The cardiovascular system contains a large and complicated variety of diseases that can adversely affect an individual's ability to perform work activity.  In the cardiovascular system, there are two components to consider when addressing limitations.  Those components are physical and psychological in nature and both may be present in any given case.  The physical components (or symptoms) of cardiovascular diseases include chest pain, SOB (shortness of breath), dyspnea, weakness and fatigue 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 disorders such as diabetes.

     The psychological component of cardiac disease is 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 which causes a real decrease in the patient's ability to function. Because the pathology of cardiovascular disorders are so complex, we will center our discussion around the explanation of symptom-generated limitations and their supportive evidence.
 

General Evaluation 

     When evaluating diseases of the heart and vessels for physical restrictions, you must focus on the specific symptomatic characteristics of that particular disease state.  Since each disease may be radically different in symptom and etiology, the actual symptoms of the disorder should be used as your guide to identifying and highlighting any physical limitations.

     Supportive evidence can also be very complex in these types of disorders and may be technically above your head.  You can overcome this shortfall by focusing on the conclusion or summaries which are often present with cardiovascular tests.  We will identify some of the typical heart tests and cardiac disease symptoms so that you can identify them for your argument.

     With such a complex system of diseases, you must take the time to refer to other medical texts in order to have a true understanding of how these disorders can affect your client.  It would be impossible, given the limitations of this text, for us to supply all of the interactions which can occur between the cardiovascular system and other disease states.  However, we will attempt to supply you with some of the most common disease interactions.

    The following is a list of the most commonly seen disorders of the cardiovascular system.   Following this list, there will be a brief discussion of each listed disorder pointing out any 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 valvular defects.  Essentially any abnormal functioning or structural defect of a heart valve will manifest itself as one of the above diagnosis.  Heart valve defects usually cause symptoms which are associated with the particular valve which is affected.  Generally individuals with one of these disorders will experience dyspnea, fatigue, chest pain, lightheadedness and heart palpitations. Supportive diagnostic tests include angiocardiography, echocardiography and cardiac catheterization.   These complicated test will usually show the actual structural defect and are perfect tools to use in support of your argument.

     When evaluating an individual with a valvular disorders, keep in mind 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.  A few claimants will refuse to undergo such a procedure.  If claimant refuses to undergo surgical correction of a valvular disorder, SSA must accept his decision and base their disability decision on the extent of the claimant's physical limitations.

Essential hypertension:

     Essential hypertension (or high blood pressure) may be of a singular or unknown etiology.   This disorder is perhaps the most common secondary allegation seen in disability cases.  Generally, hypertension has no overt symptoms, although it is still a very dangerous disorder.  Hypertension has been shown to be linked to strokes, heart attacks and other lethal disease states.   Hypertension may also be caused or affected by renal disease and may be an indication of a serious kidney disorder.

     Symptoms of advanced or poorly controlled HBP include headaches, dizziness, nosebleeds and fatigue.  Complications of hypertension include heart failure, artherosclerotic heart disease, bleeding in the eye, decreased vision, strokes and brain damage.  With poorly controlled hypertension, the claimant's physical activity should be moderated.  You should evaluate this disorder as to how it may affect other underlying disorders as well as its effects on other organ systems.  If the claimant has a history of artherosclerotic heart disease and HBP, consider further limiting his activities due to the additional danger caused by the presence of the 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 BP (blood pressure) should be rechecked at least twice on each visit to rule out the usual stress or activity effect on blood pressure.  If the pressures are consistently high (140/100) or greater, the doctor must then try 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 HBP, use it to the claimant's advantage.

Acute myocardial infarction:

     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 pain, SOB, diaphoresis, and extreme apprehension on the part of the patient.  Evaluation of this disorder would begin with the diagnosis made at the time of the initial hospitalization.  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, which will verify the existence of the disorder.  You will have no trouble showing that claimant has had a heart attack, but it is not so easy to prove that the condition is totally disabling.

   SSA has several tricks which are used to deny claimants with cardiac disorders.  First, most claimants are placed on what is called a medical hold until three months have passed since the MI.  Then the claimant's condition is reevaluated to see if there has been any improvement.  SSA will send the claimant a cardiac questionnaire asking specific questions about his chest pain and current physical activities.  If the claimant describes no chest pain or the chest pain is described incorrectly, the claimant can be denied.  The denial will be based on duration with the assumption that the claimant's condition has improved or will improve.

     A denial can also occur if the claimant states that he is able to perform physical activity.  This activity evaluation by SSA is subtle and the claimant may inadvertently admit to taking walks, etc.   SSA will then interpret this increase in activity as proof that the claimant's condition is improving.  This is the primary reason why you were instructed to always be aware of any questionnaires sent to claimant by SSA and to help the claimant fill them out.

     Another trick of the trade is the treadmill test.  Usually about three months after a heart attack, a patient's doctor will order an exercise treadmill test to see how claimant responds to mild exercise.  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 the test.

     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:

    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.  SSA 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.  It is important that you are 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.  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 well usually respond favorably to rest and medication within minutes.  Cold weather, stress and other external factors can bring on or make the condition worse.

     The number and duration of attacks can vary greatly.  Angina does not usually cause sharp pain or a burning sensation.  These types of symptoms are usually of 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 overlooked by SSA.

Ischemic heart disease:

     Ischemic heart disease is a catch-all category which refers to any disorder caused by decreased blood flow to the muscles of the heart.  This interruption of circulation to the muscles of the heart is what causes a heart attack.  The primary symptoms are crushing chest pain and decreased 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 category for disorders which cause abnormal beating of the heart.  Any abnormal beat of the heart which occurs with some regularity can be placed into this category of cardiac impairments.  A fast, slow or irregular heart beat will fall under this category.  These disorders are usually diagnosed on physical examination.  Generally an exercise or resting EKG will be performed to verify this disorder.

     Cardiac dysrhythmias are usually the result of an abnormality in the electrical impulse apparatus of the heart.  Symptoms of these disorders range from a simple awareness of 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 RFC in accordance with the symptoms.  For example, you would want to restrict a construction worker with a symptomatic arrhythmia from working at heights.

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 as a result of damage to the chamber muscles of the heart.   This chamber 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, would eventually damage or destroy all tissues and organs of the heart.

     CHF can manifest itself with symptoms of SOB, dyspnea, fluid in lungs, venous hypertension, reduced blood flow to kidneys, liver and other organs.  These symptoms can result in all out heart failure and death of the patient.  The most alleged symptoms of this disorder will be weakness, easy fatiqability 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 RFC if there is any evidence that the disorder or damage caused by it remain.

Aneurysm:

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

Venous disorders:  

    This category of impairments include such disorders as phlebitis, thrombophlebitis 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 standing and walking.

    These conditions can also be complicated by other disease states such as diabetes, heart disease and injuries to the vessel itself.  The most common symptoms of these disorders are tenderness of involved areas, pain, swelling, discoloration and circulatory interference to the distal sites of the hands and feet.  If the diseased vessels are in the calf area for example, this may reduce blood circulation to the foot and toes which represents the distal site of the involved limb.

     A claimant with 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 coronary artery bypass, valve replacement or major arterial grafts, use these events as the reason to further lower the claimant's RFC.   

     Even if the claimant has had good results from the surgery you should still lower the RFC.  If  the claimant is now complaining of cardiac symptoms, you must play up his surgical history to strengthen your overall argument.  It is also important to note if the claimant has undergone the same surgery twice.  This is another strong indication of a serious and progressive disorder.