Manual Single National Disability Rating to Colombia - Decree 917 of 1999 (Part II of II) - Chapter VII - 7. CARDIOVASCULAR SYSTEM 7.1 General - 7.2 HEART DISEASES - 7.2.2 ischemic myocardial disease

MANUAL SINGLE NATIONAL DISABILITY
(PART II OF II)

CHAPTER VII
7. CARDIOVASCULAR SYSTEM

7.1 General

The varying degrees of permanent impairment of the cardiovascular system are the result of anatomical or functional abnormality of the same. In this chapter we define the criteria and methods for determining the degree of permanent impairment of individuals with cardiovascular disorders.

The evaluation of the cardiovascular system failure has certain characteristics and considerations other than those of other organ systems. You should consider the injury creates a permanent impairment only after exhausting the therapeutic measures, surgical or rehabilitation, or after a reasonable time of the occurrence of an acute episode, for example, the time required for development of collateral circulation after coronary occlusion. It requires a period of at least 6 months before assessing permanent impairment caused by acute myocardial infarction. Any request for disability qualification before this deadline will be rejected. If surgery has made the observation period should be at least a year.

One of the problems in the cardiovascular assessment is the frequent disparity between physical signs and symptoms found. A chronic patient may have a normal physical examination, including ECG and radiological tests and be severely limited by angina.

For practical reasons, we have established four groups of diseases that affect this system:

1. Heart disease.

2. Hypertensive vascular disease.

3. Arterial vascular disease affecting the extremities.

4. Diseases of the venous system.

When clinical findings are such that a patient can not be classified into one of these groups, or conditions beyond that classification, assessment of deficiency must be combined according to each of the diseases.

7.2 HEART DISEASES

The history and physical examination of the heart may give positive signs in most cases, but tests should help confirm diagnosis. There are different types of heart disease, congenital or acquired, as well as necrosis of the myocardium by ischemic disease. All these myocardial lesions, particularly hypertrophic cardiomyopathy and valvular stenosis, can cause major damage such as heart failure, syncope, effort and rhythm disorders, without evidence of growth of cavities in the radiological study.

7.2.1 Heart acquired for evaluation must take into account that the electrocardiogram and Doppler ultrasound can show all the significant changes reflecting morphological abnormalities of wall thickening and changes in the flow (Doppler) and valves. A normal Doppler ultrasound virtually excludes the presence of valvular disease in adults and the presence of hypertrophic cardiomyopathy.

7.2.2 ischemic myocardial disease

Coronary artery disease can cause severe disability that causes angina. This pain is classically described as pain, crushing, burning, or burning type, located in the retrosternal region, caused by the effort, should be described specifically in relation to the triggers, type, degree, level of intensity, character , location, duration and response to nitrates or rest. Irradiated manifestations of pain such as sore throat, jaw, shoulders, arms and hands are of equal validity to be considered as angina, as well as typical retrosternal pain. The presence of pain at rest or it is evolving over time, with decreased functional capacity, increased requirements of nitrates, new onset of functional capacity 3-4, should be suspected unstable angina, and therefore The assessment of disability should be deferred until they have completed the diagnostic approach by the treating physician and of course, until the picture is stable. This last group of people should be considered under observation and treatment. Many patients with chronic stable angina and unstable behave when they added an aggravating factor such as anemia, thyroid disease or intercurrent infections.

7.2.3 Congenital Heart Disease

The presence of congenital damage must be established by physical signs and diagnostic tests aid. May produce different effects among which one can mention the obstruction of ventricular outflow tract, either right or left as they are the infundibular stenosis and may lead to the capitulation of the respective ventricle. Others produce an overload of the lesser circulation because of increased pulmonary flow to be a short circuit from left to right, which may affect adulthood.

TABLE No. 7.1: CRITERIA FOR THE ASSESSMENT OF GLOBAL IMPAIRMENT BY ORGANIC HEART DISEASE

Class Description of criteria Global Deficit (%)

I · There organic heart disease but no symptoms. · Walking and climbing stairs freely and carry out daily activities without limitations. · Efforts prolonged emotional tension, the rush, the higher slopes, sports or similar activities do not trigger symptoms. • There are no signs of congestive heart failure. 1.0-7.4

II · There organic heart disease but no symptoms at rest. · Walk freely about flat, up at least one floor down stairs and carry out daily activities without symptoms. · Efforts prolonged emotional tension, the rush, the higher slopes, sports or similar activities, trigger symptoms. • There are no signs of congestive heart failure. 7.5-22.4

III · There organic heart disease without symptoms at rest. Symptoms to walk more than one or two blocks on level ground, climbing one flight of stairs normal, and carry out daily activities. Symptoms with emotional stress, running, climbing slopes, sports or similar activities. · There may be signs of congestive heart failure to yield to treatment. 22.5-37.4

IV · There organic heart disease with symptoms at rest. • Any activity that goes beyond the personal or equivalent upsets growing. · Symptoms of heart failure or anginal syndrome may occur even at rest. · Signs congestive heart failure are usually resistant to therapy. 37.5-49.5

The following are examples of Heart Disease Causing a deficiency Class

IV:

1. Rheumatic valve disease or rheumatic aortic lesions such as this notice or severe shortcomings, if they have a history of syncope, pulmonary edema or heart failure and the diagnosis was confirmed at least by Doppler echocardiography. Injuries mitral stenosis and both chronic and severe shortages

2. Cardiomyopathy, hypertrophic cardiomyopathy, particularly in long form will be considered in class IV, in individuals with marked dilatation, persistent and possibly progressive ventricular diameters, and in the young individual, with arrhythmias, syncope and family history of sudden death included in this group.

3. Pericardial: Include chronic constrictive injury of the pericardium, treatable with surgery and venous congestion produced important.

4. Myocardial ischemic angina who meets the following requirements:

· Chronic stable angina with a poor prognosis and high risk. This can be demonstrated by positive exercise test but with ST segment depression equal to or greater than 2.0 mm, significant drop in pressure with the effort associated with other evidence of pump failure, dangerous arrhythmias with significant effort and low cardiac abnormalities frequency or low load.

· Chronic angina with low functional capacity, and when you run out of therapeutic measures.

· Chronic angina where angiography shows high-risk lesions or poor global ventricular function and ejection fraction of 30% or more.

Old myocardial infarction · which meet some of the conditions given for angina or heart failure with congestion and dangerous arrhythmias.

· Levels of myocardial failure with persistent congestive heart failure with hepatomegaly, pulmonary congestion and peripheral edema on physical examination, despite adequate therapy and well run. Dilation and persistent left ventricular hypertrophy or chronic pulmonary heart.

Cardiac Arrhythmias appellants · generated by digital, resulting in uncontrolled repeated episodes of cardiac syncope or documented by Holter and refractory to treatment.

· Aneurysm of the aorta or its major branches, with acute or chronic dissection not controlled by medical or surgical treatment, or congestive heart failure as described, or renal or fainting spells.

HYPERTENSIVE VASCULAR DISEASE 7.3

Hypertensive vascular disease by itself produces no changes unless it causes severe anatomical damage in one or more of the following four target organs: heart, brain, kidney and eyes. It also produces the same damage if sequelae of vascular changes in the Central Nervous System or limbs or other organs. The criterion for assessing damage resulting from hypertensive cardiovascular disease or condition is based on symptoms, physical signs, lab diagnostic aid, electrocardiogram, stress testing, echocardiography and other procedures.

TABLE No. 7.2: GLOBAL IMPAIRMENT BY HYPERTENSION

Class Description of criteria Deficiency

Diastolic pressure with antihypertensive Additional signs: Global (%)

I asymptomatic patients with diastolic pressure is repeatedly above 90 mm Hg. Do not include abnormalities in urine analysis and testing. Do not have a history of hypertension, vascular brain injury. • There is no evidence of left ventricular hypertrophy. • The fundus may be normal or minimal narrowing of the arterioles. 1.0-7.4

II asymptomatic patients with diastolic pressure is repeatedly above 90 mm Hg.

· You can find proteinuria or abnormal urine sediment, without impairment of renal function. · May have a history of hypertension, vascular brain injury. · The Fund may be cross-eyed and exudates arterial old. 7.5-22.4

III asymptomatic patients with diastolic pressure is clearly between 90 mmHg.

· Pressure frequent diastolic readings above 120 mmHg. · There proteinuria and abnormal urine sediment with impaired renal function, manifested by increased BUN and creatinine and creatinine clearance less than 50%. · There cerebro-vascular injury residual hypertension, with persistent neurological deficits. · There

Left ventricular hypertrophy evident at physical examination, electrocardiogram and chest radiograph without evidence of congestive heart failure. · When Fundus is copper or silver, tortuous vessels, arterio-venous crossings, with or without haemorrhages and exudates . 22.5-37.4

IV diastolic pressure is clearly between 90 mmHg. · Pressure frequent diastolic readings above 120 mmHg. · There proteinuria and abnormal urine sediment with impaired renal function, manifested by increased BUN and creatinine and creatinine clearance less than 50. · Brain injury -vascular hypertension with persistent neurological deficit and significant. · left ventricular hypertrophy · History of Congestive Heart Failure. · retinopathy manifested by alterations in the arterioles, the retina or optic nerve. • O the patient has hypertrophy with or Congestive heart failure, even in the presence of digital and Duret. 37.5-49.5

7.4 VASCULAR DISEASE AFFECTING EXTREMITIES

Vascular diseases affecting the limbs refer to those involving the arterial territory and the venous system. The assessment in each case considers three aspects:

1. Clinical severity.

2. Findings noninvasive, duplex Doppler segmental pressures that registers, pulse, flow and imaging, ankle-brachial index, contrast studies such as angiography and venography, which define the location and extent of obstruction, vessels involved, distal, etc. . 3. Medical and surgical treatment performed (see Tables No.7.3 and 7.4).

TABLE No. 7.3 DEFICIENCY PRODUCED BY GLOBAL ARTERIAL VASCULAR DISEASE AFFECTING EXTREMITIES

Class Description of criteria Global Deficit (%)

I · there disease or vascular disease. • There are no intermittent claudication or rest pain. · There transient edema. 0

There II disease or vascular disease and one or more of the following symptoms: ·

Intermittent claudication when walking for less than 100 meters at a normal pace. • Evidence Vascular physical deterioration, the presence of single finger stump amputee painless evaluated at least 6 months after surgery. Presence of moderate edema, uncontrolled with support elastic. 2.5 - 9.9

There III disease or vascular disease, with one or more of the symptoms following: • Intermittent pain when walking between 25 and 100 meters at a normal pace. • Evidence vascular physical deterioration, such as amputation of two or more fingers of a limb with vascular disease that persists. · manifestations of intermittent claudication and vascular damage in the contralateral limb after revascularization elsewhere.

Presence of marked edema which is partially controlled with elastic support. 10.0-22.4

There IV disease or vascular disease, with one or more of the following symptoms:

· Intermittent claudication while walking less than 25 meters, or have pain even when at rest. Any activity that goes beyond the personal or equivalent upsets growing.

• Evidence vascular physical deterioration as amputation level

ankle or above, or two or more fingers tips, with persistence of vascular disease.

· Failure of arterial bypass surgery of the limb involved. Presence of marked edema did not improve with elastic support. 22.5 - 37.4

V There is disease or vascular disease, with one or more of the following symptoms:

· Pain strong and steady even at rest. · Physical evidence of vascular damage and amputation at the ankle of both legs and amputation of all fingers of two or more limbs, with persistence of vascular disease. Without the possibility of surgery, or to failure of her 37.5 - 47.5 Examples of Arterial Vascular Diseases Causing a Disability Class IV or V:

a) Intermittent claudication without being able to visualize the common femoral artery or the deep, of limb arteriography.

b) intermittent claudication or absence of beats femoral, popliteal, posterior tibial or media, or plethysmography Doppler in an extremity;

c) amputation at or above the hock due to peripheral vascular disease.

d) Failure of peripheral arterial bypass surgery.

TABLE No. 7.4 AMPUTATION DUE TO DEFICIENCY OF BLOOD DISEASES

Global% deficiency

Type Upper Extremity

Amputation of the fourth of the trunk 35.0

Dislocation of the shoulder at 30.0

Amputation of arm above the deltoid insertion 30.0

Amputation of the arm between deltoid insertion and elbow joint 27.5

Elbow disarticulation at 27.5

Forearm amputation below the elbow joint with insertion of the biceps tendon 27.5

Forearm amputation below the elbow 27.0

Disarticulation at the wrist 27.0

Midcarpal or amputation of the hand mediometacarpiana 27.0

Amputation of all fingers except the thumb at the metacarpophalangeal joints 16.0

Amputation of thumb at the level of meta-carpo phalangeal joint or bone resection carpometa-carpal 12.5

At the joint interfalángica7.5

Lower extremity. 40.0 hemipelvectomy

Disarticulation at the hip joint 35.0

Amputation above the knee joint with small stump (3 inches or less below the tuberosity of ischium) 30.0

Amputation above the knee joint with functional stump 25.0

Disarticulation at the knee joint 20.0

Gritti-Stokes amputation 17.5

Amputation below the knee joint with small stump (3 inches or less below intercondylar node) 17.5

Amputation below the knee joint with functional stump 17.5

Amputation at the ankle (or Syne) 15.0

Partial amputation of the foot (or Chopart) 12.5

Amputation mediometatarsiana 12.5

Amputation of all toes in 10.5

Amputation of the more knuckle metatarsal bone resection 7.5

Amputation of the knuckle higher at the metatarsophalangeal 6.5

At the level of the metatarsophalangeal joint proximal 3.5

At the joint interfalángica3.5

Amputation of the remaining toes (from 2 to 5 º) with resection of the metatarsal bone 1.5

At the level of the metatarsophalangeal 0.5

At the level of the proximal interphalangeal joint 0.0

A level of 0.0 distal interphalangeal joint

TABLE No. 7.5 DEFICIENCY GLOBAL SYSTEM FOR VENOUS OBSTRUCTION OF THE LOWER LIMB.

Class Description of criteria Global Deficit (%)

I * Only occasionally is experienced edema. 1 - 4.9%

II · There ulcer healed • There is a persistent moderate edema are not fully controlled with pressure gradient stockings. 5.0 - 11.9

III · There is a persistent superficial ulceration. · There is marked edema, partially controlled pressure gradient stockings. 12.0-22.4

IV · There is marked edema that is not controlled by average gradient Pressure and trophic disorders occur in one or both ends. • And, there are persistent and widespread ulceration or deep in a · the two ends. · Failure of revascularization extremity arterial compromised. • O, no recurrent ulceration and failure of surgical procedures indicated and well made, considering the pathogenesis of the lesion. 22.5 - 37.5

Examples of Vascular Diseases Affecting the Extremities and produce a higher overall deficiency of 40%.

a) Chronic Venous Insufficiency of Lower Limbs, failure or obstruction of deep venous varicose veins associated with superficial, with large hard swelling with stasis dermatitis and ulceration persistent or recurrent non-healing after 6 months of medical therapy or Surgical prescribed and well run.

b) ulceration of one or both legs that does not heal well run treatment after 6 months.