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Cardiovascular System Symptomatic Limitation
In this section reference is made to limitation of activities of daily living because of symptoms. Information about such limitation is subjective, and it is open to interpretation on the part of both patient and examiner. Therefore, when it is possible, the examiner should obtain objective data about the extent of the limitation before attempting to estimate the degree of permanent impairment. When estimating the extent of a limitation due to symptoms, the physician should use the functional classification in Table 1.
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Table 1
Functional Classifications
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Class 1:
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The patient has cardiac disease, but no resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
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Class 2:
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The patient has cardiac disease resulting in slight limitation of physical activity. The patient is comfortable at rest and in the performance of ordinary, light, daily activities. Greater-than-ordinary physical activity, such as heavy physical exertion, results in fatigue, palpitation, dyspnea, or anginal pain.
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Class 3:
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The patient has cardiac disease resulting in marked limitation of physical activity. The patient is comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
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Class 4:
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The patient has cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of inadequate cardiac output, pulmonary congestion, systemic congestion, or the anginal syndrome, may be present, even at rest. If any physical activity is undertaken, discomfort is increased.
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EXERCISE TESTING In most circumstances the physician should attempt to quantitate limitations due to symptoms by observing the patient during exercise. The most widely used and standardized exercise protocols involve the use of a motor-driven treadmill with varying grades and speeds. The protocols vary slightly, but they all attempt to relate the exercise to excess energy expended and to functional class. The excess energy expended usually is expressed with the “MET,” a term that represents the multiples of resting metabolic energy utilized for any given activity. One MET is
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