"The SSA has always had a serious problem with treating physician diagnoses of congestive heart failure, because it is not unusual to find that diagnosis in medical records with little or even no evidence to support it.  …  The poor longitudinal quality of many medical records makes it difficult and sometimes impossible for the SSA to determine if heart failure ever occurred in a claimant with that allegation."   §4.02.1.a

"The SSA should not cite the New York Heart Association or other classification as the fundamental basis for denying or allowing a claim, but such Class should be treated as opinion evidence.  It should not be assumed that improperly trained SSA adjudicators will not give undue weight to such classification."  §4.02.1.a

"An SSA adjudicator might try to disregard cardiothoracic ratio findings on a chest x-ray in a case that would otherwise be an allowance, because of echocardiographic findings.  Lacking legal regulatory authority, that action would be improper and possibly a basis for appeal."  §4.02.1.b

"Some SSA adjudicators will try to use the objective cardiac performance alone to determine RFC.  There is no way an accurate RFC can be determined without close consideration of the claimant’s symptoms as well as the objective data."  §4.02.2

"The claimant should not be considered to have completed 5 METs of exertion unless he or she completes the entire duration of the 5 MET stage of the protocol used, usually 3 minutes and no less than 2 minutes.  Careful attention should be given this issue, because it is one in which an adjudicator with insufficient medical knowledge in this area can easily err."  §4.02.2

"Some cardiologists will not even have considered the possibility of diastolic dysfunction, but the acknowledgment of that as a possibility can add credibility to a claimant’s alleged symptoms.  It should not be assumed that that the SSA adjudicator, even if a medical doctor, will think of diastolic dysfunction when reviewing a cardiac claim."  §4.02.2

"The SSA does not have cardiologists reviewing most heart impairment claims."  §4.02.2

"Many claimants with lung disease also have heart disease.  The presence of significant lung disease in a claimant who has had an episode of chronic heart failure in the past due to chronic heart disease should always lower the over-all impairment severity rating by at least one level.  Failure to recognize increased severity as a result of the inter-dependence of cardiac and pulmonary impairments is a major source of error by SSA adjudicators, despite federal regulations requiring consideration of the combined effect of impairments (20 CFR §§404.1522(b), 416.922(b))."  §4.02.2

"It should be remembered that many activities can be slowly completed that could not be done at a normal pace; that does not mean such functional capacity is an effective work-related ability.  So, activity completion durations are important in all forms of heart disease."  §4.02.2

"Medical conditions are not static in their effects on people; a person might be able to perform at a certain activity level one day but not other days.  A person can perform a number of activities such as shopping and cooking but be exhausted for several days afterward.  Even the quality of sleep can make a big difference in function the next day; medications and the development of transient pulmonary edema at night can easily ruin a night’s rest."   §4.02.2

"Most claimants do not understand how to complete daily activity forms given to them by the SSA; the responses are too brief and vague.  Unfortunately, this can get a deserving claimant denied, because critical functional details were not given to the SSA." §4.02.2

"When trying to understand medical evidence in heart failure or other cardiac impairment cases, it is useful to keep in mind that the treatment given by physicians is not a reliable indicator of the nature or severity of the underlying disease."   §4.02.3