Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Angina, Unstable


Related Terms

  • Accelerating Angina
  • Acute Coronary Insufficiency
  • Crescendo Angina
  • Intermediate Coronary Syndrome
  • New-Onset Effort Angina
  • Preinfarction Angina
  • Preinfarction Syndrome
  • Progressive Angina
  • Rest Angina

Differential Diagnosis

Specialists

  • Cardiologist, Cardiovascular Physician

Comorbid Conditions

Factors Influencing Duration

Factors influencing the length of disability include the individual's response to therapy, the presence or absence of complications of unstable angina (especially the presence or absence of heart attack), and the availability of lighter or part-time work on either a temporary or permanent basis. A cardiac rehabilitation program may facilitate recovery and shorten the period of disability.

Medical Codes

ICD-9-CM:
411.1 - Intermediate Coronary Syndrome; Impending Infarction; Preinfarction Angina; Preinfarction Syndrome; Unstable Angina

Overview

Unstable angina is usually considered as angina occurring at rest, usually longer than 20 minutes within the past week.

This condition represents a degree of hardening of the coronary arteries (coronary atherosclerosis) between that which characterizes stable effort angina and myocardial infarction (heart attack). Unstable angina is caused by temporarily inadequate oxygen delivery to a portion of the heart muscle (myocardial ischemia). Not all individuals with unstable angina go on to infarction, although when infarction does occur, it is considered a serious development.

Incidence and Prevalence: The annual incidence of unstable angina in the industrialized world among the general population is about 6 out of 10,000 (Sarkees). Some 2.5 million hospital admissions worldwide are attributed to unstable angina and non-ST segment elevation MI resulting in a major cause of mortality and morbidity in the Western world (Grech).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Since unstable angina is an expression of coronary atherosclerosis, in general, risk factors for unstable angina are the same as those for atherosclerosis.

Source: Medical Disability Advisor



Diagnosis

History: Pain in the center of the chest under the breastbone (sternum) occurring at rest or with minimal exertion is typical. The individual often reports a dull, heavy, or burning sensation, not a sharp one. Pain may radiate to the arms, neck, back, shoulders or jaw and can occur in one of these regions without involving the chest.

Physical exam: During an episode of rest angina, the exam may reveal a change in the individual's blood pressure (hypertension or hypotension), disordered heart rhythm (gallop), a transient heart murmur, or skipped beats. Often, no abnormalities are present on physical exam.

Tests: A 12-lead electrocardiogram (ECG) during pain at rest may show characteristic changes of the ST-T segments (ST segment elevation or depression, inverted T waves) but may occasionally be normal. A physical stress test such as a treadmill or a chemical stress test such as a dobutamine dipyridamole, or Adenosine study may be performed if the chest pain does not recur or occurs infrequently. Coronary angiography during cardiac catheterization is often indicated to define anatomy and refine the prognosis. Blood tests to measure the release of cardiac enzymes from dead heart tissue help confirm or exclude the diagnosis of myocardial infarction. Blood enzyme tests usually remain normal with unstable angina since actual damage to the heart is absent or minimal. If these tests are abnormal, the diagnosis is myocardial infarction, not unstable angina. These enzyme blood tests include CK-MB, troponin-T, troponin-I, CK-MB isoforms, and myoglobin.

In some emergency rooms, there is a "holding unit" that keeps unstable angina patients until the next morning. Then, (1) if chest pain persists or has been recurring, the person is admitted with unstable angina, (2) if enzymes and ECGs on several occasions have shown myocardial infarction has not occurred, and if the chest pain has resolved, either exercise stress testing or CT scan coronary angiography after intravenous contrast agent administration are performed. If there is no ischemia on stress test imaging, or if there are no significant coronary lesions on CT coronary angiograms, the individual is low risk and is discharged, sometimes with medications for "risk factors" (e.g. high cholesterol, high blood pressure, or diabetes), or (3) if myocardial infarction has not occurred, and yet episodes of chest pain continue to occur, or if stress testing shows ischemia, or if CT angiography shows significant lesions, the individual is usually admitted for a cardiac procedure.

Source: Medical Disability Advisor



Treatment

Initial medical treatment during hospitalization for unstable angina typically includes a number of medications.

If testing indicates “high risk” and/or recurring episodes of ischemia without infarction are occurring, coronary arteriography is performed. It will indicate whether the blocked arteries can be successfully treated by a coronary revascularization procedure. Current revascularization procedures include balloon angioplasty with or without the addition of a metal “stent” to mechanically hold open the artery, cleaning out the atherosclerotic material using a sharp device (rotational atherectomy), laser removal of atherosclerotic material, and coronary artery bypass grafting (CABG) using veins from the legs or arteries from the chest wall.

Some individuals are determined to have only mild coronary artery disease and normal heart pumping function. These low-risk individuals are treated medically (multiple medications) instead of with a procedure. Some individuals are found to have extensive coronary artery disease, but in a pattern that can not be treated with a revascularization procedure. These individuals are also treated medically, because the only potentially available procedure is cardiac transplantation. Thus, individuals treated medically include both those with the best prognosis (mild coronary disease) and the worst prognosis (severe, “end-stage” coronary disease).

Source: Medical Disability Advisor



Prognosis

This discussion assumes the diagnosis remains unstable angina after admission and testing, and that myocardial infarction did not occur. The outcome of unstable angina depends on several factors, one being the severity of the underlying coronary artery disease and whether it involves one, two, or all three of the coronary arteries. Prognosis also depends on the type of treatment subsequently given. In many cases, revascularization by angioplasty, directional atherectomy, stenting, or CABG improves the prognosis. Unstable angina will either resume a stable course or progress to a heart attack. In general, the prognosis for unstable angina is substantially worse compared to chronic stable angina with in-hospital death and infarction occurring among 5% to 10% of patients within the first week and another 5% to10% dying within a month after the acute episode (Grech).

Source: Medical Disability Advisor



Rehabilitation

Once the individual is fully evaluated, treated, and the condition has stabilized, he/she may be a candidate for participation in a monitored cardiac rehabilitation program. This program consists of gradually progressive exercise under the supervision of cardiac nurses with resuscitation equipment available in case exercise precipitates cardiac arrhythmias, angina, or cardiac arrest.

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistAngina, Unstable
Physical or Occupational TherapistFrom 2 to 5 visits per week within 3 to 12 weeks

Source: Medical Disability Advisor



Complications

The major complication of unstable angina is a myocardial infarction. Sudden death from a ventricular arrhythmia may occur. Additional complications arising from a myocardial infarction may also develop.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Activity is significantly limited during unstable angina. Restriction to no work or lighter and/or part-time work may be required after unstable angina has resolved, depending on the individual's functional classification following a treadmill or other stress test. Return to work for individuals who have an acute myocardial infarction (AMI) or go on to CABG is based on the time needed to recover from the AMI or surgery.

Risk: Consideration must be given here for both risk factors that must be addressed as well as risk of the work environment. For more information, refer to "Work Ability and Return to Work," page 264, and to "Disease and Injury Causation" pages 238-239.

Capacity: Stress imaging remains the ideal method for stratifying a patient's capacity. Performance can be translated into capacity. Please refer to "Work Ability and Return to Work," page 261, Table 14-6.

Tolerance: Psychological factors will predominate here, in part as a result of the concern of not being able to predict when symptom onset will occur. For more information, refer to "Work Ability and Return to Work," page 266.

Source: Medical Disability Advisor



Maximum Medical Improvement

Treated unstable angina without myocardial infarction would reach MMI optimally within 45 days.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Is unstable angina the correct diagnosis?
  • If the diagnosis was uncertain, were other conditions with similar findings ruled out (i.e., coronary artery spasm, costochondritis, pulmonary embolism, pericarditis, or pleurisy)?

Regarding treatment:

  • Did the individual accept and receive, or refuse, the appropriate treatment?
  • Did the individual participate in a structured and medically supervised cardiac rehabilitation program to increase exercise ability and to educate him/her on safe levels of activity?
  • Is the individual compliant with ongoing medical management of things such as blood pressure, cholesterol, and smoking?
  • Is the individual compliant with a progressively increasing exercise program?

Regarding prognosis:

  • Did the angina stabilize following medical interventions?
  • Was percutaneous (angioplasty/stent/atherectomy) or surgical revascularization (CABG) done? If so, what was the outcome?
  • Did individual participate in a cardiac rehabilitation program, as recommended? If not, are barriers present that prevent compliance with rehabilitation recommendations, i.e., insurance limitations, lack of transportation, or lack of motivation?
  • Was the unstable angina complicated by a myocardial infarction?
  • Did the individual have a prior infarction resulting in decreased cardiac pumping ability?
  • Does individual have any medical conditions that may affect ability to recover or influence prognosis (obesity, hypertension, diabetes mellitus, lung disease, heart valve disease, peripheral atherosclerosis, cardiomyopathy, or alcoholism)?

Source: Medical Disability Advisor



References

Cited

Grech, E. D. , and D. R. Ramsdale. "Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction." BMJ 326 (7401) (2003): 1259-1261.

Haskell, W. L. , et al. "Task Force II: Determination of Occupational Working Capacity in Patients With Ischemic Heart Disease." Journal of the American College of Cardiology 14 (4) (1989): 1016-1042.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Nease, D. E. "Depression in Post-MI Patients: An Opportunity for Primary Care. Am Fam Physician." American Family Physician 80 (9) (2009): 917.

Sarkees, M. L. , and A. A. Bavry. "Acute coronary syndrome (unstable angina and non-ST elevation MI)." Clinical Evidence (2009): NA.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

General

Belkic, K. L. , et al. "Is job strain a major source of cardiovascular disease risk?" Scandinavian Journal of Work, Environment and Health 30 (2004): 85-128.

Cannon, Christopher P., and E. Braunwald. "Unstable Angina." Heart Disease: A Textbook of Cardiovascular Medicine. Eds. E. Braunwald, et al. 6th ed. Philadelphia: W.B. Saunders, 2001. 1232-1255.

Kales, S. N. , et al. "Emergency duties and deaths from heart disease among firefighters in the United States." New England Journal of Medicine 356 (2007): 1207-1215.

van Amelsvoort, LG, et al. "Impact of one year of shift work on cardiovascular disease risk factors." Journal of Occupational and Environmental Medicine 46 (2004): 699-706.

Source: Medical Disability Advisor






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