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.

Mitral Regurgitation


Differential Diagnosis

  • Congenital heart murmur, or a murmur related to other cardiac condition

Specialists

  • Cardiovascular Internist
  • Thoracic Surgeon

Comorbid Conditions

  • High blood pressure (hypertension)
  • Obesity
  • Prior heart attack (MI) or other cardiac condition such as angina
  • Respiratory disease

Factors Influencing Duration

Factors that may affect length of disability include age, response to treatment, severity of symptoms, and general state of health. Duration of disability depends on job requirements, amount of physical labor involved in individual's job, and strength and severity of symptom.

Medical Codes

ICD-9-CM:
394.2 - Mitral Stenosis with Insufficiency; Mitral Stenosis with Incompetence or Regurgitation
396.3 - Mitral Valve Insufficiency and Aortic Valve Insufficiency
424.0 - Mitral Valve Disorders

Overview

Mitral regurgitation (MR), is a condition characterized by the reverse flow of blood from the primary pumping chamber of the heart (left ventricle) into the receiving chamber (left atrium) of the heart. The mitral valve lies between the left upper chamber of the heart (the left atrium) and the left lower chamber of the heart (left ventricle). After blood receives oxygen from the lungs it enters the left atrium and flows through the mitral valve into the left ventricle, and from there it is pumped into the aorta, the largest artery supplying the body with blood.

The mitral valve relies on a group of tissues supporting its function to allow only a one-way flow of blood; that is, atrium to ventricle. These tissues include the mitral annulus, valve leaflets, chordae tendinae, and muscles and supporting walls of the heart chamber. A failure of any one of the valve components may result in regurgitation from ventricle back through the mitral valve to atrium. The atrium then becomes overloaded, which in turn decreases overall cardiac output.

Mitral valve disease is the most frequent cardiac valve abnormality. Mitral regurgitation, mitral valve prolapse, and mitral stenosis, are the three disorders seen most often to affect mitral valve performance. A prior diagnosis of mitral valve prolapse or mitral stenosis may lead to severe mitral regurgitation.

Individuals with a history of rheumatic fever and subsequent damage to the mitral valve were those most frequently diagnosed with MR early in the twentieth century. Today, rheumatic fever and related rheumatic mitral stenosis have decreased considerably. Instead, the increase in coronary artery disease among the adult population places individuals who have hardening of the coronary arteries (coronary artery disease, arteriosclerosis or atherosclerosis) and mitral valve prolapse at greatest risk for MR.

Myxomatous degeneration can increase risk with or without the presence of mitral valve prolapse. A prior heart attack (myocardial infarction or MI) with related dysfunction of the papillary muscles can be a risk as well. Rheumatic valve damage can still be a causative factor although is rarely a cause in itself without either mitral stenosis or underlying prolapse. Less common causes include bacterial endocarditis; an enlarged, poorly contracting heart due to a variety of causes (cardiomyopathy); ruptures of the supporting structures of the valve (chordae tendineae); and mitral annular calcification, typically in elderly women. MR can be congenital and can also occur in infants with ruptured papillary muscles. Infrequent causes of MR include connective tissue disorders, cardiac trauma, and effects of radiation therapy.

Incidence and Prevalence: Mitral regurgitation affects between 1% and 6% of the population (Beers).

Source: Medical Disability Advisor



Causation and Known Risk Factors

MR occurs predominately in adult males corresponding to the higher number of men who develop coronary artery disease (arteriosclerosis).

Source: Medical Disability Advisor



Diagnosis

History: Common symptoms include shortness of breath with activity (dyspnea with exertion) or when lying down (orthopnea). Lack of stamina and fatigue are common. Palpitations or a rapid irregular heart rate (atrial fibrillation) may be reported.

Physical exam: MR can produce a rapid pulse and murmurs audible with the stethoscope. Murmurs occur when the left ventricle contracts, pumping blood backwards across the valve into the left atrium. Silent MR, the absence of murmur even though insufficiency is present, may occur in conjunction with acute myocardial infarction (MI). Other murmurs may coexist when rheumatic heart disease is the cause. Atrial fibrillation, an irregular heart rate due to enlargement of the left atrium, may be present on a single examination or intermittently during continuous monitoring. Pulmonary hypertension may be present.

Tests: An electrocardiogram (ECG), chest x-ray, and echocardiogram (color-flow Doppler ultrasound) are done initially and at periodical intervals thereafter, helping to determine the severity of MR. Chest x-rays may show an enlarged left atrium and ventricle as well as pulmonary vessel congestion, which can be confused with pneumonia. The chest x-ray and echocardiogram together provide information about how the heart is coping with the insufficient flow of blood, including the presence or absence of heart fatigue.

In the case of mitral valve prolapse (MVP), an echocardiogram may demonstrate prolapse in the absence of a murmur and in the presence of a normal ECG and chest x-ray. MVP may or may not be the underlying cause of the mitral insufficiency.

Heart catheterization may be performed in some cases in which MR has caused heart failure and valve reconstruction or replacement is an option for treatment.

Source: Medical Disability Advisor



Treatment

Individuals with mild, rheumatic MR are usually treated with a broad-spectrum antibiotic such as penicillin before dental work or when infection is present to prevent harmful bacteria from entering the bloodstream. Young people with congenital or rheumatic MR are sometimes given regular antibiotic treatment until they reach adulthood. Bacterial infection can result in a serious cardiac complication known as bacterial endocarditis.

Individuals with dyspnea upon exertion and fatigue are usually treated with medications to reduce the likelihood of congestive heart failure (CHF). A combination of drugs may be prescribed to remove excess fluid (diuretics) from body tissues and the circulatory system, to steady and strengthen the heart's contraction (digitalis), and/or to decrease the work of the heart by opening up blood vessels (vasodilators). Medications that prevent the formation of clots (anticoagulants) are also used to reduce the possibility of heart attack in individuals at risk.

In severe MR, mitral reconstruction or replacement may be done, usually with immediate improvement in blood flow and reduction of symptoms. Surgery is generally elective unless the MR causes heart failure, which makes valve replacement necessary. Surgery may also be required for conditions such as ruptured chordae tendineae where heart function is severely compromised. Surgical procedures have increased as the treatment of choice for MR, with mitral valve repair more prevalent than valve replacement. Replacement valves can be either mechanical or biological; mechanical valves have shown a tendency to cause blood clot development, whereas biological valves have shown subsequent degeneration and failure within 11 years after the surgery (Chikwe 46).

Source: Medical Disability Advisor



Prognosis

Outcome is good with mild MR and longevity may be normal in the absence of bacterial endocarditis or other cardiac problems that develop later in life.

Elective valve replacement surgery has a perioperative mortality of 5% to 7%, although most individuals have a good long-term prognosis after successful surgery. Valve reconstruction generally has lower perioperative mortality and a good prognosis. Aging, associated coronary arteriosclerosis, angina, and prior MI increase the operative risk. If severe MR causes heart failure, early valve replacement is recommended and perioperative mortality increases to 25% (Beers). Post-surgical survival is approximately 75% at 5 years and 60% at 10 years. Survivors usually show significant symptomatic improvement.

Source: Medical Disability Advisor



Complications

The primary complications of MR are congestive heart failure, atrial fibrillation, and occasionally bacterial endocarditis.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

No work restrictions or accommodations are necessary for individuals without symptoms. For those experiencing dyspnea with exertion and/or fatigue, reassignment to a less strenuous position may be necessary. Individuals taking anticoagulants may need reassignment if their job involves an increased risk of injury.

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:

  • Does individual have a history of rheumatic fever, coronary arteriosclerosis, bacterial endocarditis, cardiomyopathy, or ruptured chordae tendineae?
  • Does individual have dyspnea with exertion or when lying down? Fatigue?
  • Does individual have atrial fibrillation?
  • With auscultation is a murmur audible? Is the heart rhythm irregular?
  • Has individual had an ECG, chest x-ray and echocardiogram? Are the tests repeated periodically?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Does individual have mild mitral insufficiency? Does individual take antibiotics prior to any dental work or other procedures where bacteria may enter the bloodstream?
  • Does individual have more severe mitral insufficiency? Is the individual on medications such as diuretics, digitalis, vasodilators and anticoagulants?
  • Is valve replacement a consideration?

Regarding prognosis:

  • Is individual's employer able to accommodate and necessary restrictions?
  • Does individual have any conditions that may affect ability to recover?
  • Does individual have any complications of mitral insufficiency such as congestive heart failure, atrial fibrillation or bacterial endocarditis?

Source: Medical Disability Advisor



References

Cited

Beers, Mark H., and Robert Berkow, eds. "Mitral Valve Disease." The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck and Company, Inc., 1999. Merck. Merck & Co., Inc. 27 Dec. 2004 <http://www.merck.com/mrkshared/mmanual/section16/chapter207/207b.jsp>.

Chikwe, J., A. Walthier, and J. Pepper. "The Surgical Management of Mitral Valve Disease." Journal of Cardiology 11 1 (2004): 42-48.

Source: Medical Disability Advisor






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