence of another known cause for left ventricular hypertrophy (e.g., hypertension, aortic valve disease)
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From page 91... ...
If these patients are identified by their physicians as having severe symptoms and being at excessive risk for exercise testing, they will meet the functional limitation criteria. • Hypertrophic cardiomyopathy excluded from exercise testing with cardiologist documentation of the following: o Major risk associated with exercise testing (see Recommenda tion 5-2)
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From page 92... ...
sufficient for listing would have to be documented by abdominal imaging, because it cannot reliably be distinguished from abdominal adiposity. Exercise Testing Based on its review of the 2010 ACC/AHA exercise guidelines, the committee concludes that the listing criteria to evaluate claimants for dis
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From page 93... ...
If standard exercise testing without gas exchange is the test information provided, objective evidence of true cardiac limitation can be as follows: • Signs may include fall in blood pressure, evidence of myocardial ischemia from ST-segment depression or elevation, or ventricular tachycardia. These will rarely be present.
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From page 94... ...
The occurrence of one such episode, even if specific therapy were required for termination, should trigger specific therapy of the arrhythmia and subsequent repeat exercise testing if a person is seeking disability under the heart failure criteria. Severe Reduction of Ejection Fraction An EF of 20 percent or less represents a decrease to less than one-third of normal heart pumping function.
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From page 95... ...
2010. Clinician's guide to cardiopulmonary exercise testing in adults.
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From page 96... ...
2000. Diastolic heart failure.
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