Recurrent Arrhythmias

Residual Functional Capacity Assessment for Recurrent Arrhythmias

What Is RFC?

When your recurrent arrhythmias are 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 recurrent arrhythmias. The lower your RFC, the less the Social Security Administration believes you can do.

Assessing Impairment Caused by Recurrent Arrhythmias

If the SSA gives an RFC for an arrhythmia, it is the tacit admission of a significant work-related impairment. Such RFCs should have environmental restrictions. Examples of environmental limitations would be no driving commercial vehicles, no work flying airplanes, no use of dangerous equipment, and no work at unprotected heights.

Some claimants with arrhythmias have had electrophysiologic studies (EPS) in which the evaluating specialist has determined how easy it is to induce the arrhythmia with electrical stimulation delivered through a catheter; this is a way of evaluating the efficacy of treatment. If there is this kind of information available, which there usually is not, environmental limitations and RFCs can be more appropriately individualized. If you have a treating arrhythmia specialist, you should make every effort to obtain that physician’s opinion about a safe level of exercise and what environmental restrictions are appropriate. However, if the treating physician—however knowledgeable—recommends levels of exertion far more restrictive than would appear justifiable based on the available information, the SSA should inquire further into the basis for the physician’s reasoning.

Unfortunately, there is very little objective information in the medical literature about different kinds of arrhythmias and the capacity to perform various kinds of jobs in terms of danger to the worker and others; reasonable medical judgment must be applied on a case by case basis in view of the complexity of the possible impairments. Some cases are obvious, however. A person who is having breakthrough arrhythmias should not be cited a job as an air traffic controller, police officer, truck driver, river barge captain, etc.

Pacemakers

Pacemakers are implantable electronic devices that artificially stimulate the heart to maintain a regular rate and rhythm, and are frequently seen in cardiac disability claims. They are especially useful in maintaining an adequate heart rate when bradycardia is present. As far as disability determination is concerned, the important question for claimants with pacemakers is whether they can increase their heart rate to accommodate increasing levels of exertion. If the heart is capable of responding, modern pacemakers can automatically adapt to increasing heart rates as needed. In these situations, the SSA does not consider the presence of pacemaker per se a reason for exertional limitation. Because of the SSA’s position, many claimants have failed to receive exertional limitations on RFC by virtue of just having a pacemaker. However, this may be a presumptive and unsupportable policy by the SSA. Programming a pacemaker so that the maximal attainable heart rate is too low will decrease exercise tolerance, while programming the pacemaker too high for maximum heart rate could be harmful to the patient.

In view of this fact, it is reasonable to limit all claimants with pacemakers to no higher than a medium RFC in the absence of individual evidence objectively showing greater exertional capacity. Maximal age-predicted heart rate is calculated by the simple equation:

Predicted Maximum Heart Rate = 220 – Age

There are some claimants who have what is known as a fixed rate pacemaker and cannot significantly increase their heart rate as needed. In these cases, it is not unreasonable to restrict exertion to a light work RFC. In all claimants with pacemakers, the SSA accepts environmental limitations against exposure to intense electrical or magnetic fields.

It should be remembered that pacemakers treat arrhythmias and do not otherwise mitigate the severity of any additional heart disease, such as coronary artery obstructions or chronic heart failure. Claimants with pacemakers frequently do have additional cardiac impairments, and require additional appropriate restrictions.

Pacemakers and Sleep Apnea

It has recently been reported that as many as 59% of pacemaker patients have sleep apnea, and in 21% of such patients, the sleep apnea is severe. This association of sleep apnea in the pacemaker population is not yet widely known, and it is unlikely that the SSA will consider sleep apnea when assessing medical severity in claimants with pacemakers. However, specific questions should be asked, such as whether you suffer from excessive daytime sleepiness, whether you wake up with headaches, and whether your spouse has noticed periods of cessation of breathing during your sleep.

It is not suggested here that pacemakers cause sleep apnea, but that patients who require pacemakers also have a substantial statistical risk for having sleep apnea because of the nature of their underlying disease. Therefore, the possibility of sleep apnea should be kept in mind when reviewing claims of pacemaker patients; some may also need evaluation under Listing 3.10 (Sleep-Related Breathing Disorders).

ICDs

ICDs always require the same environmental restrictions as pacemakers in regard to avoiding strong magnetic fields, electromagnetic fields (EMFs), and also additional restrictions in the form of limitations against working at unprotected heights, driving commercial vehicles, use of firearms, flying airplanes, working with heavy or dangerous equipment the use of which could pose a danger to the claimant or others, or any other activity in which a sudden electrical shock could endanger the claimant or other people.

Such shocks are not trivial; they can be painful and may come at any time as a surprise to the patient. Multiple shocks can be particularly incapacitating for 30 minutes or longer, but it also depends on the individual and the severity of the shocks in context of the underlying disease. It is very important to obtain details of shocks from the claimant and how they affect his or her function. Inappropriate exposure of ICDs to EMFs can randomly re-program the device so that it cannot correct bradycardia, or deliver ATP or shocks as needed until the device is re-programmed. Obviously, this could be fatal.

Additionally, the need of an ICD implies a severe and difficult to control ventricular arrhythmia. Such arrhythmias further imply severe underlying ischemic heart disease, usually coronary artery disease. So the chances of the claimant having additional severity in addition to the ICD per se are great.

Since the ICD is set to discharge at a given heart rate, the claimant must not be given an RFC that will reach that threshold. Also, as the rate increases so does the likelihood of precipitating a dangerous ventricular arrhythmia. No assumptions on the part of the SSA adjudicator can be made in that regard. Every patient’s arrhythmia is different and the ICDs can be flexibly programmed by the treating physician. The SSA adjudicator must understand enough about ICDs and have the details of its programming, or an inappropriate RFC is likely.

All factors considered, it is extremely unlikely that the SSA could justify an exertional level above light work for claimants who have an ICD, without clearance from the treating cardiologist along with the objective data (exercise test performance) showing that ability. Medium work is too likely to induce a dangerous rhythm and elevate heart rate so that the ICD will discharge. Many of these claimants are easily limited to sedentary work.

Chronic Atrial Fibrillation

Chronic atrial fibrillation alone would preclude heavy work, because of loss of atrial function in moving blood into the ventricles. An important additional factor is the rate at which the AF drives the ventricles (ventricular response rate); the faster the resting ventricular rate, then the less chronotropic reserve the person has for exertional activities. To control this abnormally fast rate, the treating physician will give medication such as calcium blockers and beta blockers. The goal is to maintain a resting ventricular rate of 60 to 80 beats/min that does not exceed 100 beats/min after slight exercise. With a requirement for heart rates so controlled, it could be argued that the RFC should not exceed light work.

The anticoagulation needed to prevent cerebral embolism presents an additional environmental limitation. Usually, the RFC will contain some general wording such as, “The claimant should not work around sharp objects or blades where there is a significant likelihood of being cut.” The vocational analyst usually does not have much difficulty in citing jobs that satisfy these criteria, but such restrictions could make a difference in a few claims. A factor that is more nebulous and difficult to apply vocationally is nevertheless a valid medical restriction: the claimant must not engage in activities in which severe blunt blows to the body are possible. Such blows could cause internal bleeding. Obviously, jobs falling in this category would include boxing, wrestling, and other types of contact sports. Furniture moving, or any kind of carrying or handling heavy objects in which bruising type blows are likely could result in serious internal bleeding and should be avoided. The SSA has never developed specific policies in regard to the types of jobs that should be avoided in anticoagulated individuals and has a tendency to apply few restrictions to claimants who are anticoagulated.

Ventricular Arrhythmias

If a ventricular arrhythmia is precipitated by exercise testing in a person with ischemic heart disease, the SSA should provide an RFC below the MET level that causes the arrhythmia. If there is an electrophysiologic study (EPS) which provides information as to the heart rate at which an arrhythmia appears, then the RFC should be low enough that such a heart rate will not likely occur. For example, if a life-threatening arrhythmia appears at a heart rate of 100 beats/min, it is doubtful the claimant could safely do medium work. If no timely exercise testing or EPS is available, the SSA adjudicator must make a medical judgment about what RFC will not induce recurrence of the arrhythmia based on the available information. However, such judgment is susceptible to substantial error without objective information about what level of exertion or heart rate induces the arrhythmia. Correlation of Holter monitor results with ADL logs can also be helpful in this matter.

CPVT is a very dangerous arrhythmia that should be treated with an implantable defibrillator. CPVT is exercise-related, which means that the risk of triggering an episode of this deadly arrhythmia increases with exercise. Even if there is an ICD implanted, the RFC should not exceed light work in the absence of exercise stress tests data showing a higher exercise capacity without inducing the arrhythmia.

Driving and ICDs

Although frequent arrhythmias resulting in syncope or significant alterations in consciousness are obviously a prohibition to driving, most patients with arrhythmias pose a small risk to public safety in private use of an automobile. Even if an ICD is implanted, incapacitation during the usual amounts of private driving has been estimated to be less than 1% in asymptomatic patients.

Commercial driving is a different matter, as driving periods are longer, emotional and physical stress greater, and trucks are much more dangerous than private vehicles when involved in accidents. In the case of ICDs, the American Heart Association (AHA) recommends following the guidelines previously prepared for cardiovascular disease in determining the eligibility for commercial driving licenses. Naturally, these guidelines are very restrictive.

Mortality and Implantable Cardiac Defibrillators

Does the need of an ICD imply a particular cardiac risk of death? This question can be answered in the affirmative if left ventricular ejection fraction (LVEF) is also considered. If only the ICD is considered, there is an annualized mortality ranging from 2-11% in various studies. If, however, one considers ICDs and a LVEF of less than 25%, then the mortality is 27.2% at 1 year and 50.5% at 3 years. A claimant with the presence of an ICD and a LVEF less than 25% should never be assigned a RFC for more than sedentary work. Moreover, such cases should be carefully reviewed for the possibility of finding equivalent severity to the listing.

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