The physical components or symptoms of cardiovascular disease include chest pain, shortness of breath, dyspnea (difficulty breathing), weakness and easy fatigability just to name a few.  Diseases of the circulatory system are bad enough in and of themselves, but can be made worse in the presence of other chronic disorders such as diabetes.

The psychological component of cardiac disease may also play a role in determining a claimant's ability to perform work.  Most psychological components are associated with the claimant's fears or anxieties concerning his disease state.  Very often a person suffering from a heart condition will actually fear normal activity.  These fears can cause additional stress that can worsen the claimant's condition, further reducing his ability to function.  Because the pathology of cardiovascular disorders are so complex, we'll center our discussion around the explanation of symptom-generated limitations and their supportive evidence.  
 

General Evaluation of Evidence 

When evaluating diseases of the heart and vessels to identify physical limitations, you should focus on the specific nature and symptomatic characteristics of the disease in question.  Since cardiovascular disorders can be radically different in symptom and etiology, it is best to use the claimant's symptoms as your guide to identifying and highlighting physical limitations.  Using symptoms allows you to target the effects of the cardiac disorder without necessarily understanding the underlying disease.

Because of the complex nature of heart disease, supportive evidence can be confusing.  You can overcome this complexity by focusing on the medical summaries provided with most cardiac patient records.  However, with such a complex array of cardiac diseases, you should take the time to refer to medical texts like the Merck Manual to learn more about the specific disorders affecting your client. 

The following is a short list of the most commonly seen disorders of the cardiovascular system.  Following this list, I'll provide a brief discussion of each disorder, pointing out special disability criteria you should note.

Valvular disorders
Rheumatic heart disease
Essential hypertension
Hypertensive vascular and renal disease
Acute myocardial infarction
Angina pectoris
Chronic ischemic heart disease
Cor pulmonale
Cardiomyopathy
Cardiac dysrhythmias
Heart failure
Aortic aneurysm
Peripheral vascular disease
Congenital abnormalities of the heart
 

Valvular disorders

Valvular disorders of the heart include such diseases as mitral valve prolapse, mitral stenosis, aortic, tricuspid and pulmonic valve defects.  Essentially any abnormal functioning or structural defect of a heart valve will fall within the category of hear valve disease.  Heart valve defects usually cause symptoms that are associated with the particular valve that is affected.  Generally, individuals with significant heart valve disease will experience dyspnea, fatigue, chest pain, lightheadedness and heart palpitations.  Supportive diagnostic tests include angiography, echocardiography and cardiac catheterization.  These diagnostic test will usually show the structural defect in the valve and can be used to support both the diagnosis of heart disease and its symptoms.

When evaluating an individual with heart valve disease, focus on the functional limitations caused by the symptoms of the disorder.  Most of these defects can be surgically corrected, although this may involve open heart surgery.  More than a few claimants will refuse to undergo such a dramatic procedure.  If the claimant refuses to undergo surgical correction of a valve, Social Security must accept the claimant's decision.  This means that Social Security will have to base their decision on the claimant's medical evidence and perceived physical limitations.  Social Security cannot demand that a claimant undergo any type of invasive procedure in order to receive disability benefits.

Essential hypertension

Essential hypertension, also known as high blood pressure, is a common disorder that may be of unknown etiology.  I've seen numbers with hypertension as high as sixty percent of a population over the age of fifty.  This disorder is one of the most common secondary allegations seen in Social Security disability cases.  Generally, hypertension has no overt symptoms, although it is still a very dangerous disorder.  Hypertension has been shown to be linked to kidney disease, strokes, heart attacks and other lethal diseases.  Hypertension is also caused and/or affected by renal disease and may be an indication of a serious underlying kidney disorder.

 Symptoms of advanced or poorly controlled hypertension include headaches, dizziness, nosebleeds and fatigue.  Complications of hypertension include heart failure, retinal bleeding, strokes and brain damage.  With poorly controlled hypertension, the claimant's physical activities should be moderated.  You should evaluate hypertension to see how it may affect other underlying disorders and organ systems.  If the claimant has a history of artherosclerotic heart disease with hypertension, consider further limiting his activities due to the additional danger caused by the presence of high blood pressure.  

Supportive evidence of hypertension is determined by getting at least three blood pressure checks over a period of a few weeks.  The blood pressure should be rechecked at least twice on each visit to rule out the usual stress or activity effect on a blood pressure reading.  If the pressures are consistently high, above 140/90, a doctor needs to pinpoint the cause.  Sometimes this disorder can be treated by weight loss or a change in dietary habits.  Despite this fact, if the claimant has hypertension, try to use it to the advantage of the claimant.  Keep in mind that hypertension alone will never result in an allowance determination for Social Security disability benefits.


Acute myocardial infarction (MI)

Acute myocardial infarction is called by several other names such as heart attack and ischemic heart disease.  This disorder is commonly seen among male individuals applying for disability benefits.  The symptoms of this disorder can include chest pressure, acute or chronic chest pain on exertion, shortness of breath, diaphoresis and extreme apprehension on the part of the patient. 

Evaluation of an acute infarction is usually made in an emergency room.  Usually a patient who has suffered an MI will show elevated cardiac enzyme levels.  These enzymes are referred to as LDH, CPK and SGOT.  The claimant will also have changes on his EKG, formally called an electrocardiogram.  An EKG can be used to confirm the existence of a serious cardiac disorder.  In this disease, you should have no trouble showing that a claimant has had a heart attack.  But it is not so easy to prove that the claimant's MI is totally disabling.

Social Security has several tricks that it uses to deny claimants with acute cardiac disorders.  One of these tricks is to place the claimant on what is called a medical hold.  A medical hold means that the case will sit at the DDS for three months to give the claimant time to recover.  If the claimant shows improvement during the medical hold period, the case will be denied on duration. 

Social Security will also send the claimant a cardiac questionnaire asking specific questions about his chest pain and current physical activity level.  If the claimant describes no chest pain or the chest pain is described incorrectly, the claimant could be denied.  Again, the denial will be based on duration with the assumption made by Social Security that the claimant's condition has or will improve before one year.

A denial can also occur if the claimant states that he is able to perform physical activity.  This activity evaluation by Social Security may be subtle.  If the claimant admits to taking walks without experiencing chest pain or fatigue, this could result in a denial decision.  Any increase in the claimant's physical activity can be used by Social Security as evidence of an improving condition.  This is why it is important for the advocate to see and assist the claimant in filling out questionnaires sent by Social Security. 

Another trick used by Social Security to deny acute onset cardiac patients is the treadmill test.  Usually about three to six months after a heart attack, a patient may undergo an exercise treadmill test to see how he responds to mild exertion.  If the claimant undergoes this procedure and is shown to be able to do about four to five METS, the claimant will again be denied.  We suggest that you do not allow your client to take a treadmill test unless it is ordered by the claimant's attending physician, not Social Security.

SSA cannot force an invasive test on the claimant.  The best excuse the claimant can give for not wanting to take such a test is fear of the test or induced chest pain.  Individuals who have suffered a MI are usually very apprehensive about physical exertion.  This type of anxiety can lead to depression or phobias which could be as restrictive to the claimant's ability to work as the disease.

Angina Pectoris (Chest Pain)

Angina (chest pain) is not a disease, but a symptom.  Its causes range from an infection of the bony joints of the chest wall to deep pressure-like pain caused by ischemic heart disease.  Many claimants who have heart conditions may allege that the chest pain is a result of the heart condition.  Social Security will then send the claimant a chest pain questionnaire as a means of ruling out chest pain of cardiac origin.  If the claimant describes the chest pain incorrectly, there is a possibility that a denial decision could be made.  For this reason, it is important that the disability advocate be aware of standard descriptions for chest pain of cardiac origin.

Chest pain of cardiac origin is usually felt beneath or just to the left of the sternum.   It may be vague or it may be intense with a crushing or pressure-like sensation in the chest.  The pain may radiate to the left shoulder or jaw or it may be described as radiating down the left arm and into the fingers.  Angina is most often described as being triggered by physical exertion and relieved by rest and nitroglycerin.  The duration of attacks is usually short and the patient will usually respond favorably to rest and medication within minutes.  Cold weather, stress and other external factors can bring on or make the pain worse.

The number and duration of chest pain attacks can vary greatly.  Angina usually does not cause a burning sensation in the chest.  Chest pain of cardiac origin also does not increase with pressing on the chest wall.  These types of chest pain symptoms are more closely associated with inflammation or gastrointestinal origin.   If your client receives a chest pain questionnaire, be sure to assist him in filling it out in order to avoid having this potentially serious symptom disregarded by Social Security.
 

Ischemic heart disease

Ischemic heart disease is a catch-all category that refers to any disorder caused by decreased blood flow to the muscles of the heart.  An interruption of circulation to the muscles of the heart is what causes a heart attack.  The primary symptoms are acute and crushing chest pain and severely limited exercise tolerance.  Supportive evidence for this condition includes EKGs, cardiac enzyme test, cardiac catheterization and myocardial imaging.

If the claimant has been diagnosed as having ischemic heart disease, one or all of the above tests will be a part of his medical records.  Do not overlook findings on physical examination such as abnormal heart sounds on x-ray, diaphoresis and response to oral nitroglycerin.  If nitro stops the pain, this response is indicative of ischemic heart disease.


Cardiac dysrhythmias

Cardiac arrhythmia is a catch-all term for disorders that cause abnormal beating of the heart.  Any abnormal beat of the heart that occurs with some regularity can be placed into this category of cardiac impairments.  A fast, slow or irregular heart beat will fall under the category of a cardiac dysrhythmia.  These disorders are usually diagnosed on physical examination or during an exercise or resting EKG.

Cardiac dysrhythmias are usually the result of an abnormality in the electrical impulse apparatus of the heart.  Symptoms of these disorders range from the simple awareness of a fast or slow heartbeat by the claimant, to weakness, dizziness, pre-syncope, oxygen deprivation of the brain and fainting episodes.  If the claimant has a diagnosis of a heart arrhythmia with symptoms, restrict the residual functional capacity in accordance with the symptoms.  For example, you may want to restrict a construction worker with a symptomatic arrhythmia from performing high exertion work at heights above ten feet.

Heart failure:

Congestive heart failure (CHF) is a serious condition in which the heart fails to properly propel blood to the rest of the body.  Heart failure can be caused by several physiological circumstances, including infections that damage the chamber muscles of the heart.  Heart chamber muscle damage decreases the heart's ability to forcefully eject blood to the rest of the body.  Heart failure can cause congestion of the lungs and diminished blood flow to the tissues of the body.  This condition, if not treated promptly, eventually damages or destroys cardiac output and kills the patient. 

CHF can manifest itself with symptoms of shortness of breath, difficulty breathing, fluid in the lungs, venous hypertension, reduced blood flow to kidneys, liver and other organs.  The most alleged symptoms of this disorder will be weakness, easy fatigability and difficulty breathing (dyspnea).  If a claimant has this disorder, do not allow the performance of an exercise stress test.   A treadmill test is contraindicated for anyone with a history of CHF.  Although this condition is treatable, anyone who has had CHF should be given a significantly reduced residual functional capacity even if there is no evidence of obvious damage.

Aneurysm

An aneurysm is a condition in which there is a rupturing of a vessel causing bleeding into interstitial spaces.  This condition can cause massive bleeding and decreased blood flow to the original circulatory site.  Aneurysms are caused by the weakening of the wall of a vessel that may lead to its eventual rupture. The seriousness of this condition is determined by the degree of vessel occlusion and the effect on the organ the vessel feeds.   An aneurysm occurring in the brain for example, may cause loss of cerebral function and death.  

Determining limitations caused by this disorder should focus on the effects it has on the involved organ.  If the aneurysm occurred in the brain, look for limitations in everything from speech to memory.  Document the specific residual limitation and show how the limitation has reduced the claimant's ability to perform work.


Peripheral vascular disease: 

Peripheral vascular disease is another catch-all category of impairments that include such disorders as arterial occlusion, arteritis and Raynaud's disease.  These conditions involve circulatory interference within a vessel, infections of the wall of the vessel or an abnormal functioning of the vessel itself.   In Raynaud's for example, there are arteriole wall spasms in response to cold stimuli, which essentially cuts off the circulation to the fingers and toes.  Although this condition is intermittent, it would still limit a claimant's ability to work outside or in other cold environments that might trigger the Reynaud response.

Venous disorders

This category of impairments include such disorders as phlebitis and varicose veins.  These conditions usually affect the lower limbs and can cause a significant decrease in circulation to these areas.  A claimant will usually complain of extreme pain and may have problems with standing and walking.  Venous disorders can also be complicated by other disease states such as diabetes, heart disease and trauma to the vessel itself.  The most common symptoms of venous disorders are tenderness of involved vessels, pain, swelling, discoloration and circulatory interference to the distal sites of the involved limb.  If the diseased vessels are in the calf area, for example, this may reduce circulation to the foot and toes, which represents the distal site of the involved limb.  A claimant with venous vessel disease may have difficulty standing and walking.  He should be limited according to these symptoms.  The claimant may also have ulcerations of the involved limbs, which is a sign of serious circulatory deficiency.
 

Heart Surgery

If the claimant has a history of major cardiac surgery such as a coronary artery bypass, valve replacement or arterial grafts, use these events to expend the claimant's recovery period and reduce the claimant's residual functional capacity.  Even if the claimant has had good results from a surgery, you should still lower his residual functional capacity.  It takes time to recovery from surgeries of this magnitude, and the claimant may never regain his former physical capabilities.  If a claimant has had heart surgery but is complaining of current cardiac symptoms, you must play up his surgical history to strengthen your overall argument for a reduced RFC. It is also important to note if the claimant has undergone the same surgery twice.  If he has, this is another strong indication that the claimant has both a serious and progressive disorder. 

If you address the issues as set forth in this report concerning claimants with severe heart conditions, you'll be able to extract enough supportive evidence to produce at least a fair argument for disability. 

There are several other important considerations when evaluating cardiac disorders that are not discussed here.  For additional information about cardiac disorders and how they are evaluated by Social Security, see full discussion link.