Chronic heart failure (CHF), also known as congestive heart failure, is the inability to pump enough oxygentated blood to the body resulting in fluid overload (retention).
Two most common causes of CHF
- Coronary artery disease
- Long-standing, poorly controlled hypertension
Two types of CHF
- Systolic dysfunction – inability of the heart to pump out blood during the contraction phase known as systole
- Diastolic dysfunction – reduced ability of the heart to relax and fill with blood during the relaxation phase known as systole
Someone may have both systolic and diastolic dysfunction and that is why the Social Security Agency (SSA) uses the term “predominant” when referring to these types.
If is there is a low EF (typically less than 50 per cent), SSA considers this predominant systolic dysfunction.
Both types result in the inability to pump out a sufficient amount of blood from the heart.
Systolic dysfunction
Most commonly refers to reduced function of the left ventricle (largest left-sided chamber of the heart responsible for pumping blood out to the body) as shown by a reduced ejection fraction
Measured by ejection fraction (EF) – blood present in the left ventricle when the ventricle has finished filling with blood and expelled during contraction of the heart
SSA Listing criteria for systolic heart failure include
- Left ventricular end diastolic dimension greater than 6.0 cm (indicating a dilated left ventricle) or
- Ejection fraction (EF) of 30 per cent or less
These measurements are usually found in an echocardiography (ECHO)/heart ultrasound report.
These measurements alone do not necessarily reflect a person’s functional ability, which is why the heart failure Listings may require other evidence, such as signs (physical and diagnostic findings) and symptoms (physical sensations) of heart failure.
Ejection fraction (EF)
- Reduced in predominant systolic dysfunction and typically normal in predominant disatolic dysfunction
- Usually measured by echocardiography (ECHO) – ultrasound of the heart
- Can also be measured on MUGA scan and ventriculography – nuclear medicine scans of the heart
- 30 percent or less is one of the criteria for listing 4.02 B
Diastolic dysfunction
- Unlike systolic dysfunction, the ejection fraction (EF) may be normal
- Seen as an impaired relaxation phase (when the heart fills with blood) of the heart on an ECHO
- Commonly caused by long-standing hypertension
- Commonly associated with Left Ventricular Hypertrophy (LVH) - thickening of the wall of the left ventricle due to years of pumping against high blood pressure
A classic example of diastolic heart failure is when someone is admitted to the hospital in heart failure (volume overload), but the ejection fraction (EF) is normal
SSA Listing criteria for diastolic heart failure include
- Left ventricular posterior wall plus septal thickness totaling 2.5 cm or greater and an enlarged left atrium (smaller left sided chamber of the heart) greater than or equal to 4.5 cm and
- Normal or elevated ejection fraction (EF) during a period of stability (not during an episode of acute heart failure)
These measurements are usually found in an echocardiography (ECHO) or heart ultrasound report.
These measurements alone do not necessarily reflect a person’s functional ability, which is why the heart failure Listings may require other evidence, such as signs (physical and diagnostic findings) and symptoms (physical sensations) of heart failure.
Physical findings (signs) associated with CHF
- Jugular venous distention (JVD) - distended neck veins from blood volume overload causing elevated venous blood pressure
- S3 gallop - abnormal heart sound heard with a stethoscope on physical exam
- Rales or crackles - sounds on lung exam due to fluid accumulation
- Hepatomegaly - enlarged liver due to fluid accumulation
- Ascities - fluid accumulation in the abdomen causing a distended belly
- Peripheral edema - fluid accumulation in the legs causing swelling (edema)
- Rapid weight gain due to fluid retention
Laboratory (diagnostic) findings (signs) associated with CHF
- Cardiomegaly – enlarged heart seen on imaging such as chest xray or ECHO
- Left ventricular diastolic diameter (LVDD ) – measurement on ECHO of the diameter of the left ventricle at the end of diastole (when the heart relaxes and fill with blood)
- Reduced ejection fraction (EF) – decrease in the amount of blood expelled from the heart during contraction
- Pulmonary vascular congestion - prominent vascular markings on chest x-ray due to fluid in the lungs
Symptoms (sensations) of CHF
- Shortness of breath (SOB), also known as dyspnea
- Dyspnea on exertion (DOE) – shortness of breath with activity
- Orthopnea – shortness of breath when lying flat
- Paroxysmal nocturnal dyspnea (PND) - waking up at night with a sensation of suffocation
- Fatigue - tiredness
- Dizziness, lightheadedness or fainting - resulting from reduced blood flow to the brain
- Chest pain - possibly due to reduced blood flow to the heart (myocardial ischemia)
- Palpitations – may be due to abnormal heart rhythm (cardiac arrhythmia)
Signs and symptoms of CHF may not always be present if the condition is controlled with prescribed treatment.
Acute heart failure can be triggered by an abnormal heart rhythm, dietary salt overload, high altitude, not taking medication, or a heart attack.
These types of reversible causes of acute heart failure are common reasons why SSA may wait at least 3 months to see how one responds to treatment.
Exercise Stress Testing (EST/GXT/ETT)
- Usually involves walking on a treadmill while attached to a heart monitor
- Used to screen for or monitor coronary artery disease
- Used to measure aerobic capacity (fitness level related to exertion) in heart failure patients while exercising in a controlled environment
- Does not correlate with ability to perform lifting and carrying heavy loads
- Does not necessarily correlate with ability to perform throughout the work day
- Does not correlate with activities required for work in all possible work environments
- Results are expressed in metabolic units called METS (a measure of oxygen uptake)
- Listings 4.02 B calls for specific findings at a workload equivalent to 5 METS or less
- Can be combined with nuclear imaging studies or ECHO (heart ultrasound) to provide more information
SSA may order an exercise stress test to evaluate CHF when
- SSA cannot find you disabled on some other basis in your medical record
- There is no recent exercise stress test in your medical record
- There is a question of whether your condition meets or equals a listing
- SSA needs to assess your aerobic functional capacity, and there is insufficient medical evidence in your file to determine this
Importance of longitudinal medical evidence
To properly evaluate disability claims for CHF, the Social Security Administration (SSA) usually needs at least three months of detailed records describing your medical history, physical exams, lab studies, and response to treatment. A record of your medical findings over an extended period of time is called “longitudinal medical evidence.”
The reason SSA looks at your condition over an extended period of time is to see if your ability to function despite your condition will stay the same, worsen, or improve with treatment. SSA won’t wait at least three months to make a decision on all CHF claims; especially if your longitudinal medical records show that your condition has continued to worsen or has not improved with treatment.
If your condition is unstable when you apply for disability, SSA may wait until your condition stabilizes with treatment to see how well you are able to function at that time. That wait-time for stabilization to occur is typically 3 months. For example, if you are hospitalized with CHF, SSA may wait 3 months to see how well you do on medications after discharge.
What your medical records should cover
- Information from hospitalizations and office visits
- When you were diagnosed with CHF
- What caused you to develop CHF
- What medications are used to treat your condition and how you respond to treatment
- Compliance with treatment - take your medication as instructed and follow-up with treating doctors
- Description of your ability to function despite your condition
Consultative Exam
It is unusual to have significant CHF and not have a treating doctor. But if this is the case, and it is not clear that you are disabled under Social Security’s rules, SSA will send you to a special examination with a doctor. See the “Consultative Exam” section on this web site for more information about that exam. In addition, SSA may order tests to check your condition, such as a chest X-ray or exercise stress test.
Important: SSA will not decide you are disabled based purely on the finding of a reduced ejection fraction. Your medical records and your statements about your ability to function must reflect that you are significantly limited in the ability to perform daily activities.
New York Heart Association (NYHA) Functional Classification
The NYHA functional classification for chronic heart failure is a good way for treating doctors to clarify an individual's level of function. It places patients in one of four categories depending on how limited they are during physical activity.
Class Level of Function
I Symptoms with more than ordinary activity
II Symptoms with ordinary activity
III Symptoms with minimal activity
IV Symptoms at rest
The higher the NYHA Class, the more likely that patient will win Social Security disability benefits.
Letter from your doctor
Finally, I recommend that you get your doctor to write a letter in support of your disability application. The letter should include a summary of your diagnosis, tests performed, and treatment rendered. It should also describe your ability to function – how much you can lift, carry, and walk; and if you should avoid environmental conditions, such as excessive heat or cold. The treating doctor should give a NYHA Class.
A good way for your doctor to end the letter is for him or her to say, “Due to my patient’s severe congestive heart failure 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.