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Mussack: Keep It Simple When Rating Heart Conditions With AMA Guides

  • State: California

With more and more applicants pleading internal issues, it’s important for defendants to understand how to properly rate impairment under the AMA Guides.

That starts with understanding AMA Guides Chapters 3 and 4, which address the cardiovascular system and disorders of the heart. To be more specific, Chapter 3 is titled, “The Cardiovascular System: Heart and Aorta,” and Chapter 4 is titled, “The Cardiovascular System: Systemic and Pulmonary Arteries.”

Both chapters address the functional flow of blood to, through and from the heart. For most cases, only one table from the cardiovascular system will be needed to evaluate the heart.

In fact, the only heart condition that requires multiple separate impairments of the heart to be combined is arrhythmia, which is discussed on page 56 of the AMA Guides.

Chapters 3 and 4 contain eight tables that evaluate dysfunction of the heart. From Chapter 3:

  • Valvular heart disease — table 3-5.
  • Coronary heart disease — table 3-6a.
  • Congenital heart disease — table 3-8.
  • Cardiomyopathies — table 3-9.
  • Pericardial heart disease — table 3-10.
  • Arrhythmias — table 3-11.

From Chapter 4:

  • Hypertensive cardiovascular disease — table 4-2.
  • Diseases of the aorta — table 4-3.

It’s worth noting that there are other tables that address other conditions in Chapters 3 and 4 of the AMA Guides. For example, in Chapter 4, two tables, 4-4 and 4-5, address dysfunction from peripheral vascular disease and resultant issues of the extremities. Table 4-6 is used to evaluate pulmonary hypertension and resultant damage within the lungs.

Each of the eight tables for evaluating impairment of the heart uses The New York Heart Association (NYHA) Functional Classification system for cardiac disease from Table 3-1, page 26. Each of these eight tables provides four classes of impairment, and each class of impairment considers the same range of whole person impairment (WPI).

Rating arrhythmias

As noted above, arrhythmia is addressed in Table 3-11 and is the sole condition that would allow separate impairments of the heart to be combined.

The AMA Guides state that “arrhythmias tend to fluctuate remarkably,” which thus makes a precise objective assessment of impairment more difficult. As a result, “the degree of impairment from cardiac arrhythmias often has to be combined with the degree of impairment due to underlying heart disease.”

So be sure to remember that unless it is an arrhythmia, you don’t need to combine impairments from the various tables in Chapters 3 and 4 when rating heart problems. If someone were to combine impairment ratings for a heart problem that is not an arrhythmia, he would be duplicating consideration of the injury’s effects on the cardiovascular system and impacted activities of daily living.

Disorders of the heart — AMA Guides examples

The examples for evaluation of the heart in the AMA Guides each review abnormal structure of the heart and/or resultant dysfunction of the left or right ventricle.

There are 50 examples within Chapter 3, and 16 examples within Chapter 4 that address WPI evaluation for heart disorders. Of those 50 examples, there are only two that recommend combining impairments for the heart, which are example 3-27 and example 3-49. Each of those examples addresses arrhythmia and the potential need to combine with another disease of the heart.

The use of one table for evaluation of the heart is specifically addressed within example 4-8, page 69. This example reviews evaluation of cardiovascular hypertension (table 4-2).

The comment states that impairment from table 4-2 would not be combined with impairment from table 3-6a because “impairment for hypertensive cardiovascular disease (CVD) is not combined with cardiomyopathy, since hypertensive CVD class 4 includes cardiomyopathy.”


When rating impairment for heart conditions in the AMA Guides, remember that only one condition — arrhythmia — requires consideration for separate impairments of the heart to be combined.

So unless it’s an arrhythmia case, only one table from the AMA Guides’ chapters on the cardiovascular system will be needed to evaluate the industrial impairment of the heart.

Tim Mussack is a senior AMA analysis and rating specialist who works in Bradford & Barthel's Sacramento office. This entry from Bradford & Barthel's blog appears with permission

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