4.02 Chronic heart failure while on a regimen of prescribed treatment, with symptoms and signs described in 4.00D2. The required level of severity for this impairment is met when the requirements in both A and B are satisfied.
It would be wise to first read the “Chronic Heart Failure and Disability” article on this website to help you better understand theses chronic heart failure Listings.You must have a diagnosis of chronic heart failure with symptoms (sensations) and signs (abnormal findings on physical exam or diagnostic studies) that limit your ability to function and work.
Important: You must be on prescribed treatment (medication) to meet this Listing. It is unusual to have established chronic heart failure and not be on prescribed treatment. But if this is the case, it is always possible to equal this Listing since you are unlikely to get better without medication.
If you are not taking prescribed medication, be sure to let SSA know why, such as the inability to afford the medication or lack of transportation to the doctor’s office.
A. Medically documented presence of one of the following:
1. Systolic failure (see 4.00D1a(i)), with left ventricular end diastolic dimensions greater than 6.0 cm or ejection fraction of 30 percent or less during a period of stability (not during an episode of acute heart failure); or
Systolic heart failure implies a reduced ejection fraction (EF). EF measures the percentage of blood pumped from the left ventricle of the heart with each heartbeat. Normal EF is around 55-75%.
EF can be measured by the following:
- Echocardiography (ECHO) - ultrasound of the heart *most common
- Left ventriculogram via cardiac catheterization
- Multiple gated acquisition (MUGA) - nuclear medicine scan of the heart
An EF of 30 percent or less is considered Listing level severity though an EF of 40 percent or less usually indicates a limited level if function due to significant heart disease. Someone with an EF greater than 30 percent may equal this Listing if they have significant functional limitations and possibly other coexisting conditions such as obesity.
Note that SSA allows for an alternative measure of Listing level impaired systolic function (other than a reduced EF) as a left ventricular end diastolic dimension (LVED) of greater than 6.0 cm. This increased LVED indicates a dilated left ventricle (LV), also known as an “enlarged heart,” and this measurement can be found in an ECHO report.
Important: EF and LVED must be documented during a period of stability, and not during an episode of acute heart failure. This means some type of imaging study, such as an ECHO, must show this during a period separated by at least 2 weeks between bouts of any episodes of acute heart failure. Doctors, especially cardiologists, often recheck these measurements with an ECHO after an acute heart failure episode.
Do not confuse percent fractional shortening (FS) with EF on an ECHO report as they are both measured as percentages, but are not the same. SSA doesn’t care about the fractional shortening (FS).
2. Diastolic failure (see 4.00D1a(ii)), with left ventricular posterior wall plus septal thickness totaling 2.5 cm or greater on imaging, with an enlarged left atrium greater than or equal to 4.5 cm, with normal or elevated ejection fraction during a period of stability (not during an episode of acute heart failure);
Diastolic heart failure implies chronic heart failure with a normal EF.
SSA requires two measurements of disastolic heart failure of Listing level severity, which are typically found in an ECHO report and must include:
- a left ventricular posterior wall plus septal thickness totaling 2.5 cm or greater (reflects thickening of the heart muscle wall of the left ventricle - lower left chamber of the heart)
- and an enlarged left atrium greater than or equal to 4.5 cm (reflects a dilated left atrium, which is the upper left chamber of the heart)
Important: These measurements must be documented at baseline when not in acute heart failure. This means some type of imaging study such as an ECHO must show this during a period separated by at least 2 weeks between bouts of any episodes of acute heart failure.
Someone could equal this Listing by having an ECHO report indicating “impaired relaxation,” a history of chronic heart failure, and limited function without exactly matching the above numbers. Usually, the ECHO report will say there is “evidence of diastolic dysfunction.”
A classic example of diastolic heart failure is when someone is admitted to the hospital with heart failure and an ECHO shows a normal ejection fraction (EF).
AND
B. Resulting in one of the following:
1. Persistent symptoms of heart failure which very seriously limit the ability to independently initiate, sustain, or complete activities of daily living in an individual for whom an MC, preferably one experienced in the care of patients with cardiovascular disease, has concluded that the performance of an exercise test would present a significant risk to the individual; or
Persistent means that the longitudinal medical record shows that the required finding(s) has been present, or is expected to be present, for a continuous period of at least 12 months, indicating a pattern of ongoing severity.
This issue can be tricky as some medical consultants will give a “durational denial” assessment saying that there is evidence of Listing level severity, but with treatment and time, the condition will improve. One way to bypass this type of assessment is to get your treating doctor to submit a statement saying “Due to the severity of my patient’s heart condition, no significant functional improvement is expected within the next 12 months, even with medical treatment.”
It is important to submit detailed activities of daily living (ADLs) showing how you are significantly limited by your heart disease. If your doctor’s medical records do not report limited ADLs, it is important to submit a statement from your treating doctor outlining how you are limited in daily functional activities by your condition.
Your doctor might say “Due to my patient’s severe heart disease, he/she is unable to walk to the mail box, grocery shop, or vacuum a room.”
Any medical consultant (MC) who is employed by or consults for SSA may make the decision that an exercise stress test would be too risky to undergo.
If you can submit a statement from a treating doctor saying that it is too risky for you to undergo an exercise (stress) test, the MC would be highly unlikely to override it, though the your medical records would have to show severe heart disease and significant loss of function to support that statement.
Keep in mind this Listing applies to an exercise stress test, and does not apply to a drug-induced stress test where you lie on a table and the heart is stimulated chemically.
2. Three or more separate episodes of acute congestive heart failure within a consecutive 12‑month period (see 4.00A3e), with evidence of fluid retention (see 4.00D2b (ii)) from clinical and imaging assessments at the time of the episodes, requiring acute extended physician intervention such as hospitalization or emergency room treatment for 12 hours or more, separated by periods of stabilization (see 4.00D4c); or
Be sure to submit all medical records relating to any emergency (ER) visits or hospitalizations for congestive heart failure. ER visits are the tricky part of this Listing as they must be 12 hours or more, and may be documented as a “short stay” or overnight stay. Treatment may be as simple as giving an intravenous diuretic such as Lasix (furosemide).
Important: “Separated by periods of stabilization” means that there must be a period of at least 2 weeks between episodes of acute heart failure during which your condition returned to a baseline status with evidence of clearing of fluid retention (volume overload). This can be shown in the medical records by the clearing of fluid on any follow-up chest x-rays or physical exams.
3. Inability to perform on an exercise tolerance test at a workload equivalent to 5 METs or less due to:
Metabolic equivalents of task (METs) is a measure of exercise capacity.
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.
5 METS or less is associated with a poor prognosis (poor expected outcome) if the stress test was stopped due to symptoms of heart failure such as shortness of breath, fatigue, or chest pain.
13 METS suggests a good functional ability and prognosis despite an abnormal exercise stress test.
Important: In general, if a person is unable to walk for three minutes on a Bruce protocol exercise stress test, they would meet this component of the Listing. Be aware, there are other types of protocols used for exercise stress tests, and different times on the treadmill will reflect a different number of METS reached. Be sure your doctor clarifies how many METS you were able to reach on the exercise stress test.
a. Dyspnea, fatigue, palpitations, or chest discomfort; or
These are typical symptoms of heart failure, which may cause someone to stop walking on the treadmill during an exercise stress test.
Sometimes a doctor may stop a stress test when the patient reaches a certain heart rate, and not continue to the exercise stress test to see how many METS could be reached.
SSA will look to see why the exercise stress test was stopped, and if it was stopped based purely on heart rate, they would probably not consider this a valid exercise stress test for this Listing.
But with significant heart failure, one will inevitably have some symptoms of heart failure when undergoing an exercise stress test.
b. Three or more consecutive premature ventricular contractions (ventricular tachycardia), or increasing frequency of ventricular ectopy with at least 6 premature ventricular contractions per minute; or
Ventricular tachycardia and ventricular ectopy are extra beats by the ventricle showing up as extra blips on the electrocardiograph (EKG or ECG) strip. Ventricular tachycardia (a dangerous abnormal heart rhythm) and ventricular ectopy with at least 6 premature ventricular contractions per minute during a stress test indicates significant heart disease and a poor prognosis (poor expected outcome).
c. Decrease of 10 mm Hg or more in systolic pressure below the baseline systolic blood pressure or the preceding systolic pressure measured during exercise (see 4.00D4d) due to left ventricular dysfunction, despite an increase in workload; or
Systolic blood pressure (SBP) is the top number of a blood pressure reading. This part of the Listing requires that a reduced LV function (low EF) result in a 10 point drop in the SBP during an exercise stress test.
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 results in this drop in the blood pressure. The poor blood supply can be associated with a low ejection fraction (EF) as in systolic heart failure or with decreased filling of the heart due to a stiff heart muscle wall as in diastolic heart failure.
If the drop in blood pressure occurs early (during the first three minutes of exercise), SSA notes it 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 the poor left ventricular function.
d. Signs attributable to inadequate cerebral perfusion, such as ataxic gait or mental confusion.
An ataxic (off balance) gait and mental confusion indicates that the brain is not getting enough blood flow during an exercise stress test. Other such signs might include severe generalized weakness, severe dizziness, nearly passing out, or completely passing out.