TN 3 (10-99)
DI 34124.003 Cardiovascular Listings from 01/06/86 to 02/09/94
4.00 CARDIOVASCULAR SYSTEM
Severe cardiac impairment results from one or more of three consequences of heart disease: (1) congestive heart
failure; (2) ischemia (with or without necrosis) of heart muscle; (3) conduction disturbances
and/or arrhythmias resulting in cardiac syncope.
With diseases of arteries and veins, severe impairment may result from disorders of
the vasculature in the central nervous system, eyes, kidneys, extremities, and other
The criteria for evaluating impairment resulting from heart diseases or diseases of
the blood vessels are based on symptoms, physical signs and pertinent laboratory findings.
Congestive heart failure is considered in the Listing under one category whatever the etiology (i.e., arteriosclerotic,
hypertensive, rheumatic, pulmonary, congenital, or other organic heart diseases).
Congestive heart failure is not considered to have been established for the purpose
of 4.02 unless there is evidence of vascular congestion such as hepatomegaly or peripheral
or pulmonary edema which is consistent with clinical diagnosis. (Radiological description
of vascular congestion, unless supported by appropriate clinical evidence, should
not be construed as pulmonary edema.) The findings of vascular congestion need not
be present at the time of adjudication (except for 4.02A), but must be causally related
to the current episode of marked impairment. The findings other than vascular congestion
must be persistent.
Other congestive, ischemic, or restrictive (obstructive) heart diseases such as caused
by cardiomyopathy or aortic stenosis may result in significant impairment due to congestive
heart failure, rhythm disturbances or ventricular outflow obstruction in the absence
of left ventricular enlargement as described in 4.02B1. However, the ECG criteria
as defined in 4.02B2 should be fulfilled. Clinical findings such as symptoms of dyspnea,
fatigue, rhythm disturbances, etc., should be documented and the diagnosis confirmed
by echocardiography or at cardiac catheterization.
Hypertensive vascular disease does not result in severe impairment unless it causes severe damage to one or more
of four end organs; heart, brain, kidneys, or eyes (retinae). The presence of such
damage must be established by appropriate abnormal physical signs and laboratory findings
as specified in 4.02 or 4.04, or for the body system involved.
Ischemic heart diseases may result in a marked impairment due to chest pain. Description of the pain must
contain the clinical characteristics as discussed under 4.00E. In addition, the clinical
impression of chest pain of cardiac origin must be supported by objective evidence
as described under 4.00F., G., or H.
Chest pain of cardiac origin is considered to be pain which is precipitated by effort and promptly relieved by
sublingual nitroglycerin or rapid-acting nitrates or rest. The character of the pain
is classically described as crushing, squeezing, burning, or oppressive pain located
in the chest. Excluded is sharp, sticking or rhythmic pain. Pain occurring on exercise
should be described specifically as to usual inciting factors (kind and degree), character,
location, radiation, duration, and responses to nitroglycerin or rest.
So-called “anginal equivalent” locations manifested by pain in the throat, arms, or hands have the same validity
as the chest pain described above. Status anginosus and variant angina of the Prinzmetal
type (e.g., rest angina with transitory ST elevation on electrocardiogram) will be
considered to have the same validity as classical angina pectoris as described above.
Shortness of breath as an isolated finding should not be considered as an anginal
Chest pain that appears to be of cardiac origin may be caused by noncoronary conditions.
Evidence for the latter should be actively considered in determining whether the chest
pain is of cardiac origin. Among the more common conditions which may masquerade as
angina are gastrointestinal tract lesions such as biliary tract disease, esophagitis,
hiatal hernia, peptic ulcer, and pancreatitis; and musculoskeletal lesions such as
costochondritis and cervical arthritis.
Documentation of electrocardiography.
Electrocardiograms obtained at rest must be submitted in the original or a legible copy of a 12-lead tracing, appropriately
labeled, with the standardization inscribed on the tracing. Alteration in standardization
of specific leads (such as to accommodate large QRS amplitudes) must be shown on those
The effect of drugs, electrolyte imbalance, etc., should be considered as possible
noncoronary causes of ECG abnormalities, especially those involving the ST segment.
If needed and available, pre-drug (especially pre-digitalis) tracings should be obtained.
The term “ischemic” is used in 4.04 to describe a pathologic ST deviation. Nonspecific repolarization
changes should not be confused with ischemic configurations or a current of injury.
Detailed descriptions or computer interpretations without the original or legible
copies of the ECG are not acceptable.
Electrocardiograms obtained in conjunction with exercise tests must include the original tracings or a legible copy of appropriate leads obtained
before, during and after exercise. Test control tracings, taken before exercise in
the upright position, must be obtained. An ECG after 20 seconds of vigorous hyperventilation
should be obtained. A posthyperventilation tracing may be essential for the proper
evaluation of an “abnormal” test in certain circumstances, such as in women with evidence of mitral valve prolapse.
A tracing should be taken at approximately 5 METs of exercise and at the time the
ECG becomes abnormal according to the criteria in 4.04A. The time of onset of these
abnormal changes must be noted, and the ECG tracing taken at the time should be obtained.
Exercise histograms without the original tracings or legible copies are not acceptable.
Whenever electrocardiographically documented stress test data are submitted, irrespective
of the type, the standardization must be inscribed on the tracings and the strips
must be labeled appropriately, indicating the times recorded. The degree of exercise
achieved, the blood pressure levels during the test, and any reason for terminating
the test must be included in the report.
When to purchase. Since the results of a treadmill exercise test are the primary basis for adjudicating
claims under 4.04, they should be included in the file whenever they have been performed.
There are also circumstances under which it will be appropriate to purchase exercise
tests. Generally, these are limited to claims involving chest pain which is considered
to be of cardiac origin but without corroborating ECG or other evidence of ischemic
Exercise tests should not be purchased in the absence of alleged chest pain of cardiac
origin. Even in the presence of an allegation of chest pain of cardiac origin, an
exercise test should not be purchased where full development short of such a purchase
reveals that the impairment meets or equals any Listing or the claim can adjudicated
on some other basis.
Methodology. When an exercise test is purchased, it should be a treadmill type using a continuous
progressive multistage regimen. The targeted heart rate should be not less than 85
percent of the maximum predicted heart rate unless it becomes hazardous to exercise
to the heart rate or becomes unnecessary because the ECG meets the criteria in 4.04A
at a lower heart rate (see also 4.00F.2.). Beyond these requirements, it is prudent
to accept the methodology of a qualified, competent test facility. In any case, a
precise description of the protocol that was followed must be provided.
Limitations of exercise testing. Exercise testing should not be purchased for individuals who have the following:
unstable progressive angina pectoris; recent onset (approximately 2 months) of angina;
congestive heart failure; uncontrolled serious arrhythmias (including uncontrolled
auricular fibrillation); second or third-degree heart block; Wolff-Parkinson-White
syndrome; uncontrolled marked hypertension; marked aortic stenosis; marked pulmonary
hypertension; dissecting or ventricular aneurysms; acute illness; limiting neurological
or musculoskeletal impairments; or for individuals on medication where performance
of stress testing may constitute a significant risk.
The presence of noncoronary or nonischemic factors which may influence the ECG response
to exercise include hypokalemia, hyperventilation, vasoregulatory asthenia, significant
anemia, left bundle branch block, and other heart disease, particularly valvular.
Digitalis may cause ST segment abnormalities at rest, during, and after exercise.
Digitalis-related ST depression, present at rest, may become accentuated and result
in false interpretations of the ECG taken during or after exercise test.
Evaluation. Where the evidence includes the results of a treadmill exercise test, this evidence
is the primary basis for adjudicating claims under 4.04. For purposes of the Social
Security disability program, treadmill exercise testing will be evaluated on the basis
of the level at which the test becomes positive in accordance with the ECG criteria
in 4.04A. However, the significance of findings of a treadmill exercise test must
be considered in light of the clinical course of the disease which may have occurred
subsequent to performance of the exercise test. The criteria in 4.04B are not applicable
if there is documentation of an acceptable treadmill exercise test. If there is no
evidence of a treadmill exercise test or if the test is not acceptable, the criteria
in 4.04B should be used. The level of exercise is considered in terms of multiples
of METs (metabolic equivalent units). One MET is the basal O2 requirement of the body in an inactive state, sitting quietly. It is considered by
most authorities to be approximately 3.5 ml. O2/kg./min.
Coronary arteriography. This procedure is not to be purchased by the Social Security Administration. Should
the results of such testing be available, the report should be considered as to the
quality and kind of data provided and its applicability to the requirements of the
Listing of Impairments. A copy of the report of the catheterization and ancillary
studies should be obtained. The report should provide information as to the technique
used, the method of assessing coronary lumen diameter, and the nature and location
of any obstructive lesions.
It is helpful to know the method used, the number of projections, and whether selective
engagement of each coronary vessel was satisfactorily accomplished. It is also important
to know whether the injected vessel was entirely and uniformly opacified, thus avoiding
the artifactual appearance of narrowing or an obstruction.
Coronary artery spasm induced by intracoronary catheterization is not to be considered
as evidence of ischemic heart disease.
Estimation of the functional significance of an obstructive lesion may also be aided
by description of how well the distal part of the vessel is visualized. Some patients
with significant proximal coronary atherosclerosis have well-developed large collateral
blood supply to the distal vessels without evidence of myocardial damage or ischemia,
even under conditions of severe stress.
Left ventriculography. The report should describe the local contractility of the myocardium as may be evident
from areas of hypokinesia, dyskinesia, or akinesia; and the overall contractility
of the myocardium as measured by the ejection fraction.
Proximal coronary arteries (see 4.04B7) will be considered as the:
Right coronary artery proximal to the acute marginal branch; or
Left anterior descending coronary artery proximal to the first septal perforator;
Left circumflex coronary artery proximal to the first obtuse marginal branch.
Results of other tests. Information from adequate reports of other tests such as radionuclide studies or
echocardiography should be considered where that information is comparable to the
requirements in the listing. An ejection fraction measured by echocardiography is
not determinative, but may be given consideration in the context of associated findings.
Major surgical procedures. The amount of function restored and the time required to effect improvement after
heart or vascular surgery vary with the nature and extent of the disorder, the type
of surgery, and other individual factors. If the criteria described for heart or vascular
disease are met, proposed heart or vascular surgery (coronary artery bypass procedure,
valve replacement, major arterial grafts, etc.) does not militate against a finding
of disability with subsequent assessment postoperatively.
The usual time after surgery for adequate assessment of the results of surgery is
considered to be approximately 3 months. Assessment of the magnitude of the impairment
following surgery requires adequate documentation of the pertinent evaluations and
tests performed following surgery, such as an interval history and physical examination,
with emphasis on those signs and symptoms which might have changed post-operatively,
as well as X-rays and electrocardiograms. Where treadmill exercise tests or angiography
have been performed following the surgical procedure, the results of these tests should
Documentation of the preoperative evaluation and a description of the surgical procedure
are also required. The evidence should be documented from hospital records (catheterization
reports, coronary arteriographic reports, etc.) and the operative note.
Implantation of a cardiac pacemaker is not considered a major surgical procedure for
purposes of this section.
Evaluation of peripheral arterial disease. The evaluation of peripheral arterial disease is based on medically acceptable clinical
findings providing adequate history and physical examination findings describing the
impairment, and on documentation of the appropriate laboratory techniques. The specific
findings stated in Listing 4.13 represent the level of severity of that impairment;
these findings, by themselves, are not intended to represent the basis for establishing
the clinical diagnosis. The level of the impairment is based on the symptomatology,
physical findings, Doppler studies before and after a standard exercise test, and/or
The requirements for evaluation of peripheral arterial disease in Listing 4.13B are
based on the ratio of systolic blood pressure at the ankle, determined by Doppler
study, to the systolic blood pressure at the brachial artery determined at the same
time. Results of plethysmographic studies, or other techniques providing systolic
blood pressure determination at the ankle, should be considered where the information
is comparable to the requirements in the listing.
Listing 4.13B 1 provides for determining that the listing is met when the resting
ankle/brachial systolic blood pressure ratio is less than 0.50. Listing 4.13B 2 provides
additional criteria for evaluating peripheral arterial impairment on the basis of
exercise studies when the resting ankle/ brachial systolic blood pressure ratio is
0.50 or above. The results of exercise studies should describe the level of exercise
(e.g., speed and grade of the treadmill settings), the duration of exercise, symptoms
during exercise, the reasons for stopping exercise if the expected level of exercise
was not attained, blood pressures at the ankle and other pertinent levels measured
after exercise, and the time required to return the systolic blood pressure toward
or to, the preexercise level. When exercise Doppler studies are purchased by the Social
Security Administration, it is suggested that the requested exercise be on a treadmill
at 2 mph on a 12 percent grade for 5 minutes. Exercise studies should not be performed
on individuals for whom exercise is contraindicated. The methodology of a qualified,
competent facility should be accepted. In any case, a precise description of the protocol
that was followed must be provided.
It must be recognized that application of the criteria in Listing 4.13B may be limited
in individuals who have severe calcific (Monckeberg's) sclerosis of the peripheral
arteries or severe small vessel disease in individuals with diabetes mellitus.
4.01 CATEGORY OF IMPAIRMENTS, CARDIOVASCULAR SYSTEM
4.02 Congestive heart failure (manifested by evidence of vascular congestion such as hepatomegaly,
peripheral or pulmonary edema). With:
Persistent congestive heart failure on clinical examination despite prescribed therapy;
Persistent left ventricular enlargement and hypertrophy documented by both:
Extension of the cardiac shadow (left ventricle) to the vertebral column on a left
lateral chest roentgenogram; and
ECG showing QRS duration less than 0.12 second with Sv1 plus Rv5 (or Rv6 ) of 35 mm. or greater and ST segment depressed more than 0.5 mm. and low, diphasic or inverted T waves in leads with tall R waves, or
Persistent “mitral” type heart involvement documented by left atrial enlargement shown by double shadow
on PA chest roentgenogram (or characteristic distortion of barium-filled esophagus)
ECG showing QRS duration less than 0.12 second with Sv1 plus Rv 5 (or Rv6 ) of 35 mm. or greater and ST segment depressed more than 0.5 mm. and low, diphasic or inverted T waves in leads with tall R waves, or
ECG evidence of right ventricular hypertrophy with R wave of 5.0 mm. or greater in
lead V1 and progressive decrease in R/S amplitude from lead V 1 to V5 or V6 ; or
Cor pulmonale (non-acute) documented by both:
Right ventricular enlargement (or prominence of the right out-flow tract) on chest
roentgenogram or fluoroscopy; and
ECG evidence of right ventricular hypertrophy with R wave of 5.0 mm. or greater in
lead V1 and progressive decrease in R/S amplitude from lead V1 to V5 or V6 .
4.03 Hypertensive vascular disease. Evaluate under 4.02 or 4.04 or under the criteria for the affected body system.
4.04 Ischemic heart disease with chest pain of cardiac origin as described in 4.00E. With:
Treadmill exercise test (see 4.00F and G) demonstrating one of the following at an
exercise level of 5 METs or less:
Horizontal or downsloping depression (from the standing control) of the ST segment
to 1.0 mm. or greater, lasting for at least 0.08 second after the J junction, and
clearly discernible in at least two consecutive complexes which are on a level baseline
in any lead; or
Junctional depression occurring during exercise, remaining depressed (from the standing
control) to 2.0 mm. or greater for at least 0.08 second after the J junction (the
so-called slow upsloping ST segment), and clearly discernible in at least two consecutive
complexes which are on a level baseline in any lead; or
Premature ventricular systoles which are multiform or bidirectional or are sequentially
inscribed (3 or more); or
ST segment elevation (from the standing control) to 1 mm. or greater; or
Development of second or third degree heart block; or
In the absence of a report of an acceptable treadmill exercise test (see 4.00G), one
of the following:
Transmural myocardial infarction exhibiting a QS pattern or a Q wave with amplitude
at least 1/3rd of R wave and with a duration of 0.04 second or more. (If these are
present in leads III and aVF only, the requisite Q wave findings must be shown, by
labeled tracing, to persist on deep inspiration); or
Resting ECG findings showing ischemic-type (see 4.00F1) depression of ST segment to
more than 0.5 mm. in either (a) leads I and aVL and V6 or (b) leads II and III and aVF or (c) leads V3 through V6 ; or
Resting ECG findings showing an ischemic configuration or current of injury (see 4.00F1)
with ST segment elevation to 2 mm. or more in either (a) leads I and aVL and V6 or (b) leads II and III and aVF or (c) leads V3 through V6 ; or
Resting ECG findings showing symmetrical inversion of T waves to 5.0 mm. or more in
any two leads except leads III or aVR or V1 or V2 ; or
Inversion of T wave to 1.0 mm. or more in any of leads I, II, aVL, V 2 through V6 and R wave of 5.0 mm. or more in lead aVL and R wave greater than S wave in lead
“Double” Master Two-Step test demonstrating one of the following:
Ischemic depression of ST segment to more than 0.5 mm. lasting for at least 0.08 second
beyond the J junction and clearly discernible in at least two consecutive complexes
which are on a level baseline in any lead; or
Development of a second or third degree heart block; or
Angiographic evidence (see 4.00H) (obtained independent of Social Security disability
evaluation) showing one of the following:
50 percent or more narrowing of the left main coronary artery; or
70 percent or more narrowing of a proximal coronary artery (see 4.00H3) (excluding
the left main coronary artery); or
50 percent or more narrowing involving a long (greater than 1 cm.) segment of a proximal
coronary artery or multiple proximal coronary arteries; or
Akinetic or hypokinetic myocardial wall or septal motion with left ventricular ejection
fraction of 30 percent or less measured by contrast or radio-isotopic ventriculographic
Resting ECG findings showing left bundle branch block as evidenced by QRS duration
of 0.12 second or more in leads I, II, or III and R peak duration of 0.06 second or more in leads I, aVL, V5 or V6, unless there is
a coronary angiogram of record which is negative (see criteria in 4.04B7).
4.05 Recurrent arrhythmias (not due to digitalis toxicity) resulting in uncontrolled repeated episodes of cardiac
syncope and documented by resting or ambulatory (Holter) electrocardiography.
4.09 Myocardiopathies, rheumatic or syphilitic heart disease. Evaluate under the criteria in 4.02, 4.04, 4.05, or 11.04.
4.11 Aneurysm of aorta or major branches (demonstrated by roentgenographic evidence). With:
Acute or chronic dissection not controlled by prescribed medical or surgical treatment;
Congestive heart failure as described under the criteria in 4.02; or
Renal failure as described under the criteria in 6.02; or
Repeated syncopal episodes.
4.12 Chronic venous insufficiency of the lower extremity with incompetency or obstruction of the deep venous return,
associated with superficial varicosities, extensive brawny edema, stasis dermatitis,
and recurrent or persistent ulceration which has not healed following at least 3 months
of prescribed medical or surgical therapy.
4.13 Peripheral arterial disease. With:
Intermittent claudication with failure to visualize (on arteriogram obtained independent
of Social Security disability evaluation) the common femoral or deep femoral artery
in one extremity; or
Intermittent claudication with marked impairment of peripheral arterial circulation
as determined by Doppler studies showing:
Resting ankle/brachial systolic blood pressure ratio of less than 0.50; or
Decrease in systolic blood pressure at ankle on exercise (see 4.00K) to 50 percent
or more of preexercise level and requiring 10 minutes or more to return to preexercise level; or
Amputation at or above the tarsal region due to peripheral arterial disease.