4.05 Recurrent arrhythmias, not related to reversible causes, such as electrolyte abnormalities or digitalis glycoside or antiarrhythmic drug toxicity, resulting in uncontrolled (see 4.00A3f), recurrent (see 4.00A3c) episodes of cardiac syncope or near syncope (see 4.00F3b), despite prescribed treatment (see 4.00B3 if there is no prescribed treatment), and documented by resting or ambulatory (Holter) electrocardiography, or by other appropriate medically acceptable testing, coincident with the occurrence of syncope or near syncope (see 4.00F3c).
“Uncontrolled” means the impairment does not adequately respond to standard prescribed medical treatment.
“Recurrent” means that the longitudinal medical record shows that, within a consecutive 12-month period, the finding(s) occurs at least three times, with intervening periods of improvement of sufficient duration that it is clear that separate events are involved.
An arrhythmia is a change in the regular beat of the heart. Your heart may seem to skip a beat or beat irregularly, very quickly (tachycardia), or very slowly (bradycardia).
There are many types of arrhythmias, which are identified by where they occur in the heart (atria or ventricles) and by what happens to the heart's rhythm when they occur. Arrhythmias arising in the cardiac atria (upper chambers of the heart) are called atrial or supraventricular (above the ventricle) arrhythmias. Ventricular arrhythmias begin in the ventricles (lower chambers). In general, ventricular arrhythmias are the most serious.
SSA will use Listing 4.05 when you have arrhythmias that are “uncontrolled” by medication, an implanted pacemaker, or an implanted cardiac defibrillator, AND you have uncontrolled “recurrent” episodes of syncope (passing out) or near syncope (nearly passing out). SSA will not use this Listing if these arrhythmias are due to reversible causes such as abnormal electrolyte (magnesium, potassium, etc.) levels or drugs.
If your arrhythmias are controlled, SSA will look at other aspects of your underlying heart disease to see if it meets criteria for other cardiac Listings.
SSA considers near syncope to be a period of altered consciousness, since syncope is a loss of consciousness or a faint. Near syncope is not merely a feeling of light-headedness, momentary weakness, or dizziness; and for Listing purposes must cause a significant alteration in consciousness.
For Listing 4.05, your medical records must show an association between the syncope or near syncope and the recurrent arrhythmia. The recurrent arrhythmia, not some other cardiac or non-cardiac disorder, must be established as the cause of the syncope or near syncope. This documentation of the association between the syncope or near syncope and the arrhythmia may come from Holter monitoring (ambulatory electrocardiography), a cardiac event monitor, and tilt-table testing with a concurrent ECG.
A Holter monitor is a portable device attached to an individual that measures heart rhythms over a 24 hour period. Cardiac event monitors are worn for longer periods and also measure heart rhythms. With these devices, patients are asked to keep a diary of activities and to document what symptoms occur, such as syncope (passing out) or near syncope (nearly passing out).
With tilt table testing, patients lie on a table connected to an electrocardiogram (ECG) machine, and the table is tilted varying degrees for certain amounts of time while heart rhythm, heart rate, and blood pressure are measured. In some tilt table testing, the patient is injected with a medication that mimics adrenaline, a stress hormone. Tilt table testing is usually done to see if syncope or near syncope is due to an abnormal drop in blood pressure, but sometimes tilt table testing reveals an underlying arrhythmia. Even if a tilt table test does not show a Listing level arrhythmia, one could still “equal” this Listing if uncontrolled and recurrent bouts of syncope or near syncope are due to the abnormal drops in blood pressure.
Although an arrhythmia may occur during an exercise stress test, SSA will not purchase an exercise stress test to document the presence of a cardiac arrhythmia.
Implantable Cardiac Defibrillators and Disability
Implanted cardiac defibrillators are used to correct life-threatening ventricular arrhythmias by preventing death due to cardiac arrest where the heart stops beating normally and one loses consciousness.
SSA gives special consideration to individuals with implanted cardiac defibrillators, but whose arrhythmias may not meet the requirements of Listing 4.05. In certain cases where the defbrillator shocks repeatedly and/or inappropriately despite the absence of Listing level arrhythmias with syncope and near syncope, SSA may decide that the condition warrants “equaling” this Listing. An example would be if the shocks are so frequent, that they prevent the individual from sustaining normal daily work activities.
The largest group at risk for sudden cardiac death consists of individuals with cardiomyopathy (ischemic or non-ischemic) and reduced ventricular function. However, life-threatening ventricular arrhythmias can also occur in individuals with little or no ventricular dysfunction.
The shock from the implanted cardiac defibrillator attempts to correct an abnormal heart rhythm and may rescue an individual from cardiac arrest. However, as a consequence of the shock(s), individuals may experience psychological distress, which SSA may evaluate under the mental disorders Listings in 12.00.
Most implantable cardiac defibrillators have rhythm-correcting and pacemaker capabilities. In some individuals, these functions may result in the termination of ventricular arrhythmias without an otherwise painful shock. (The shock is like being kicked in the chest.) Implanted cardiac defibrillators may deliver inappropriate shocks, often repeatedly, in response to benign arrhythmias or electrical malfunction. Exposure to strong electrical or magnetic fields, such as from MRI (magnetic resonance imaging), can trigger or reprogram an implanted cardiac defibrillator, resulting in inappropriate shocks. SSA will consider the frequency of, and the reason(s) for, the shocks when evaluating the severity and duration of your heart condition.
Exercise limitations in individuals with an implanted cardiac defibrillator are caused by the underlying heart impairment. However, the exercise limitations may be greater when the implanted cardiac defibrillator delivers an inappropriate shock in response to an increase in heart rate with exercise, or when there is exercise-induced ventricular arrhythmia.