Impairments involving the heart are one of the most challenging areas of evaluation for the disability consultant. This report will focus on how SSA views the three month post-cardiac episode period in the evaluation of a cardiac case. In this report, we will use as our example one of the most common of cardiac impairments, the Myocardial Infarction.

The Myocardial Infarction

A Myocardial Infarction or MI is commonly referred to as a "heart attack". The physiological cause of a myocardial infarction is the blockage of a coronary artery. Coronary arteries feed oxygen enriched blood to the muscular layers of the heart. The muscles of the heart are responsible for the pumping action that results in the circulation of blood throughout the body. As with any muscle, if it is starved of oxygen, it will usually demonstrate noticeable symptoms. Specifically, if one or more coronary vessels are blocked, the result will be ischemic damage to the affected cardiac muscle. The term ischemic is used here to describe the denial of oxygen to the heart muscle which is the underlying cause of the dynamic symptoms seen in MI patients.

Evaluating a Myocardial Infarction

Despite the seriousness of a myocardial infarction, it is by no means an automatic allowance under Social Security disability policy. To win a disability case on a person with ischemic heart disease, you must pay careful attention to the claimant's medical history, symptoms and objective medical findings.

Medical History

It is not uncommon for an otherwise healthy appearing individual to suffer an acute myocardial infarction. If the claimant does not die, he/she will be incapacitated for a period of time while recovery is occurring. SSA has set the standard recovery period for an acute MI at three to six months. The degree of recovery is generally determined by the claimant's quality of care and the extent of the underlying damage to the heart muscle. If the damage to the heart is minor, the claimant may experience almost full recovery. If cardiac damage is severe, involving a major portion of the heart, no amount of treatment will bring the claimant back to his previous level of physical performance. In other words, SSA will be looking for signs of cardiac improvement within six month from the date of the actual event. What SSA is looking for is a condition called maximum medical improvement. If improvement occurs and is of a degree great enough to allow the claimant to return to some level of work, SSA will deny the case.

In response to the different levels of potential damage to cardiac tissue, Social Security will rarely make a determination of a case involving an acute Myocardial Infarction until at least three months post ischemic episode. This minimum three month time frame is used by Social Security for the following reasons:

1. To allow for healing and recovery from the condition.

When a person suffers an acute MI, he should not immediately apply for disability benefits. It is wiser to allow for the three month recovery period as does SSA, before trying to determine if maximum medical improvement has occurred. Normally, the claimant will also be receiving intense medical treatment during the recovery phase. This data is primarily used by SSA to establish the existence of the impairment. If the claimant applies immediately after an MI, SSA will simply place the case on what is called an administrative hold. This action by SSA essentially places the case in limbo until the end of the three month recovery period.

Once the recovery period has ended, SSA will begin documenting the claimant's condition in order to establish maximum medical improvement. If the medical evidence shows significant improvement of the claimant's cardiac condition, SSA will create an RFC and deny the case using the usual sequential approach.

2. To allow for medical treatment and documentation.

Medical evidence produced during the recovery period is used by SSA primarily as a means of establishing a diagnosis and the degree of injury to the heart. This evidence is also used to determine the effects of treatment during the recovery phase. Unless the claimant has suffered multiple cardiac episodes or undergone bypass surgery, SSA will usually not make a decision based solely on medical evidence generated during the three month recovery phase.

The most important documentation will be generated after the recovery period! If the claimant shows continued uncontrolled symptoms such as exertional chest pain after the recovery period, this will help the consultant to argue for a reduced RFC that could result in an allowance determination. Therefore, the claimant's medical history prior to and at least six months post MI become extremely important in the evaluation of a cardiac case. SSA is specifically interested in determining how the impairment affects the claimant's ability to perform work three to six months post MI. If the claimant has not improved by six months post MI, SSA has the option of making a decision or sitting on the case for another three months as they document the claimant's progress. If the claimant has made no significant improvement in his ability to work by nine months post MI, the chances for an allowance increase significantly.

3. To determine the nature of symptoms after the optimal recovery period has passed.

Once the three month recovery period has passed, SSA will slowly document a cardiac case to see if symptoms improve. If the claimant shows improvement six months or less into the condition, SSA will deny the case on a duration basis. That is, SSA will make a determination that the impairment is not expected to prevent all work for twelve continuous months. This of course is called a duration denial.

To avoid a duration denial, the consultant must pay careful attention to the claimant's cardiac signs and symptoms in the post recovery period. This period can last up to nine months from the date of the cardiac episode. However, in most cases the claimant will reach maximum improvement by six months or so into the condition. The consultant can then use the same documentation as SSA to argue that although some improvement may have occurred, it is not enough to allow the claimant to return to work. Depending upon the medical findings, the claimant's age, education and other factors, the consultant should argue that the claimant is not capable of adjusting to any type of work activity. In doing so, the consultant is essentially creating an opposing RFC that would result in an allowance determination for the claimant.

Post recovery period signs and symptoms

SSA will base their decision on the claimant's signs and symptoms in the post recovery period. The consultant should use these same signs and symptoms to support their argument for disability. The following is a list of the most important medial signs and symptoms used to establish a cardiac disability under the Social Security disability process:

Medical Signs

Signs are slightly more important than symptoms in the evaluation of a disability case because the results are objective. That is, signs represent test results that cannot be altered or manipulated by the claimant. Therefore, if a sign points to a serious impairment or a physical restriction, it is valuable ammunition in your argument for disability. The medical tests listed below are considered to be definitive in diagnosing serious post myocardial damage.

Electrocardiograph (ECG)

Exercise test

Cardiac Catherization

Coronary arteriography

The above clinical tests are used to determine both diagnosis and the degree of damage to cardiac tissue. If the claimant demonstrates significant residual cardiac insult in the post recovery period, one or more of these tests will show it. If a test is positive, the consultant can use the results to argue for a reduced RFC that could result in an allowance determination.

Cardiac Symptoms

As medical signs are valuable in establishing the existence of an impairment, symptoms are valuable in establishing a condition's physical effects upon the claimant. The most important physical symptoms in the post recovery period of a person who has suffered a myocardial infarction are fatigue, dysnia (difficulty breathing) and chest pain.

The most important of the symptoms is exertional chest pain also known as angina pectoris. SSA will almost always ask for a description of the claimant's post recovery period chest symptoms. The usual description of angina will be chest discomfort described as pressure, acute left or mid chest discomfort, which is sharp, sticking or cramping. The pain usually occurs with activity and/or emotional stress. Chest pain of cardiac origin is usually relieved by rest or sublingual nitroglycerin. SSA will also ask for a description of chest pain timing, inciting factors, character, location, radiation, duration and response to nitrates and rest. The wrong description of chest pain could be taken by SSA as proof that the claimant does not have chest pain of cardiac origin. Therefore, the consultant must be careful in making sure that the chest symptoms are properly documented and described.

If the claimant is having no chest pain or if the pain is easily controlled by medication, SSA will probably deny the case based on medical improvement. If the chest pain is mild to moderate and somewhat controlled by medication, claimant will be given a reduced RFC by SSA that may or may not result in an allowance. If the claimant has severe chest pain on exertion with only sporadic relief from medication, the claimant has the best chance of receiving benefits.

Again, none of the claimant's symptoms will be decisive in making a disability determination until at least three months post MI. The exception to this rule would be for claimants with serious medical complications associated with their heart condition. Claimants who suffer from serious additional impairments such as diabetes that further compromise their recovery or claimants who have undergone a previous cardiac surgery, may also be allowed benefits before the end of the three month recovery period.