Residual Functional Capacity Assessment for Congestive Heart Failure
What Is RFC?
If your congestive heart failure is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Categories of Limitations for Heart Disease
Whatever the nature of heart disease, limitations on your ability to work will always fall into certain broad categories:
1. Limitation from anginal chest pain.
2. Limitation from shortness of breath (dyspnea).
3. Limitation from weakness.
4. Limitation from easy fatigability.
5. Limitation from life-threatening arrhythmia.
6. Limitation from environmental factors.
The Social Security Administration should carefully consider each of these factors when determining your RFC.
It is important that the treating physician carefully document the nature and severity of your symptoms, something that is critical not only to treatment but also to disability determination.
There is no way an accurate RFC can be determined without close consideration of your symptoms as well as the objective data.
This point has to be emphasized, because some Social Security Administration adjudicators will try to use objective cardiac performance alone to determine RFC. Of course, the Social Security Administration still must judge your credibility. Alleged symptoms that deviate markedly from what would be expected based on the objective evidence could mean more development of the medical evidence is needed to uncover the cause of the symptoms. But other possibilities include malingering (the symptoms are consciously made up to get benefits), exaggeration, or a mental disorder.
Left Ejection Fraction
Both in clinical medicine and in disability determination, the most frequently used measure of cardiac performance is the left ventricular ejection fraction. LVEF is the percentage of blood in the left ventricle that is pumped out with each heart beat. As the LVEF falls, so does exertional capacity. That does not mean that the only basis for determining exertional capacity is the LVEF; it is one thread in the overall impairment severity.
- An LVEF of 40-49% implies a limitation to no more than medium work.
- An LVEF of 30-39% implies a limitation to no more than light work.
- An LVEF of 20-29% implies a limitation to no more than sedentary work.
- An LVEF of less than 20% implies a limitation to less than sedentary work and that would meet or equal a listing and result in a finding of disability.
These numbers are not Social Security Administration policy and should not be applied arbitrarily; they just provide a modifiable framework for a more refined determination. They are used as ceilings on exertional limitation which should not be exceeded without proof of higher exertional capacity, such as performance on an exercise test. (Rare individuals can perform levels of exertion on objective testing that substantially exceed what one would expect if anticipating performance based on LVEF alone.) Obviously, a claimant with a history of documented heart failure could meet listing 4.02B with an ejection fraction of 30% and other abnormalities and so should not be assigned an RFC for light work.
It is well-known that poor LVEF after treatment for chronic heart failure has a poor survival prognosis, with death occurring within 6 months in 21% of those with an LVEF of 40% or less. Recently, it has been determined that there is a considerable disability and mortality burden on CHF patients even if their LVEF is well-preserved (40% or higher), with a 6-month mortality of 13% and functional decline (symptoms and hospital readmissions) almost as great as those with lower ejection fractions (21% vs. 30%).
Diastolic Cardiac Dysfunction
Diastolic cardiac dysfunction can be associated with a normal left ventricle ejection fraction (LVEF). In these cases, the left ventricle is stiff and cannot relax properly. In such claims, the Social Security Administration should not cite a normal LVEF as an important factor in determining RFC.
Unfortunately, many treating physicians, even cardiologists, do not address whether a patient has diastolic dysfunction in the medical records. A cardiologist who is involved in evaluating your heart disease should be asked specifically about diastolic dysfunction when your symptoms of weakness and shortness of breath exceed what would be expected based on the usual systolic function of the left ventricle, i.e., the LVEF or similar systolic performance indicators.
Some cardiologists will not even have considered the possibility of diastolic dysfunction, but the acknowledgement of that as a possibility can add credibility to your alleged symptoms. It should not be assumed that the Social Security Administration adjudicator, even if a medical doctor, will think of diastolic dysfunction when reviewing a cardiac claim. The chances of a cardiologist considering this abnormality as a possibility is greater than for other doctors, but the Social Security Administration does not have cardiologists reviewing most heart impairment claims.
Since the left ventricular ejection fraction may be normal in diastolic failure, the LVEF (as discussed above) is of little value in assessing exertional capacity. In these cases, more weight must be given to symptoms such as fatigue and shortness of breath as exertionally limiting. For example, if you have well-compensated and uncomplicated systolic heart failure with a LVEF of 50% and normal heart size, you could arguably be considered capable of medium work. However, such an exertional RFC would be a disservice if you have diastolic heart failure and a LVEF of 50%, with symptoms compatible with no more than light work. In this case, your symptoms must be given increased weight.
Cardiopulmonary exercise testing has objectively demonstrated that there is no significant difference in systolic and diastolic heart failure patients in regard to exertional capacity, despite marked differences in LVEF.
When Medium RFC Is Appropriate
If you have had one documented episode of CHF in the past due to chronic heart disease and are compensating well with treatment, you might be given a medium RFC if all factors—including symptoms, information about exertional capacity, coronary artery disease status, and ventricular performance data—are compatible with that level of work. This situation indicates you are doing extremely well in the treatment of your heart failure. It is inconceivable that you should receive a “not severe” determination if you have had chronic heart disease severe enough to have ever produced heart failure.
When Light RFC Is Appropriate
If you had a documented episode of CHF in the past due to chronic heart disease and still have a significantly enlarged heart with a cardiothoracic ratio (CT ratio) of 55% or more, it would be difficult to justify an RFC higher than light work. Depending on your relevant symptoms on daily activities, as well as other abnormalities, the RFC could be lower.
When Sedentary RFC Is Appropriate
If you had a documented episode of CHF in the past due to chronic heart disease and can only complete 5 to 6 METs on an exercise test (a level of exertion roughly equivalent to brisk walking), a restriction to sedentary work would be appropriate. Although exercise tests are very helpful in obtaining objective information about exercise capacity, the Social Security Administration should never purchase such testing if you already satisfy the listing. However, your treating physician may have performed testing and those results become relevant to the disability determination.
Significant heart disease should be a reason to limit exposure to extreme heat or cold while working, because these temperature extremes add significant stress to the body’s physiology with a corresponding decrease in exertional ability. For example, it would not be reasonable to expect someone with significant heart disease to work in 90° plus heat or in freezing temperatures; symptoms will onset earlier under such circumstances. In some cases, environmental stressors can be tolerated if the exertional workload is lessened. The Social Security Administration ignores environmental stress in most heart cases and this is not proper.
Informed medical judgment is required to evaluate the possible effect of environmental temperatures on cardiac disease, but assurance of precision is not possible and great weight should be given to your individual medical condition.
Lung Disease in Claimants With Congestive Heart Failure
If you have significant lung disease and you have had an episode of CHF in the past due to chronic heart disease, your over-all impairment severity rating should be reduced by at least one level, i.e., from medium work to light work or light work to sedentary work, or sedentary work to a finding of equivalence to listing requirements.
The pulmonary and cardiovascular systems are interactive and co-dependent. For example, if a claimant has an RFC for medium work capacity based on emphysema and an RFC for medium work capacity for heart disease, then the overall RFC should never be higher than light work with restrictions from being exposed to extreme heat or cold, or excessive dust and fumes. The only exceptions to this rule would be rare instances in which a claimant demonstrates a higher exertional capacity on objective exercise testing.
Many claimants with lung disease also have heart disease. This is especially true of cigarette smokers, who often have both chronic obstructive pulmonary disease (chronic bronchitis and emphysema) and coronary artery disease. Failure to recognize increased severity as a result of the inter-dependence of cardiac and pulmonary impairments is a major source of error by Social Security Administration adjudicators, despite federal regulations requiring consideration of the combined effect of impairments. See Can I Get Social Security Disability Benefits for Lung Disease?
Your Symptoms and Activities of Daily Living
Your symptoms are important. In considering activities of daily living (ADLs), you should make every effort to provide the Social Security Administration with clear examples of activities that precipitate symptoms—whether those symptoms are chest pain, shortness of breath, weakness, dizziness or something else.
Can you walk half a mile? A block? Half a block? Up two flights of stairs? One flight? How are you affected by heat and cold, with specific examples? What objects can you lift? How far can you carry them? What activities could you perform before you had heart disease that you are no longer able to do?
Even if you can complete many activities, but at a slower than normal pace, you may not have functional capacity for an effective work-related ability. So, activity completion durations are important in all forms of heart disease. If you can walk half a mile but it takes an hour with frequent stops, because of shortness of breath or anginal chest pain, it would be ridiculous to consider this a meaningful walking distance for any real-life job function.
If you have CHF, particularly with a history of heart failure and continuing ventricular dysfunction, you may be able to perform at a certain activity level one day but not other days. You may be able to perform a number of activities such as shopping and cooking but be exhausted for several days afterward. Medical conditions are not static in their effects on people. Even the quality of sleep can make a big difference in function the next day. Medications and the development of transient pulmonary edema at night can easily ruin a night’s rest.
Most treating physicians do not know the level of detail about a claimant’s activities of daily living (ADL) that is needed for accurate adjudication. While their opinion is important, detailed information about ADLs almost always must come from you or people who have observed you in daily life.
Use of the arms is particularly demanding on the heart; that is why women with heart disease sometimes get exhausted trying to wash their hair and cannot push a vacuum cleaner around. Vague statements about ADLs, with answers such as “I don’t do anything” or “none” for questions from the Social Security Administration about activities are close to useless for evaluation and do not increase the likelihood of a favorable decision. Most claimants do not understand how to complete daily activity forms given to them by the SSA; the responses are too brief and vague. Unfortunately, this can get a deserving claimant denied, because critical functional details were not given to the Social Security Administration.
Other Issues Affecting Disability and Heart Failure
Right Ventricular Function
The listing for chronic heart failure says nothing about right ventricular function, and often medical evidence contains no information about the right side of the heart. Most claimants for disability benefits have left ventricular dysfunction caused by ischemic heart disease, specifically coronary artery disease. See Can I Get Social Security Disability Benefits for Ischemic Heart Disease?
When cardiac catheterization data is available, it usually involves only the left side of the heart, because the cardiologist performing the procedure is interested in evaluating the large epicardial coronary arteries supplying the heart muscle with blood (see Figure 6 below); these arteries have to be approached from the left heart. Catheterization of the right side of the heart would require a separate procedure.
Figure 6: Closed heart valves with views of the coronary arteries.
However, dysfunction of the right ventricle—as evidenced by a decreased right ventricular ejection fraction (RVEF)—significantly adds to the severity of the impairment. In fact, cor pulmonale specifically affects the right side of the heart. In other instances, heart attacks damage the right ventricle as well as the left ventricle. The treating physician should have information about right heart function, if you have cor pulmonale or other disorder that affects the right side of the heart. Non-invasive imaging studies of the heart, such as cardiac MRIs and radionuclide angiography, can provide specific information about right heart function.
The Social Security Administration adjudicator should not disregard right ventricular dysfunction. Yet this can happen when the adjudicator—such as a disability examiner or SSA hearing officer—is not a physician and therefore does not have the medical knowledge necessary to evaluate cardiac cases.
Anemia is common in heart failure. In some studies it affects more than half of patients. Exercise capacity is significantly dependent on hemoglobin concentration. Even heart failure patients who have no symptoms while on treatment may have decreased exercise tolerance due to anemia. If you have ever had heart failure, you should have your hemoglobin or hematocrit measured before the Social Security Administration decides you case. Anemia can provide a credible explanation to symptoms that might otherwise be hard to explain. This is a factor that a Social Security Administration is likely to overlook.
Even modest anemia can justify further lowering your RFC and sometimes even a finding that your impairment equals a listing.
Left Bundle Branch Block
Another consideration is left bundle branch block (LBBB), because it is present in about a fourth to a third of patients with heart failure. The presence of LBBB with heart failure results in increased risk of mortality, including sudden death, compared to those heart failure patients without LBBB (16.1% vs. 10.5%).
LBBB in heart failure impairs optimum synchronization of left ventricular contraction, causing a decreased ejection fraction and cardiac output. Biventricular pacemakers were introduced to address this problem, in an attempt to re-synchronize the contractility of the right and left sides of the heart (cardiac resynchronization therapy, CRT).
Twenty to 30% of patients don’t have functional improvement with CRT. Therefore, the Social Security Administration should not assume your condition will improve with CRT. Some biventricular pacemakers include a cardiover-defibrillator for arrhythmias. Many patients who receive CRT probably are severely enough impaired to meet the listing for chronic heart failure. It is extremely unlikely that the RFC for those who do not meet the listing would exceed light work. Those that don’t meet the listing are most likely candidates for sedentary work.
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