Ischemic Heart Disease and Disability
Ischemic Heart Disease (IHD) is also known as Coronary Artery Disease (CAD).
Coronary arteries wrap around the outside of the heart, which is made of muscle, and feed your heart with blood that has been oxygenated by your lungs. These coronary arteries can be blocked by cholesterol plaques, blood clots, and spasm (constriction) resulting in ischemia (lack of blood flow to the heart muscle).
Depending on how much and how long blood flow to the heart muscle is blocked (myocardial ischemia), varying amounts of damage to the heart can occur. If heart muscle dies from lack of blood flow, this results in a myocardial infarcation (heart attack).
Angina - pain or discomfort in the body resulting from lack of blood flow to the heart muscle due to narrowing of coronary arteries from spasm and plaques. Can also be caused by any condition that results in decreased blood flow to the heart muscle including other types of heart disease - valve problems, congestive heart failure, high blood pressure in the lungs (pulmonary hypertension) and anemia (low red blood cells).
SSA wants angina to be thoroughly documented with the following description:
- What degree of physical activity (exertion) or emotion causes the angina.
- How often the angina occurs and how long it lasts.
- What relieves the angina (rest, nitroglycerin).
- A description of the physical discomfort, where it occurs in the body, and any associated symptoms such as shortness of breath and sweating.
- Objective medical evidence of myocardial ischemia including any abnormal electrocardiograms (ECG/EKG) or stress test.
Types of angina:
1. Typical angina - chest discomfort caused by physical activity (exertion) or emotion that is relieved with rest and nitroglycerin. Chest discomfort can be described as pressure, crushing, squeezing, burning, or aching; with sharp, sticking or stabbing discomfort less common.
2. Atypical angina - angina that doesn’t result in typical chest pain. This type of angina also results from lack of blood flow to the heart muscle, but can be felt as pain in the left arm, neck, jaw, upper abdomen (belly), and back. With ischemic pain occurring in areas other than the chest, your medical records must show that it also caused by physical exertion and/or emotion, and be relieved by rest and/or nitroglycerin.
3. Angina equivalent - shortness of breath (dyspnea) due to ischemic heart disease without associated chest discomfort. SSA says that in this situation, your medical records must show objective evidence of myocardial ischemia to ensure that this is not effort related (exertional) shortness of breath due to conditions not related to the heart.
4. Variant angina - angina occurring at rest, especially at night, accompanied by abnormal ECG/EKG findings showing ischemia. Also known as Prinzmetal’s angina or vasospastic angina. This type of angina is caused by spasm (constriction) of the coronary artery and is often associated with serious abnormal heart rhythms (arrhythmias), such as ventricular tachycardia.
Even though variant angina can occur without obstruction of the coronary arteries by cholesterol plaques and blood clots, SSA will consider variant angina under Listing 4.04 only if the coronary artery spasm occurs in relation to an obstruction of the artery by a cholesterol plaque and/or blood clot. This obstruction may be shown in your medical records as an abnormality on a cardiac catheterization (angiogram of coronary arteries).
Sometimes during a heart catheterization (angiogram), the catheter itself will cause a coronary artery to spasm (constrict) when touched by the catheter. SSA does not consider this variant angina if there is no associated blockage of the artery by a plaque or blood clot.
Silent ischemia - myocardial ischemia (decreased or absent blood flow to the heart muscle) that occurs without symptoms such as chest pain or shortness of breath. This can occur with any diseases that alter pain perception such as diabetes and neurologic disorders.
A typical situation of silent ischemia is when someone with known coronary artery disease (CAD) has an abnormal stress test showing ischemic changes on an ECG, echocardiogram, or nuclear imaging scan, but does not have chest pain during the test.
SSA is inconsistent in its discussion of silent ischemia in regards to abnormal ECG findings on Holter monitoring in that SSA requires coexisting chest pain, which means it isn’t silent ischemia. So you shouldn’t expect SSA to given any credance to silent ischemia based on a Holter monitor test. Holter monitoring involves being hooked up to a portable ECG machine for a 24 hour period.
Noncardiac causes of chest discomfort or chest pain
There are many conditions that can cause chest discomfort besides coronary artery disease (CAD), and would not be considered under Listing 4.04. These include:
Anxiety or panic attacks
Spasm of the esophagus
Esophagitis (inflammation of the esophagus)
Hiatal hernia (where the stomach pushes up through the diaphragm muscle into the chest cavity)
Obstruction or inflammation of the gallbladder and bile ducts
Gastritis (inflammation of the stomach)
Peptic ulcer (stomach ulcer)
Pancreatitis (inflammation of the pancreas)
Chest wall muscle spasm
Costochondritis (inflammation where the ribs join the breast bone)
Chest wall syndrome (chest wall pain after a coronary bypass surgery)
Arthritis of the neck or upper back
Hyperventilation
Listing 4.40 and objective medical evidence
Objective medical evidence as it relates to coronary artery disease means symptoms (sensations) and diagnostic findings that objectively show heart disease exists, such as angina (cardiac chest pain), abnormal ST segment changes on an ECG, abnormal stress tests, and abnormal nuclear imaging studies or echocardiograms (ECHO).