Can I Get Disability Benefits for Recurrent Arrhythmias?
- About Recurrent Arrhythmias and Disability
- How to Get Disability Benefits for Recurrent Arrhythmias by Meeting a Listing
- Residual Functional Capacity Assessment for Recurrent Arrhythmias
- Getting Your Doctor’s Medical Opinion About What You Can Still Do
If you have persistently irregular heartbeats, called recurrent arrhythmias by the Social Security Administration, Social Security disability benefits may be available. To determine whether you are disabled by your recurrent arrhythmias, the Social Security Administration first considers whether your condition is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See How to Get Disability Benefits for Recurrent Arrhythmias by Meeting a Listing. If you meet or equal a listing because of your recurrent arrhythmias, you are considered disabled. If your condition is not severe enough to equal or meet a listing, the Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite the recurrent arrhythmias), to determine whether you qualify for disability benefits at Step 4 and Step 5 of the Sequential Evaluation Process.
Arrhythmias are abnormalities in the rate or rhythm of the heartbeat. In order to efficiently pump blood, the various parts of the heart muscle have to be excited to contract in a smooth, sequential manner. This occurs by a wave of electrical activity that starts at slightly different times in different parts of the heart. The conduction system of the heart consists of nerves that branch into increasingly smaller branches. The largest cardiac nerve is called the Bundle of His. The His Bundle divides into large nerves known as the left bundle branch and the right bundle branch. Further branching eventually ends in the small nerve fibers spread through the heart muscle (Purkinje fibers). There are two small pieces of nerve tissue known as the sinoatrial node (SA node) and the atrioventricular node (A-V node) that start and control electrical impulses into the His Bundle. If there is disease of either the conduction system or the heart muscle itself, arrhythmias may result. For example, in ischemic heart disease; when the heart muscle or nerve fibers are deprived of adequate blood flow as a result of coronary artery obstructions, then electrical propagation in the heart is disrupted. Additionally, electrical impulses may start in areas of the heart out of normal sequence so that the heart contracts abnormally and blood is suboptimally ejected into the circulation.
Bradycardia and Tachycardia
Heart rates below 60 beats/minute (bradycardia) or above 100 beats/minute (tachycardia) are abnormal by definition. Tachycardia or bradycardia do not necessarily cause symptoms; individual differences and numerous medical factors influence when symptoms appear. Both bradycardia and tachycardia may cause symptoms of weakness, dizziness, or chest discomfort; with too fast or too slow a heart rate, insufficient blood is pumped by the heart, there is inadequate blood flow to the brain, and consequently loss of consciousness or even death in some cases. Generally, with bradycardia heart rates have to fall into the 40 beat/minute range before symptoms appear in ordinary activities; more strenuous activities might cause symptoms to appear at much higher heart rates such as 60 beats/minute (BPM) during those activities. Tachycardia can drive heart rates into the several hundred beats/minute range with resultant symptoms. The more prolonged the episodes of bradycardia or tachycardia, the more likely the patient is to have symptoms. These rate-related problems can often be controlled with a pacemaker with minimum disruption of the person’s functional capacity, unless there is additional severe underlying disease that imposes exertional limitations. See Residual Functional Capacity Assessment for Recurrent Arrhythmias.
Ventricular arrhythmias arising from the ventricular walls of the heart are a common cause of sudden death in people with coronary artery disease, accounting for several hundred thousand deaths yearly. Silent ischemia, in which there are no warning symptoms of angina with exertion, can lead to ventricular arrhythmia and sudden death. Individuals with scar tissue from prior heart attacks are susceptible to abnormal electrical activation of the heart and resulting ventricular arrhythmias. Ventricular arrhythmias can also be congenital (relatively rare), or caused by the very drugs used to treat the arrhythmia—sometimes with a fatal result.
A distinction is sometimes made between life-threatening arrhythmias (malignant arrhythmias) and those that are less dangerous (benign arrhythmias). The distinction between them can be appropriately made in most cases. Since the left ventricle of the heart is the main pumping chamber, arrhythmias arising from it tend to be more dangerous than those arising in the right ventricle.
Ventricular tachycardia (VT) is present when there are 3 abnormal ventricular heart beats in a row. VT is extremely serious if prolonged into many beats, because the heart cannot pump blood efficiently. In such instances VT may cause dizziness or loss of consciousness due to decreased blood flow to the brain. Ventricular tachycardia may degenerate to ventricular fibrillation.
Ventricular fibrillation (VF) is an arrhythmia found in cardiac arrest. In ventricular fibrillation, the heart’s electrical activity is further decreased, and no blood is being pumped from the heart to the rest of the body. With the onset of ventricular fibrillation as occurs in many cases of sudden death from arrhythmia, there is loss of consciousness within seconds and death rapidly follows without medical intervention.
Implantable cardioverter-defibrillators (ICDs) deliver automatic shocks to restore normal heart rhythm by resetting the electrical cycle of the heartbeat. They are used for life-threatening ventricular arrhythmias that have not been controllable with medication, and these devices have saved a significant number of lives that otherwise would have been lost. Therefore, ICDs are an important part of the medical treatment for arrhythmias that resist treatment. Newer ICDs can be set to monitor for a heart rate that is considered too fast; if that rate is reached, then the ICD starts anti-tachycardia pacing (ATP). ATP allows avoidance of shocks unless absolutely necessary. Also, the newer ICDs can be programmed to deliver increasingly energetic shocks when the patient’s particular type of arrhythmia occurs. ICDs and pacemakers can exist in the same patient and interactions between the devices can be dangerous, but this is changing as ICDs become increasingly sophisticated at also performing pacemaker functions. Like pacemakers, ICDs contraindicate exposure to the intense magnetic field of magnetic resonance imaging (MRI) of any part of the body.
Some arrhythmias originate from or near the small atrial chambers of the heart. Such atrial fibrillation (AF) can often be controlled with drugs and is a very common medical problem. Since the atria are not the heart’s main pumping chambers, their inability to pump blood efficiently is rarely life-threatening in itself. Although severe atrial fibrillation may cause symptoms such as lightheadedness or dizziness, it does not result in the sudden death that may be associated with ventricular arrhythmias. However, the presence of AF means that stagnant blood in the atrial chambers can form blood clots. For example, left atrial blood clots (thrombi) can be pumped into the left ventricle and then ejected into the aorta with the normal direction of blood flow. Some of this flow goes to the brain through the internal carotid artery, carrying the thrombus with it. The clot lodges in a cerebral artery, terminating blood flow to that area of the brain, and the result is an ischemic stroke. The danger of atrial clot formation is so great—the cause of 20-25% of strokes—that people with chronic atrial fibrillation are usually anticoagulated with aspirin or warfarin (Coumadin). Unfortunately, anticoagulation carries the risk of easy bleeding that costs some people their lives; still, it is much safer than not taking the anticoagulant for people with a high risk of stroke. AF can result from ischemic heart disease, cardiomyopathies, and structural heart abnormalities. AF also can be caused by aging. However, most AF seen by the SSA is related to underlying heart disease.
There is now a study indicating that AF increases the risk of cognitive decline in all important areas—executive functioning, abstract reasoning, verbal memory, visual memory and organization, and scanning and tracking. In other words, difficulty with logical thinking is four times more likely in patients with AF, even if they have no other evident disease. Although the reasons for cognitive abnormalities were initially unclear, abnormal neuropsychological testing is now supported by imaging studies showing atrophy of the hippocampus—a structure with critical roles in memory. This is new and important information for the medical profession; neither treating physicians nor SSA adjudicators routinely consider the possibility of cognitive decline in millions of people with atrial fibrillation.
The SSA should do enough screening in AF cases to determine if cognitive decline is a possible issue and further evaluation indicated. In issues of cognitive decline, it is not enough to rely on the absence of an allegation by the claimant as they may not be thinking clearly. Specific evaluation of the medical evidence with awareness of this possibility should be done by the SSA. If a treating source has had only casual contact with you, undue weight should not be given to their opinion; at least general inquiry into your activities of daily living regarding problems in memory, planning and reasoning should be done. Family members, especially the spouse, can be helpful. It is revealing if there are activities that you could perform in the past, but can no longer do; the treating physicians may not know about this kind of change, but a spouse will often know about mental declines in cognitive ability even if you are too embarrassed to admit the fact.
Heart blocks are arrhythmias that can produce temporary or permanent interruption of electrical impulses in the nerve pathways of the heart. Congenital heart blocks date from birth and may involve different locations in the heart’s conduction system.
There may be blocks of conduction of electrical impulses through the left bundle branch of nerves (left bundle branch block, LBBB), the right bundle branch of nerves (right bundle branch block RBBB), or the smaller branches (fascicles) of the left bundle branch of nerves. LBBB is more serious than an RBBB, because it involves the left ventricle. Some patients with congenital LBBB or isolated LBBB have little limitation of cardiac function. However, LBBB is frequently associated with ischemic heart disease and if so, the prognosis for the patient is poorer. RBBB does not cause significant functional limitation.
Other types of heart block are possible. A first degree atrioventricular (AV) block does not cause symptoms or result in functional limitations. Heart blocks may also be classified as Type I (Mobitz I) and II (Mobitz II) second degree AV heart blocks. Type II blocks are more serious than Type I blocks, but not as severe as third degree (complete) AV heart blocks. Complete heart blocks require treatment with a pacemaker to keep the heart rate normal. Many symptomatic Type II second degree heart blocks also require treatment with a pacemaker, particularly when other types of heart block are also present.