4.04 Ischemic heart disease, with symptoms due to myocardial ischemia, as described in 4.00E3-4.00E7, while on a regimen of prescribed treatment (see 4.00B3 if there is no regimen of prescribed treatment), with one of the following:
To better understand these Listings, please read the “Ischemic Heart Disease and Disability” article on this website first.
If you are not under the care of a doctor and receiving medication for ischemic heart disease (IHD), the Social Security Administration (SSA) will base its evaluation of your condition on what evidence it has available to them. And if this is the case, the limited evidence may hurt your chances for getting disability benefits.
If you are not on prescribed treatment for IHD, SSA would not be able to find that you “meet” all of the requirements of the 4.04 Listings because these Listings require that you be on a regimen of prescribed treatment. This doesn’t mean you won’t be found disabled, but it may make it harder to be found disabled under SSA’s rules.
However, SSA may find you disabled if you have another condition (impairment) that in combination with your heart condition medically “equals” the severity of a Listing. SSA will also take into account your residual functional capacity (functional ability), age, education, and work experience.
SSA may decide your claim favorably on the basis of the evidence available to them, but a longitudinal record (information about your condition over time) is most important. In rare instances where there is no or insufficient longitudinal medical evidence, SSA may purchase a consultative examination (CE) to help them establish the severity and duration of your heart condition.
For more information on a Consultative Exam (CE), see the “Consultative Exam” article on this website.
A. Sign- or symptom-limited exercise tolerance test demonstrating at least one of the following manifestations at a workload equivalent to 5 METs or less:
As discussed in the section on Chronic Heart Failure, metabolic equivalents of task (METs) is a measure of exercise capacity. For disability purposes, SSA looks at the level of METs you achieve on an exercise (treadmill) stress test.
Approximately 3 METs are required for walking, sitting, or other such low level activities levels.
5 METS is approximately three minutes of walking on a typical Bruce protocol exercise stress test.
Important: In general, if you are unable to walk for three minutes on a Bruce protocol exercise stress test due to symptoms of heart disease, you would fulfill this component of the Listing. Be aware, there are other types of protocols used for exercise stress tests, and different walking times on the treadmill will reflect a different number of METS achieved. Be sure your doctor clarifies how many METS you were able to achieve on the exercise stress test.
1. Horizontal or downsloping depression, in the absence of digitalis glycoside treatment or hypokalemia, of the ST segment of at least -0.10 millivolts (-1.0 mm) in at least 3 consecutive complexes that are on a level baseline in any lead other than aVR, and depression of at least -0.10 millivolts lasting for at least 1 minute of recovery; or
An ST segment is the part of the ECG tracing found just after the QRS complex (usually the biggest blip on an ECG). Reduced blood flow to the heart muscle (myocardial ischemia) on a stress test may show as depression OR elevation of the ST segment from the baseline ECG tracing. “Baseline” means the ECG tracing before you start walking on the treadmill.
Listing-level changes on the ECG in 4.04A1 are the typical changes of horizontal or downsloping ST depression occurring both during exercise and recovery. “Recovery” means the period after stopping the exercise stress test.
SSA recognizes that sometimes ECG changes on an exercise stress test that appear to be ischemic may at times be false positive. “False positive” means that the ECG changes appear ischemic but there is no true ischemia (lack of blood flow to the heart).
If ECG changes are suspected as being false positive, additional nuclear medicine (radionuclide) imaging or an echocardiogram (ECHO) with the stress test is required for confirmation of true ischemia. This issue will be decided by the doctors involved in your case, but just know that this situation may exist.
A more typical situation is when an exercise stress test is performed with a nuclear imaging study or ECHO, and the ECG portion shows ischemia, but the imaging study shows no ischemia. In this instance, the imaging or ECHO portion of the study would take precedence over the ECG findings because the imaging portion of the test is considered more accurate than the ECG portion of the stress test.
For Listing 4.04A1, SSA requires that the depression of the ST segment of the exercise ECG last for at least 1 minute into recovery. This is because ST depression that occurs during exercise but rapidly normalizes in recovery is a common false-positive response, i.e., not true ischemia.
2. At least 0.1 millivolt (1 mm) ST elevation above resting baseline in non-infarct leads during both exercise and 1 or more minutes of recovery; or
4.04A2 specifies that the ST segment elevation must be in non-infarct leads (those ECG leads that don’t show evidence of a prior heart attack) during both exercise and recovery. This is because, in the absence of ECG signs of prior infarction (heart attack), ST elevation during exercise suggests ischemia, usually severe, requiring immediate termination of the exercise stress test.
However, if there is baseline (prior to exercise) ST elevation due to a prior infarction (heart attack) or ventricular aneurysm (weakness in wall of ventricle), further ST elevation during exercise does not necessarily indicate ischemia and could be a false-positive ECG response, i.e., no true ischemia. Diagnosis of ischemia in this situation requires additional nuclear medicine (radionuclide) imaging or an echocardiogram (ECHO) for confirmation of the ischemia.
3. Decrease of 10 mm Hg or more in systolic pressure below the baseline blood pressure or the preceding systolic pressure measured during exercise (see 4.00E9e) due to left ventricular dysfunction, despite an increase in workload; or
Listing 4.04A3 requires a 10 point drop in systolic blood pressure below the baseline (prior to exercise) level taken in the standing position immediately prior to exercise. Or a 10 point drop below any systolic pressure reading recorded during exercise.
Systolic blood pressure (SBP) is the top number of a blood pressure reading.
SSA is specifically looking for a 10 point drop in SBP due to “ischemia-induced left ventricular dysfunction,” meaning that poor blood supply to the left ventricle causes reduced functioning of the left ventricle resulting in a drop in the blood pressure during the exercise stress test.
If the drop in blood pressure occurs early (during the first three minutes of exercise), SSA will look to see whether this was due to medication or if it was due to an increased sympathetic response. An increased sympathetic response means that early in the exercise stress test, the blood pressure may be higher than usual due to nervousness or deconditioning (out of shape) of the person undergoing the stress test.
Bottom line: If a 10 point drop of SBP occurs during the first three minutes of an exercise stress test, be sure your doctor clarifies to SSA that this drop was due to "ischemia induced left ventricular dysfunction."
4. Documented ischemia at an exercise level equivalent to 5 METs or less on appropriate medically acceptable imaging, such as radionuclide perfusion scans or stress echocardiography.
In certain cases, exercise treadmill stress tests are combined with a nuclear (radionuclide) imaging study or echocardiography (ECHO) to help make the stress test more accurate than using an ECG tracing alone. Also, a nuclear imaging scan may be useful for detecting or confirming ischemia when resting ECG abnormalities, medications, or other factors may decrease the accuracy of ECG interpretation of ischemia.
Perfusion imaging may be done before and at the end of the exercise stress test to compare the images at rest and images that may change due to stressing the heart. Comparing these images of the heart before and after the stress test helps to show if ischemia is reversible. “Reversible” ischemia on imaging means the imaging portion of the stress test had a change in appearance from before and after the stress test indicating stress induced ischemia.
Imaging studies may show ischemia before and after the stress test, but if it does not change, then that ischemia may be due to a scar on the heart from a prior heart attack. In that case, the ischemia is not considered reversible, and the stress test results would not fulfill the criteria for this Listing.
Since some perfusion imaging may be done at the end of the exercise, any reversible ischemia showing up here may be at a higher MET level than that at which ischemia truly first occurs. If the imaging portion of the test shows reversible ischemia, the exercise ECG may be useful to show that ischemia occurred earlier (at a lower MET level) than which it appeared in the nuclear imaging part of the test.
Exercise tests may also be performed using echocardiography (ECHO) to detect stress-induced ischemia and left ventricular dysfunction.
Medical consultants working for SSA will look to see if there are abnormalities on the ECG or imaging part of the stress test showing ischemia occurring at or less than a level of 5 METs. (See the discussion above about METs).
Drug-induced stress test results are not measured in METS (because you don’t walk on a treadmill), and therefore cannot be used to meet this Listing.
OR
B. Three separate ischemic episodes, each requiring revascularization or not amenable to revascularization (see 4.00E9f), within a consecutive 12‑month period (see 4.00A3e).
“Ischemic episodes requiring revascularization” means surgical interventions for unstable angina or a heart attack to open up a coronary artery or arteries, such as with cardiac catheterization and angioplasty plus or minus stenting, or coronary artery bypass grafting (CABG).
A consecutive 12-month period means a period of 12 consecutive months, all or part of which must occur within the period SSA is considering in connection with an application or continuing disability review.
Each of the three ischemic episodes within a consecutive 12-month period must require revascularization or be not amenable to treatment. “Not amenable to treatment” means that the revascularization procedure could not be done because of another medical condition or because the obstructed coronary artery was not suitable for revascularization.
A coronary artery that becomes blocked again after a revascularization procedure but during the same hospitalization, and that requires a second procedure during the same hospitalization will not be counted as a separate ischemic episode.
OR
C. Coronary artery disease, demonstrated by angiography (obtained independent of Social Security disability evaluation) or other appropriate medically acceptable imaging, and in the absence of a timely exercise tolerance test or a timely normal drug-induced stress test, an MC, preferably one experienced in the care of patients with cardiovascular disease, has concluded that performance of exercise tolerance testing would present a significant risk to the individual, with both 1 and 2:
“Angiography demonstrating coronary artery disease” means a cardiac catheterization where dye is shot into the coronary arteries revealing blockage(s). SSA will not purchase angiography.
“Other appropriate medically acceptable imaging” may include radionuclide imaging scans, stress echocardiography (ECHO), scans of the coronary arteries by magnetic resonance imaging (MRI), computed tomography (CT), or electron-beam tomography (EBT).
SSA will use 4.04C only when you have symptoms due to myocardial ischemia while on a regimen of prescribed treatment, you are at risk for exercise testing, and SSA does not have a timely exercise stress test or a timely normal drug-induced stress test for you.
SSA considers stress test results to be timely for 12 months after the date they are performed, provided there has been no improvement or worsening of your heart condition.
However, an exercise test that is older than 12 months, especially an abnormal one, can still provide important information about your heart condition. A test that is more than 12 months old can give SSA longitudinal (over time) evidence about the severity of your ischemic heart disease, information on your aerobic (functional) capacity, and information about the duration or onset of your condition.
When SSA evaluates a test that is more than 12 months old, SSA must consider the results in the context of all the relevant evidence, including why the test was performed and whether there has been an intervening event or improvement or worsening of your heart condition.
An SSA medical consultant (MC) will generally give great weight to your treating doctor’s opinion about the risk of exercise testing to you, and will generally not override it. In the rare situation in which the MC does override your treating doctor's opinion, the MC must prepare a written rationale documenting the reasons for overriding the opinion.
If you do not have a treating doctor or SSA cannot obtain a statement from your treating doctor, the MC is responsible for assessing the risk to exercise testing based on a review of the records SSA has before purchasing an exercise test for you.
SSA considers exercise stress testing a “significant risk” when the following conditions exist:
- Unstable angina not previously stabilized by medical treatment.
- Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise (abnormal changes in blood pressure and/or heart rate).
- An implanted cardiac defibrillator.
- Symptomatic severe aortic stenosis.
- Uncontrolled symptomatic heart failure.
- Aortic dissection (tearing of the lining of the aorta).
- Severe pulmonary hypertension (pulmonary artery systolic pressure greater than 60 mm Hg) - elevated blood pressure in the lungs.
- Left main coronary stenosis of 50 percent or greater that has not been bypassed.
- Moderate stenotic valvular disease with a systolic gradient across the aortic valve of 50 mm Hg or greater.
- Severe arterial hypertension (systolic greater than 200 mm Hg or diastolic greater than 110 mm Hg).
- Hypertrophic cardiomyopathy with a systolic gradient of 50 mm Hg or greater.
SSA also will not purchase an exercise test when you are prevented from performing exercise testing due to another impairment affecting your ability to use your arms and legs.
1. Angiographic evidence showing:
a. 50 percent or more narrowing of a nonbypassed left main coronary artery; or
b. 70 percent or more narrowing of another nonbypassed coronary artery; or
c. 50 percent or more narrowing involving a long (greater than 1 cm) segment of a nonbypassed coronary artery; or
d. 50 percent or more narrowing of at least two nonbypassed coronary arteries; or
e. 70 percent or more narrowing of a bypass graft vessel;
“Nonbypassed” means a coronary artery that impedes blood flow to the heart muscle because the flow has not been restored through coronary artery bypass grafting (CABG).
AND
2. Resulting in very serious limitations in the ability to independently initiate, sustain, or complete activities of daily living.
Listing 4.04C requires both a specific blockage of a coronary artery and significant functional limitations in daily activity because of this blockage.
Part 2 of this Listing is rather vague in its criteria of “very serious limitations,” but suffice to say that SSA will want to see documentation by both you and your treating doctor(s) of VERY significant limitations in your day-to-day functional ability.
Give a detailed description to your disability case manager of how you are limited by your heart condition. Describe what you are able to lift and carry, for how long and how far, and the exact symptoms you experience when you attempt normal every day activities. Describe any fatigue, chest pain, weakness, and shortness of breath. Clarify what household chores and self-care you are able to do, and if you are able to travel and do such things as grocery shop or go to the post office.
It is very important that your treating doctor describe, in either forms supplied by SSA or in a letter, exactly why and how you are limited by your heart condition. A good way for your doctor to end the letter is for him or her to say, “Due to my patient’s severe coronary artery disease and associated functional limitations, (he or she) is unable to sustain an 8-hour work day five days a week.”
Good luck with your disability claim. With perseverance, you will succeed.
Keith R. Holden, M.D.