Why advocates must master this listing
Ischemic heart disease—coronary atherosclerosis producing angina, silent ischemia, or prior infarction—remains the most prevalent cardiac impairment in disability dockets. Listing 4.04 gives you five separate “on-ramps” to win at Step 3, each grounded in objective evidence: abnormal stress testing, angiographic stenosis, or repeated ischemic episodes. If you learn to translate cath-lab and stress-test data into SSA’s regulatory metrics, many claimants bypass all vocational arguments.
Full regulatory text
“4.04 Ischemic heart disease, with symptoms due to myocardial ischemia, while on a regimen of prescribed treatment, with one of the following:
A. Abnormal exercise test: Achieving a workload of 5 metabolic equivalents (METs) or less due to:
1. Horizontal or down-sloping ST depression ≥ 0.5 mV on an ECG tracing, or
2. Angina, dyspnea, fatigue, dizziness, syncope, or near-syncope, or
3. Three or more consecutive ventricular premature beats, or
4. Decrease of ≥ 10 mm Hg in systolic blood pressure below the baseline or the preceding value during exercise, or
5. Signs attributable to inadequate cerebral perfusion (such as ataxic gait or mental confusion);
or
B. Ischemic episodes: Three separate episodes of acute myocardial ischemia requiring revascularization (coronary angioplasty, stent placement, or bypass surgery) or hospitalization within a consecutive 12-month period, with episodes at least 30 days apart;
or
C. Angiographic evidence: Coronary artery disease shown by angiography (or appropriate medically acceptable imaging) and one of the following:
1. ≥ 50 percent narrowing of at least two non-bypassed coronary arteries, or
2. ≥ 70 percent narrowing of a single left main coronary artery, or
3. ≥ 50 percent narrowing with documented limitation of exertion to a workload of 5 METs or less, or
4. Very serious limitations in coronary flow reserve as described in § 4.00E9.”*
(Paragraph 4.00E details acceptable testing protocols; 4.00E9 references Doppler-derived coronary-flow-reserve measurements.)
Element-by-element checklist
| Pathway | Required proof | Core evidence |
|---|---|---|
| A. Abnormal exercise test ≤ 5 METs | Symptom-limited treadmill/bike or CPET, plus one of five aborting criteria | Stress-test report with ECG tracings; cardiologist letter if needed |
| B. Three ischemic episodes | 3 separate events in 12 months (≥ 30 days apart) each requiring PCI/CABG or overnight hospitalization | Cath-lab op notes; discharge summaries; angioplasty or CABG operative reports |
| C-1. ≥ 50 % stenosis in two vessels | Quantitative coronary angiography or CTA report | Cath report with % stenosis; diagram |
| C-2. ≥ 70 % left-main stenosis | Same | Highlight LMCA stenosis |
| C-3. ≥ 50 % stenosis + ≤ 5 METs | Combine angiography with low-workload exercise test | Both reports within 12 months |
| C-4. Impaired coronary flow reserve | Doppler or PET-derived CFR < 2.0 | Imaging center report |
Building an airtight 4.04 case
- Choose the easiest pathway first.
Cath reports with two ≥ 50 % lesions (Path C-1) win without stress testing—collect full dicom summaries. - Stress-test specifics matter.
Provide raw ECG strips showing ≥ 0.5 mV ST-segment depression or systolic BP drop; annotate workload in METs. - Document each ischemic episode clearly.
Path B requires three dates; present a table: date, troponin peak, intervention type, discharge. - Avoid “acute phase” pitfalls.
Stress tests & labs must represent stable medical treatment, not data obtained during acute MI. - Supplement with left-ventricular ejection fraction.
Low EF (< 40 %) bolsters severity and helps with RFC fallback if listing missed. - Attach medication list & compliance.
Beta-blocker, statin, dual antiplatelet therapy confirm “prescribed treatment” requirement; defuses DDS non-compliance argument. - RFC fallback
If METs reach 6–7 but claimant anginas at moderate activity, procure treating-source RFC limiting exertion to < 2 METs (slow ambulation); VE typically rules out competitive work.
Professional bottom line
Listing 4.04 provides multiple objective doors—low-workload stress tests, angiographic percent-stenosis thresholds, or a pattern of re-vascularized ischemic episodes. Assemble complete cath-lab and stress-test documentation, line up each data point against the specific paragraph, and the adjudicator is left with a textbook Step-3 allowance.
Under Listing 4.04, a Social Security Disability Lawyer can help translate stress tests, cardiac catheterization findings, and hospitalization records into SSA-compliant evidence that fits one of the listing’s five qualifying pathways. Whether the case is proven through low-MET exercise intolerance, significant coronary artery stenosis, or repeated revascularization events, properly organized medical documentation is essential to establishing disability at Step 3 and avoiding vocational analysis altogether.