Sign-in
(your email):
(case sensitive):



 
 

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.

Coronary Atherosclerosis


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Rehabilitation | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Duration Trends | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
414.00 - Coronary Atherosclerosis; of Unspecified Type of Vessel, Native or Graft
414.01 - Coronary Atherosclerosis; of Native Coronary Artery
414.02 - Coronary Atherosclerosis; of Autologous Biological Bypass Graft
414.03 - Coronary Atherosclerosis; of Nonautologous Biological Bypass Graft
414.04 - Coronary Atherosclerosis; of Artery Bypass Graft; Internal Mammary Artery
414.05 - Coronary Atherosclerosis; of Unspecified Type of Bypass Graft
414.06 - Coronary Atherosclerosis; of Native Coronary Artery of Transplanted Heart
414.07 - Coronary Atherosclerosis; of Bypass Graft (Artery) (Vein) of Transplanted Heart
414.8 - Ischemic Heart Disease, Chronic, Other Specified Forms
414.9 - Chronic Ischemic Heart Disease, Unspecified; Ischemic Heart Disease NOS

Related Terms

  • Arteriosclerotic Heart Disease
  • ASHD
  • CAD
  • Chronic Ischemic Heart Disease
  • Coronary Artery Disease

Overview

Image Description:
Coronary Atherosclerosis - The heart and its major arteries and surface vessels reveals the presence of accumulated fatty deposits known as plaque. An enlarged segment of an artery shows the narrowed interior passageway of the artery as a result of the build-up of plaque on its walls.
Click to see Image

Coronary atherosclerosis is an inflammatory disease characterized by the accumulation of white blood cells, cell debris, fatty substances (cholesterol and fatty acids), calcium, and fibrous tissue (plaque or atheromas) on the walls of the coronary arteries that supply the heart muscle. As plaque slowly increases in size over many years, the artery narrows in places (stenosis), and blood flow to part of the heart muscle is reduced. Cholesterol-containing plaques are highly dangerous even without narrowing of the vessel because the fibrous cap can be softened and rupture suddenly during acute heavy exercise or activity (e.g., athletic effort, shoveling snow). This can result in blood clot formation on top of the plaque that may totally obstruct the vessel, resulting in a heart attack (myocardial infarction). Even without the plaque rupturing, the stenosis may over time become so significant that the blood supply is inadequate to meet the needs of the heart (myocardial ischemia), and the affected part of the heart muscle no longer functions normally. Myocardial ischemia typically results in chest pain (angina pectoris), but may also cause no symptoms (silent ischemia).

Incidence and Prevalence: Coronary atherosclerosis is the most common form of heart disease and the leading cause of death for both men and women in the US. An estimated 16.3 million Americans have coronary heart disease, 7.0% of all Americans over the age of 20. In 2008, 405,309 people died from CHD. In 2009, over 1.5 million hospital discharges noted CHD as a factor (Roger; Schiller).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for coronary atherosclerosis include male gender, advanced age, family history of atherosclerosis particularly before age 50, high blood pressure (hypertension), diabetes mellitus, a high level of total cholesterol and / or a high level of low-density lipoprotein (LDL) cholesterol and a low level of high-density lipoprotein (HDL) cholesterol (dyslipidemia). Other risk factors include high levels of certain fats (triglycerides) in the blood especially among women, smoking and exposure to second-hand smoke, obesity and poor physical fitness. Emotional stresses including hostility, anger, depression, and anxiety are thought to predispose individuals to developing coronary artery disease. The term "metabolic syndrome," encompasses many risk factors for coronary atherosclerosis, including obesity, hypertension, insulin resistance, and dyslipidemia.

Among individuals younger than 75 years of age, coronary atherosclerosis is at least twice as likely to occur in men compared to women. Increased age becomes a risk factor for both sexes later in life. Men older than 45 years and women older than 55 years are at increased risk for developing coronary atherosclerosis (Roger).

Research continues into additional risk factors that may contribute to the development of coronary atherosclerosis (Genovese). Untreated sleep apnea (the abrupt starting and stopping of breathing during sleep) is believed to increase risk of hypertension. Inflammatory disease processes, such as the development of rheumatoid arthritis, may predispose individuals to developing coronary artery disease. Tests for elevated levels of C-reactive protein (CRP) in the blood, indicative of inflammation developing somewhere in the body, may help identify individuals at increased risk.

In contrast to high LDL cholesterol ("bad" cholesterol), high levels of HDL cholesterol ("good" cholesterol) decrease the risk for developing coronary atherosclerosis.

Source: Medical Disability Advisor



Diagnosis

History: Symptoms are not always apparent in the early stages of coronary atherosclerosis. In later stages, symptoms typically include exertional chest pain and pressure (angina) occasionally with radiation of pain to the arm, neck, or jaw that is relieved by rest. Individuals may have a history of heart attack (myocardial infarction). Individuals experiencing heart failure may report shortness of breath (dyspnea).

Physical exam: The exam is usually not directly helpful in this diagnosis, although it may reveal risk factors, such as hypertension, obesity, or metabolic syndrome. Visual evaluation of the retinal arteries with an ophthalmoscope gives an approximation of the degree of systemic artery atherosclerosis.

Tests: Blood cholesterol testing evaluates total cholesterol, HDL cholesterol, and LDL cholesterol, with high total cholesterol and LDL cholesterol readings suggesting coronary artery disease may be present. Other blood tests measure triglycerides, relevant blood sugar, and protein levels. A plain chest x-ray may reveal signs of heart failure, as well as any related abnormalities in the lungs or nearby blood vessels. An electrocardiogram (ECG) at rest looks for electrical abnormalities of the heart (such as prior myocardial infarction or left ventricular hypertrophy due to inadequately controlled hyper tension). An ECG during physical exertion (exercise stress test) can detect heart abnormalities induced by lack of coronary artery blood flow during exercise. If an individual cannot exercise to the degree needed for the stress test, a drug can be given to simulate the effect of exercise on the heart (pharmacologic stress test).

Nuclear scanning during a stress test (radionuclide stress test) involves injecting a radioactive isotope into a vein before imaging. During the test, the examiner can watch the flow of blood through the heart and can identify areas in which blood flow is decreased. Ultrasound (echocardiography), positron emission tomography (PET), and cardiac MRI also may be used during a stress test to observe heart rhythm, rate, and function during exertion and at rest.

The most definitive test related to coronary atherosclerosis is the coronary angiogram. During cardiac catheterization, a thin catheter is inserted into a vein in the arm, groin, or neck and guided into the opening of each of the coronary arteries. Once it is in place, radiopaque contrast dye is injected through the catheter into each coronary artery. An x-ray visually captures the movement of the dye through the artery. Through this procedure, the exact location and degree of blockage can be identified.

Techniques to improve diagnosis and early detection of coronary atherosclerosis continue to be developed. Among the newest is electron-beam computed tomography (EBCT), which detects and measures calcium deposits in and around the coronary arteries. Calcification of blood vessels is considered a risk factor for development of coronary atherosclerosis. A variant of this is CT coronary angiography, with intravenous dye injected and images obtained with a conventional CT scan unit. This is increasingly being done in emergency rooms for patients who present with possible or probable angina, and who are determined in the ER not to be having a myocardial infarction. If there is no calcified plaque in any coronary artery (no sign of atherosclerosis), the attending physicians can be confident the patient does not have unstable angina, and the patient can be discharged home.

Although x-ray angiography remains the gold standard for imaging existing coronary atherosclerosis and blockages, advances in MRI and CT technology, such as 128-slice multidetector-row CT angiography (CTA), and multidetector row CT (MDCT), show promise and may in some cases provide alternatives to x-ray angiography (Pearlman). X-ray angiography, however, offers the advantage of allowing diagnosis and treatment in the same session.

Source: Medical Disability Advisor



Treatment

Risk factors should be addressed to help prevent progression of coronary artery disease and, to some extent, reverse it. Many risk factors are potentially modifiable. Cessation of smoking is essential, as is minimizing second-hand smoke. Hypertension can be managed through diet (salt restriction), exercise, stress management, and medication. Diabetes also can be managed by diet, exercise, and medication, if necessary. Diet and exercise are also helpful in modifying cholesterol levels. If this approach is not adequate, cholesterol-lowering drugs can be added to treatment regimens. Drugs, specifically statins, have proven effective in both primary and secondary prevention of coronary atherosclerosis and offer other beneficial effects in reducing cardiovascular disease (Efthimiadis). A small daily dose of a drug (e.g., clopidogrel, abciximab, aspirin, coumadin) may be prescribed to help inhibit blood clotting.

Severe coronary atherosclerosis may require a procedure to remove areas of stenosis. Coronary angioplasty uses a catheter inserted into the coronary arteries to the site of blockage. On the end of the catheter is a deflated balloon. Once the catheter is in place, the balloon is inflated to widen the artery. In some cases, a small mesh tube (stent) is placed within the widened artery to help keep it open after the procedure. Some stents are coated with medications that are slowly and continuously released into the bloodstream to help keep the artery from becoming blocked again, although the benefit of drug-eluting stents is controversial. Drug-eluting stents appear to be the standard of care albeit more expensive than bare metal stents, and similarly effective except for certain higher risk patient among whom they are more effective. By 2004, 71% of all procedures used drug-eluting stents and by 2006 that percentage raised to 88% (Venkitachalam). If this approach is not successful, coronary artery bypass surgery may be needed. The surgeon grafts (inserts) a new blood vessel from the aorta to the blocked artery beyond the point of obstruction to increase blood flow to the ischemic part of the heart muscle.

Source: Medical Disability Advisor



Prognosis

Once coronary atherosclerosis develops, it must be managed for life. The risk of subsequent cardiac events or disruption of the general circulation depends on control of the disease through lifestyle changes and medication. These changes can prevent disease progression by reducing future deposits of cholesterol and plaque in the coronary arteries. Statins, which are sometimes prescribed with a selective cholesterol absorption inhibitor, can dramatically reduce plaque already present, raise levels of HDL cholesterol, and possibly reduce the inflammatory process believed to be responsible for the development and progression of coronary atherosclerosis. Medication has the additional effect of softening plaque deposits, making them less likely to break away from the artery wall and block blood vessels within the heart.

Surgical procedures, such as coronary angioplasty and bypass surgery, successfully improve blood flow to the heart and decrease risk of myocardial infarction and sudden cardiac death for some subgroups of patients, but the risk of blockage by future plaque deposits remains. Thus lifelong adherence to risk factor reduction is necessary.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Cardiologist, Cardiovascular Physician
  • Thoracic Surgeon

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation for coronary atherosclerosis is generally prescribed for those who have had a myocardial infarction. Cardiac rehab programs are generally not necessary for those who are determined to have in their arteries only plaque that does not limit flow (not “hemodynamically significant”), or for those who had angina and received angioplasty with or without stent placement. These individuals have no capacity limitation, and may safely participate in unmonitored (home) exercise such as walking as part of a general risk factor reduction program.

For those who have had myocardial infarction, the exercise program follows three basic progressive phases. Phase 1 often begins in the hospital and uses low levels of exercise to prevent problems associated with prolonged bed rest, decrease the likelihood of blood pressure fluctuations that can occur with changes in position (orthostatic hypotension), and maintain mobility. Exercises begin with the individual lying on his or her back (supine position) and progress to exercises performed in a sitting and later, a standing position. A gradual increase in the distance an individual is able to walk is an important part of the individual's exercise program. Initial sessions with a physical therapist may be 5 to 10 minutes, with a gradual increase in the duration and physical demands.

Phase 2 begins after discharge from the hospital and takes place in an outpatient setting such as a rehabilitation center. Goals are to improve functional capacity by increasing physical endurance and promoting return to everyday activities. Individuals undergo electrocardiograph (ECG) monitoring while performing exercise. A physical therapist keeps a daily log of the individual's blood pressure, heart rate, and cardiac rhythm.

Phase 3, also in an outpatient setting, begins 3 to 6 months from the start of rehabilitation and may last for several months. Individuals may continue an outpatient program for up to a year to accomplish their goals while remaining on modified work duty. The level of exercise is gradually increased to include recreational activities such as swimming, hiking, cycling, and light jogging according to the individual's tolerance. Modifications may need to be made for individuals who have had surgery or who have other medical conditions.

Cardiac rehabilitation should combine progressive exercise with education and lifestyle modification. It is essential to change exercise, diet, stress management, smoking, and lifestyle habits.

FREQUENCY OF REHABILITATION VISITS
ClassificationSpecialistTopicVisit
Nonsurgical or Surgical Cardiac RehabilitationCoronary Atherosclerosis2-3 visits/week for 12-18 weeks, or up to 36 total visits
With known co-morbid coronary artery disease.
For those who have had a heart attack within the last year, Medicare covers up to 36 sessions (http://www.caring.com/medicare_information/medicare-coverage-of-cardiac-rehabilitation).

Source: Medical Disability Advisor



Comorbid Conditions

  • Alcoholism
  • Diabetes mellitus
  • Dyslipidemia
  • Hypertension
  • Obesity
  • Second-hand smoke
  • Severe stress
  • Tobacco abuse

Source: Medical Disability Advisor



Complications

Angina, the chest pain associated with worsening coronary atherosclerosis, may remain stable for long periods. With progression of the disease, anginal episodes may increase in severity and duration, become less responsive to medication, and be precipitated by less exertion. A worsening or less predictable pattern of angina is referred to as unstable angina.

A heart attack (myocardial infarction) can result if the obstruction in a coronary artery becomes complete. Coronary artery obstruction may be triggered by blood clotting (thrombosis) in a narrowed artery or a clot that forms on the plaque in the artery and fully blocks that artery. A heart attack causes death (necrosis) of part of the heart muscle due to lack of oxygen.

Individuals who survive massive or repeated heart attacks may be left with so little functioning heart muscle that the heart can no longer pump effectively ( heart failure). Ischemic or damaged heart muscle may also result in disturbances of heart rhythm (arrhythmias), such as atrial fibrillation or ventricular fibrillation. Atherosclerosis also may occur in other arteries throughout the body and cause impaired circulation.

Prompted by worry over lifestyle changes and potential heart problems, individuals diagnosed with coronary atherosclerosis may experience depression and anxiety in the aftermath of their diagnosis.

Source: Medical Disability Advisor



Factors Influencing Duration

Ability to work depends on the outcome of treatment (relief of symptoms, improved ventricular function), the severity of residual symptoms, the presence or absence of other medical conditions, and the requirements of the individual's job.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

In the early stages of coronary atherosclerosis, work typically is not restricted. Although exercise is a recommended activity, it can be carried out after work hours. During periods of intense cardiac rehabilitation, time off may be required for visits to the physical therapist or participation in a rehabilitation program. Regularly scheduled doctor appointments to track blood pressure, cholesterol levels, blood sugar, and body weight are important to decrease the likelihood of coronary disease recurrence or progression. Addressing chronic emotional stress, including anxiety and depression, is important, but may be more readily done in some work settings than others. Stress reduction techniques, including exercise and counseling, are an important part of overall cardiac rehabilitation, but some techniques may require the participation or supervision of a counselor or physician.

If the condition progresses and the arteries become increasingly obstructed, physical capacity is likely to decrease due to decreased coronary blood flow and poor oxygenation of the heart. At this point, work restrictions are made and work limitations are determined on the basis of stress test results and response to treatment. Individuals with strenuous physical job requirements may need a less physically demanding job assignment. If angioplasty or bypass surgery is required, accommodations will be needed during the recovery period.

Risk: With simple brief exertional angina, no lost work time may be needed other than usual doctor appointments. If an individual does not address underlying risk factors, then job factors will not be the only ongoing risk. Risk will increase with high stress positions or jobs with very heavy physical exertion. Jobs that have a physical component, when performed under safe conditions, may be beneficial and protective for an individual. For more information, please refer to "Work Ability and Return to Work," pages 264-265.

Examining causal risk factors also aids in understanding future concerns. For more information, please refer to "Disease and Injury Causation," pages 238-243.

Capacity: Capacity is determined by exercise stress testing (treadmill test), stress ECHO testing, nuclear stress testing, or similar provocative testing. Attention should focus on METs achieved and whether testing reproduced any symptoms, arrhythmias, or signs of ischemia. For more information, please refer to "Work Ability and Return to Work," pages 265-266.

Tolerance: Individuals will often complain about chest symptoms. Knowing whether these symptoms represent angina or represent only anxiety that activity might precipitate heart problems is critical in reassuring return to work discussions. Emphasis should be on results of objective testing and ensuring optimal medical management. For more information, please refer to the section on tolerance in "Work Ability and Return to Work," pages 266-267.

Source: Medical Disability Advisor



Maximum Medical Improvement

Absent myocardial infarction, MMI can be determined at time of diagnosis.

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:

  • What testing has been done?
  • Does the individual have plaques that do not obstruct blood flow (non-hemodynamically significant plaques), or
  • Did the individual have significant plaques that have been treated with angioplasty with or without stent placement
  • Did the individual have coronary artery bypass surgery
  • Did the individual have a myocardial infarction?
  • What is the individual's ejection fraction (in the report of the ECHO, nuclear stress test, or cardiac catheterization test)?
  • What is the individual's safe exercise ability as determined by diagnosis and / or exercise stress testing?
  • Does individual have other risk factors, such as advanced age, family history of atherosclerosis (particularly before age 50), hypertension, diabetes, high blood cholesterol, smoking, exposure to second-hand smoke, obesity, poor physical fitness, , or prolonged emotional stress?
  • Were conditions with similar symptoms ruled out?

Regarding treatment:

  • Is individual taking cholesterol-lowering drugs?
  • Is individual addressing unhealthy behaviors that increase risk of heart disease or heart attack?

Regarding prognosis:

  • Is individual active in rehabilitation?
  • Can individual's employer accommodate any necessary restrictions or capacity limitations?
  • Does individual have conditions that may affect ability to recover?
  • Have any complications, such as unstable angina, myocardial infarction, congestive heart failure, and arrhythmias developed?
  • Is individual depressed or anxious over diagnosis of coronary atherosclerosis?
  • Does individual have atherosclerosis in other arteries throughout the body? Has circulation become impaired elsewhere?

Source: Medical Disability Advisor



References

Cited

Efthimiadis, A. "Rosuvastatin and Cardiovascular Disease: Did the Strongest Statin Hold the Initial Promises?" Angiology 59 (2008): 62s-64s.

Genovese, E. , and M. H. Hyman. "Causation in Common Cardiovascular Problems." Guides to the Evaluation of Disease and Injury Causation. Eds. Mark J. Melhorn and William E. Ackerman. American Medical Association, 2008. 237-261.

Pearlman, Justin D. "Coronary Artery Disease." eMedicine. Eds. Bernard D. Coombs, et al. 4 Apr. 2007. Medscape. 27 Feb. 2009 <http://emedicine.medscape.com/article/349040-overview>.

Roger, V. L. , et al. "Heart disease and stroke statistics--2012 update: a report from the American Heart Association." Circulation 125 (1) (2012): e2-e220.

Schiller, J. S. , et al. "Summary Health Statistics for U.S. Adults: National Health Interview Survey." Vital and health statistics. Series 10, Data from the National Health Survey. Centers for Disease Control and Prevention, 2010. 1-207.

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.

Venkitachalam, L. , et al. "Twenty-Year Evolution of Percutaneous Coronary Intervention and Its Impact on Clinical Outcomes." Circulation 2 6-13.

General

Warber, S. L., and S. M. Zick. "Coronary Artery Disease." Integrative Medicine. 1st ed. Philadelphia: W.B. Saunders, 2003. 173-184.

Source: Medical Disability Advisor