MSE and disability due to cardiac arrhythmias - Medical and social examination for certain diseases

The issue of disability worries many patients who suffer from severe forms of arrhythmia. To get the answer, you need to look at the basic rules and regulations followed by medical examinations.

Arrhythmia is a disorder of the heart rhythm (HRR), characterized by a change in the frequency of heart contractions, rhythm, and the basic capabilities of the organ (conductivity, automaticity, excitability). According to the Doshchitsin classification from 1991, there are 10 types of arrhythmias, among which the most severe are considered to be: atrial fibrillation, flutter and ventricular/atrial fibrillation.

Arrhythmia and disability are a pressing issue for many related to health status, performance, and disease prognosis.

To provide the correct answer to the question “Do arrhythmia provide disability?” It is not enough to know the exact diagnosis of the patient, because the assignment of disability is not only a medical field, but more of a medical and social category. Therefore, first of all, you need to know what criteria exist for differentiating patients referred for disability with heart rhythm disturbances.

CLASSIFICATION of cardiac arrhythmias (V.L. Doshchitsin, 1991).

I. Impairment of impulse formation. 1. Sinus tachycardia. 2. Sinus bradycardia. 3. Sinus arrhythmia. 4. Migration of the rhythm source. 5. Extrasystole: a) suprapentricular and ventricular; b) single, group, allorhythmic. 6. Paroxysmal tachycardia: a) supraventricular and ventricular; b) paroxysmal and constantly recurrent. 7. Non-paroxysmal tachycardia and accelerated ectopic rhythms - supraventricular and ventricular. 8. Atrial flutter: a) paroxysmal and persistent; b) regular and irregular shapes. 9. Atrial fibrillation: a) paroxysmal and persistent; b) tachysystolic and bradysystolic forms. 10. Flickering (fibrillation) and ventricular flutter.

II. Conduction disorders. 1. Sinoatrial blockade—complete and incomplete. 2. Intraatrial block - complete and incomplete. 3. Atrioventricular block: a) I, II and III degrees; b) proximal and distal. 4. Intraventricular block: a) mono-, bi- and tri-fascicular, focal, arborptic; b) complete and incomplete.

III. Combined arrhythmias. 1. Sick sinus syndrome. 2. Escaping (slipping) contractions and rhythms - supraventricular and ventricular. 3. Syndromes of premature excitation of the ventricles. 4. Parasystoles. 5. Long QT syndrome.

Classification of ventricular extrasystoles and (Lown, 1983).

1 tbsp. - single, rare monotonous extra-tables, no more than 60 per 1 hour (no more than 1 per 1 minute). Stage 2—frequent—monotopic extrasystoles, more than 1 per minute. 3st. - polytopic, frequent ventricular extrasystoles. 4st. - group ventricular extrasystoles (double and volley). 5th stage - early extrasystoles, type “R” to “T” and extra early.

3-5 tbsp. - these are extrasystoles of high gradation, indicate myocardial damage, are prognostically unfavorable (can develop into more serious rhythm disturbances).

With ischemic heart disease, almost all of the listed cardiac arrhythmias are possible, usually in combination with other manifestations of the disease: angina pectoris, myocardial infarction, heart failure. Thus, in the acute period of myocardial infarction, rhythm disturbances are recorded in almost all patients. 60-80% of patients with coronary artery disease die suddenly due to ventricular fibrillation (E. Chazov, 1985; Lown, 1983).

Indications:

patient complaints of heart rhythm disturbances not documented by ECG; identification of asymptomatic arrhythmias in individuals at high risk of their occurrence (hypertrophic cardomnopathy, aortic stenosis, etc.); examination of the ability to work of persons engaged in professions related to the performance of work, the sudden cessation of which could harm others (pilot, dispatcher, driver, etc.); syncope of unknown origin.

3. EPI - transesophageal. 4. Endocardial EPI and programmed electrical stimulation of the heart.

TREATMENT

A. Drug treatment. Classification of antiarrhythmic drugs: Group I (membrane stabilizing agents) A: quinidine, novocainamide, etc.; B: Lidocaine, diphenylhydantoin; C: ajmaline, ethmoznn, etacizin, allapinin. Group II (beta-blockers). Group III (drugs that slow down repolarization): amiodarone, bretylium tosylate. Group IV (calcium antagonists): verapamil, nifedipine.

Any antiarrhythmic drug can cause both antiarrhythmic and arrhythmogenic effects. The probability of an antiarrhythmic effect for most drugs is on average 50% and very rarely, only in a few clinical forms of arrhythmias, reaches 90-100%: a) relief of reciprocal atrioventricular tachycardia using intravenous administration of ATP, adenosine or verapamil; b) relief and prevention of paroxysmal tachycardia with complexes such as right bundle branch block and sharp deviations of the heart axis to the left with the help of verapamil; c) elimination of ventricular extrasystole with etacizine, flecainide.

In all other cases, the selection of antiarrhythmic therapy will be done by trial and error. In this case, the probability of an arrhythmogenic effect is on average 10%, in some cases life-threatening for the patient. The more severe the rhythm disturbances and the degree of myocardial damage, the higher the risk of an arrhythmogenic effect. Therefore, at present, most researchers believe that for asymptomatic and low-symptomatic arrhythmias, as a rule, the prescription of antiarrhythmic drugs is not required (A. S. Smetnen et al., 1993).

If drug therapy is necessary, the selection of antiarrhythmic drugs is based on the nature of the rhythm disturbance.

Medical and social examination

Medical and social examination and disability in cases of heart rhythm disorders DEFINITION Heart rhythm disturbances (arrhythmias) are understood as any heart rhythm that is not a regular sinus rhythm of normal frequency, caused by changes in the basic functions of the heart - automatism, excitability, conductivity or their combined disturbance. CLASSIFICATION of cardiac arrhythmias (V.L. Doshchitsin, 1991). I. Impairment of impulse formation. 1. Sinus tachycardia. 2. Sinus bradycardia. 3. Sinus arrhythmia. 4. Migration of the rhythm source. 5. Extrasystole: a) suprapentricular and ventricular; b) single, group, allorhythmic. 6. Paroxysmal tachycardia: a) supraventricular and ventricular; b) paroxysmal and constantly recurrent. 7. Non-paroxysmal tachycardia and accelerated ectopic rhythms - supraventricular and ventricular. 8. Atrial flutter: a) paroxysmal and persistent; b) regular and irregular shapes. 9. Atrial fibrillation: a) paroxysmal and persistent; b) tachysystolic and bradysystolic forms. 10. Flickering (fibrillation) and ventricular flutter. II. Conduction disorders. 1. Sinoatrial blockade—complete and incomplete. 2. Intraatrial block - complete and incomplete. 3. Atrioventricular block: a) I, II and III degrees; b) proximal and distal. 4. Intraventricular block: a) mono-, bi- and tri-fascicular, focal, arborptic; b) complete and incomplete. III. Combined arrhythmias. 1. Sick sinus syndrome. 2. Escaping (slipping) contractions and rhythms - supraventricular and ventricular. 3. Syndromes of premature excitation of the ventricles. 4. Parasystoles. 5. Long QT syndrome. Classification of ventricular extrasystoles and (Lown, 1983). 1 tbsp. - single, rare monotonous extra-tables, no more than 60 per 1 hour (no more than 1 per 1 minute). Stage 2—frequent—monotopic extrasystoles, more than 1 per minute. 3st. - polytopic, frequent ventricular extrasystoles. 4st. - group ventricular extrasystoles (double and volley). 5th stage - early extrasystoles, type “R” to “T” and extra early. 3-5 tbsp. - these are extrasystoles of high gradation, indicate myocardial damage, are prognostically unfavorable (can develop into more serious rhythm disturbances). With ischemic heart disease, almost all of the listed cardiac arrhythmias are possible, usually in combination with other manifestations of the disease: angina pectoris, myocardial infarction, heart failure. Thus, in the acute period of myocardial infarction, rhythm disturbances are recorded in almost all patients. 60-80% of patients with coronary artery disease die suddenly due to ventricular fibrillation (E. Chazov, 1985; Lown, 1983). Diagnostic methods 1. ECG at rest and during dosed physical activity (VEM). 2. Daily (Holter) monitoring. Indications: patient complaints of heart rhythm disturbances not documented by ECG; identification of asymptomatic arrhythmias in individuals at high risk of their occurrence (hypertrophic cardomnopathy, aortic stenosis, etc.); examination of the ability to work of persons engaged in professions related to the performance of work, the sudden cessation of which could harm others (pilot, dispatcher, driver, etc.); syncope of unknown origin. 3. EPI - transesophageal. 4. Endocardial EPI and programmed electrical stimulation of the heart. Indications: repeated episodes of ventricular fibrillation; severe attacks of ventricular tachycardia; frequent and severe attacks of supraventricular tachycardia; syncope of presumably arrhythmic origin; indications for surgical treatment of arrhythmias; selection of drug antiarrhythmic therapy. TREATMENT A. Drug treatment. Classification of antiarrhythmic drugs: Group I (membrane stabilizing agents) A: quinidine, novocainamide, etc.; B: Lidocaine, diphenylhydantoin; C: ajmaline, ethmoznn, etacizin, allapinin. Group II (beta-blockers). Group III (drugs that slow down repolarization): amiodarone, bretylium tosylate. Group IV (calcium antagonists): verapamil, nifedipine. Any antiarrhythmic drug can cause both antiarrhythmic and arrhythmogenic effects. The probability of an antiarrhythmic effect for most drugs is on average 50% and very rarely, only in a few clinical forms of arrhythmias, reaches 90-100%: a) relief of reciprocal atrioventricular tachycardia using intravenous administration of ATP, adenosine or verapamil; b) relief and prevention of paroxysmal tachycardia with complexes such as right bundle branch block and sharp deviations of the heart axis to the left with the help of verapamil; c) elimination of ventricular extrasystole with etacizine, flecainide. In all other cases, the selection of antiarrhythmic therapy will be done by trial and error. In this case, the probability of an arrhythmogenic effect is on average 10%, in some cases life-threatening for the patient. The more severe the rhythm disturbances and the degree of myocardial damage, the higher the risk of an arrhythmogenic effect. Therefore, at present, most researchers believe that for asymptomatic and low-symptomatic arrhythmias, as a rule, the prescription of antiarrhythmic drugs is not required (A. S. Smetnen et al., 1993). If drug therapy is necessary, the selection of antiarrhythmic drugs is based on the nature of the rhythm disturbance. Supraventricular rhythm disturbances. 1. Acute (extrasystole, paroxysmal atrial fibrillation, atrial flutter): procainamide, quinidine; (paroxysmal tachycardia): physical methods, isoptin, ATP, beta-blockers. 2. Prevention of paroxysms: cordarone, quinidine, beta-blockers. Ventricular rhythm disturbances. 1. Acute (extrasystole, paroxysmal tachycardia, fibrillation): lidocaine, nonocainamnd, etacizium, cordarone. 2. Prevention of paroxysms: cordarone, quinidine, diphenylhydantoin, novocainamide. Special forms of rhythm disturbance: 1. WPW syndrome: cordarone, ethmosin, gilurythmal (ajmalin). Contraindicated: cardiac glycosides and partially isoptic. 2. Sick sinus syndrome: rhythmylene, quinidine (under control of sinus node activity). B. Non-drug treatment methods. 1. Electrical defibrillation. 2. Electrical stimulation of the heart. B. Surgical treatment. 1. Intersection of additional pathways. 2. Removal, destruction or isolation of arrhythmogenic foci in the heart. 3. Cardiac stimulation (permanent, temporary). 4. Destruction of the atrioventricular node with implantation of a pacemaker. MSE IN NSR IS DETERMINED BY THE FOLLOWING MAIN FACTORS: a) the severity of rhythm disturbances; b) the nature of the disease that caused the rhythm disturbances; c) the presence of contraindicated working conditions; d) the nature of the treatment (medicinal, surgical). Severity of heart rhythm disturbances. The severity of heart rhythm disturbances is determined by: a) the frequency of their occurrence (paroxysmal form); b) duration (paroxysmal form); c) hemodynamic state; d) actual and probable complications: heart failure (acute and chronic); acute coronary insufficiency or progressive chronic; acute cerebrovascular insufficiency or progressive chronic; thromboembolic complications; syncope or sudden death. In terms of assessing work capacity, it is inappropriate to separate different forms of NSR and conductivity according to their severity and prognostic significance. 1. Mild degree (insignificant NSR and conductivity): supraventricular and ventricular extrasystoles (I-II gradations according to Lown); brady- or normosystolic constant form of atrial fibrillation; sick sinus syndrome with a rhythm frequency of more than 50 per minute; paroxysms of atrial fibrillation and supraventricular tachycardia, occurring once a month or less, lasting no more than 4 hours and not accompanied by subjectively perceived changes in hemodynamics; A-B blockade of the 1st degree and 2nd degree (Mobitz type I); mono- and bifascicular blockades of the branches of the His bundle. 2. Moderate severity: polytopic frequent (1: 10) ventricular extrasystole (III gradation according to Lown); paroxysms of atrial fibrillation, atrial flutter; supraventricular tachycardia, occurring 2-4 times a month, lasting more than 4 hours, accompanied by changes in hemodynamics felt by patients; conduction disorders: A-B Mobitz block II and III degrees, tri-fascicular block of the branches of the His bundle, sick sinus syndrome, sinoauricular block III degree, junctional rhythm with a heart rate of more than 40 per minute and the absence of HF. 3. Severe degree: ventricular extrasystole - frequent polytopic, volley, early (IV-V gradations according to Lown); paroxysms of atrial fibrillation, atrial flutter, supraventricular tachycardia, occurring several times a week, accompanied by pronounced changes in hemodynamics, difficult to tolerate by patients; paroxysms of ventricular tachycardia; a permanent form of atrial fibrillation, tachysystolic atrial flutter, not corrected by medications and accompanied by progressive heart failure; sick sinus syndrome, trifascicular His bundle block, Frederick's syndrome with heart rate less than 40 per minute, attacks of MES and syncope, progressive heart failure. Functionally significant deterioration of hemodynamics as a result of rhythm and conduction disturbances, the emergence or increase in the severity of heart failure is determined not only by the form of NSR, but also by the initial state of the myocardium (cardiosclerosis) and coronary and cerebral arteries (atherosclerosis). Thromboembolic complications, syncope and sudden death can occur when NSR and conduction are the only manifestation of the disease: congenital anomalies of the cardiac conduction system; isolated damage to the artery supplying the sinus node, isolated focal cardiosclerosis involving the conduction system of the heart, non-progressive hypertrophic cardiomyopathy. Contraindicated working conditions: 1. Working conditions contraindicated for the underlying disease that caused NSR and conductivity (coronary artery disease, rheumatism and others). 2. The presence or risk of ventricular arrhythmias and asystole: work that poses a danger to others and the patient in the event of its sudden cessation (driver, pilot, railway and aeroflot dispatcher, work at height and in extreme conditions). In most cases of NSD, the ability of patients to work is determined by the underlying disease that was their cause. Difficulties in MSE, as a rule, arise more often when the only manifestation of the pathological process is a violation of rhythm and conduction. Able to work: 1. Insignificant (mild) rhythm disturbances. 2. Average severity of rhythm disturbances with the exception of contraindicated labor factors. Reduced ability to work (limited ability to work - disability group III): 1. Severe degree of rhythm disturbance. Heart rhythm and conduction disturbances, as a rule, do not have independent significance in permanent disability and are considered in combination with the underlying disease that caused their occurrence. It should be taken into account that NSR and severe conduction may contribute to the progression of heart failure and indicate a high risk of sudden death. The greatest difficulties arise when it is necessary to assess the ability to work and rationally employ patients with continuous electrical cardiac stimulation (PECS). This method is currently widely used for the treatment of the following NSR and conduction: acquired complete A-B block in the presence of MES attacks and a heart rate of less than 40 beats per minute; congenital permanent A-B block with a heart rate less than 50 beats per minute; A-B blockade of the second degree (Mobitz II); blockade of both bundle branches; sick sinus syndrome, tachybradcardia syndrome; supraventricular paroxysmal tachycardia and atrial fibrillation, resistant to drug therapy; WPW syndrome. Indications for referring patients with implanted pacemakers to MSE: 1. To extend the duration of VUT in cases of effective pacemaker implantation and a favorable clinical and labor prognosis in the following cases: - the presence of complications in the postoperative period (pleurisy, pericarditis, etc.); - heart rhythm disturbances of moderate severity (for example, ventricular extrasystole more than 6-8 per minute, parasystole, etc.), requiring active and long-term drug therapy; — presence of signs of the initial stage of heart failure; disorders of psychological adaptation to ECS requiring psychotherapeutic correction. 2. To determine the disability group for persons of working age: - the presence of absolute medical contraindications to the continuation of the previous professional activity and the need, in connection with this, to transfer to another job with a reduction in volume, qualifications or a change in profession; — ineffectiveness of PEX, as a result of which attacks of NSR and conduction persist, which is accompanied by significant dysfunction of the cardiovascular system; — presence of complications of PEX requiring long-term treatment; - absolute dependence of the patient on PEX; - worsening of the underlying disease. 3. Re-examination of disabled people with PEX. The required minimum of research when referring a patient for medical examination. The required amount of research is determined by the underlying disease and includes: a) the results of a study of the degree of dependence of the patient on the pacemaker; b) ECG at rest; VEM test (threshold power - 75 W); c) daily monitoring (according to indications); d) integral rheography or echocardiography; e) chest x-ray; f) consultation with a psychotherapist. Contraindicated working conditions (absolute): 1. Work associated with exposure to strong static charges, magnetic fields and pronounced effects of microwave fields. 2. Work related to electrolytes and under conditions of exposure to strong induction of thermal and light radiation from stoves and radiators. 3. Work related to the maintenance of existing powerful electrical installations. 4. Work in conditions of severe vibration. 5. Work associated with constant or episodic significant physical stress throughout the entire working day, at a prescribed pace, and in a forced body position. 6. Work associated with potential danger to others due to its sudden cessation by patients. Patients should be considered able to work if they are effectively treated with a permanent pacemaker: the disappearance of previously existing PSR and conductivity, significant or complete regression of HF phenomena, and the absence of complications in the postoperative period. As a result, in such patients, after 1.5-2 months, the quality of life improves, a normal psychological reaction is established, the required level of physical activity is achieved, and they can resume their professional activities in professions of mental or light physical labor. A necessary condition for the restoration of working capacity is the patient’s independence from the pacemaker: the emergence of his own heart rhythm after suppression of the pacemaker. Disability criteria In case of pathology of the cardiovascular system (including heart rhythm disturbances), the decisive criterion for establishing disability is the stage of CHF (chronic heart failure). The relationships between the stages of CHF and disability are as follows: With CHF 0 and CHF 1st. - disability is not established. With CHF 2Ast. — 3rd disability group in adults (category “disabled child” in children). With CHF 2Bst. — 2nd disability group in adults (category “disabled child” in children). With CHF stage 3. — 1st disability group in adults (category “disabled child” in children). The above ratios apply provided that the patient has a PERSISTENT (not treatable for at least the last 4-6 months before MSA) corresponding stage of CHF. Exceptions to the above ratios are cases where a child (a person under the age of 18 years) has: - an implanted pacemaker (in this case, the category “disabled child” is established regardless of the stage of CHF, i.e. even with CHF stage 0); — the presence of a vascular implant that periodically requires replacement due to the growth of the child (in this case, the category “disabled child” is also established regardless of the stage of CHF, i.e. even with CHF stage 0).
A patient can receive an official conclusion on the presence (or absence) of grounds for establishing disability only based on the results of his examination at the ITU Bureau relevant region

.
The procedure for completing documents for undergoing MSE (including the algorithm of actions in case of refusal of attending physicians to refer a patient to MSE) is described in sufficient detail in this section of the forum: Registration of disability in simple language
Source

Special forms of rhythm disturbance:

1. WPW syndrome: cordarone, ethmozin, gilurythmal (ajmalin). Contraindicated: cardiac glycosides and partially isoptic. 2. Sick sinus syndrome: rhythmylene, quinidine (under control of sinus node activity).

B. Non-drug treatment methods. 1. Electrical defibrillation. 2. Electrical stimulation of the heart.

B. Surgical treatment. 1. Intersection of additional pathways. 2. Removal, destruction or isolation of arrhythmogenic foci in the heart. 3. Cardiac stimulation (permanent, temporary). 4. Destruction of the atrioventricular node with implantation of a pacemaker.

Severity of heart rhythm disturbances. The severity of heart rhythm disturbances is determined by:

a) the frequency of their occurrence (paroxysmal form); b) duration (paroxysmal form); c) hemodynamic state; d) actual and probable complications: heart failure (acute and chronic); acute coronary insufficiency or progressive chronic; acute cerebrovascular insufficiency or progressive chronic; thromboembolic complications; syncope or sudden death.

In terms of assessing work capacity, it is inappropriate to separate different forms of NSR and conductivity according to their severity and prognostic significance.

1. Mild degree (insignificant NSR and conductivity): supraventricular and ventricular extrasystoles (I-II gradations according to Lown); brady- or normosystolic constant form of atrial fibrillation; sick sinus syndrome with a rhythm frequency of more than 50 per minute; paroxysms of atrial fibrillation and supraventricular tachycardia, occurring once a month or less, lasting no more than 4 hours and not accompanied by subjectively perceived changes in hemodynamics; A-B blockade of the 1st degree and 2nd degree (Mobitz type I); mono- and bifascicular blockades of the branches of the His bundle.

2. Moderate severity: polytopic frequent (1: 10) ventricular extrasystole (III gradation according to Lown); paroxysms of atrial fibrillation, atrial flutter; supraventricular tachycardia, occurring 2-4 times a month, lasting more than 4 hours, accompanied by changes in hemodynamics felt by patients; conduction disorders: A-B Mobitz block II and III degrees, tri-fascicular block of the branches of the His bundle, sick sinus syndrome, sinoauricular block III degree, junctional rhythm with a heart rate of more than 40 per minute and the absence of HF.

3. Severe degree: ventricular extrasystole - frequent polytopic, volley, early (IV-V gradations according to Lown); paroxysms of atrial fibrillation, atrial flutter, supraventricular tachycardia, occurring several times a week, accompanied by pronounced changes in hemodynamics, difficult to tolerate by patients; paroxysms of ventricular tachycardia; a permanent form of atrial fibrillation, tachysystolic atrial flutter, not corrected by medications and accompanied by progressive heart failure; sick sinus syndrome, trifascicular His bundle block, Frederick's syndrome with heart rate less than 40 per minute, attacks of MES and syncope, progressive heart failure.

Functionally significant deterioration of hemodynamics as a result of rhythm and conduction disturbances, the emergence or increase in the severity of heart failure is determined not only by the form of NSR, but also by the initial state of the myocardium (cardiosclerosis) and coronary and cerebral arteries (atherosclerosis).

Thromboembolic complications, syncope and sudden death can occur when NSR and conduction are the only manifestation of the disease: congenital anomalies of the cardiac conduction system; isolated damage to the artery supplying the sinus node, isolated focal cardiosclerosis involving the conduction system of the heart, non-progressive hypertrophic cardiomyopathy.

Main aspects of determining MSE for arrhythmia

There are a number of factors that are taken into account during the medical and sanitary examination during the NSR:

severity of heart rhythm disorder;
the nature of the underlying disease that causes the development of arrhythmia;
are there any contraindications due to working conditions;
the therapy used, medical or surgical.

Severity of violation

During the examination of a patient with arrhythmia for examination for assignment of disability, the severity of heart rhythm disturbances is assessed. For this purpose it is determined:

duration of the arrhythmia attack;
frequency of occurrence of paroxysms;
state of the circulatory system;
determination of complications or the degree of risk of their occurrence.

In terms of complications, the presence of concomitant diseases in the form of heart failure, coronary insufficiency, cerebral insufficiency, thromboembolism and its complications, and syncope has a particular influence on the assignment of disability. All of these pathologies are considered in acute and exacerbation of chronic form.

Nature of the underlying disease

Conducting a medical and social examination does not imply the separation of various forms of NSD according to the severity of the clinical picture and prognostic value. Therefore, it is customary to distinguish general degrees of severity for all manifestations of arrhythmias:

Mild degree . The clinical picture of rhythm disturbances and conduction function is not very pronounced. Attacks occur no more than once a month and last no more than four hours. In the presence of a syndrome such as weakness of the sinus node, the heart rate should be 50 beats/minute or higher. With AV block corresponds to Mobitz type 1. Atrial fibrillation is constantly detectable, normo- or bradysystolic type.
Average degree . The frequency of attacks is from 2 to 4 times a month, their duration is 4 hours or more. With SSSS, the heart rate is from 40 times per minute. With AV block, Mobitz type 2 is determined. Atrial fibrillation of paroxysmal type.
Severe degree . The frequency of attacks is more than 4 times a month. Arrhythmias with a slow rhythm of less than 40 beats per minute. Av blockade of Mobitz of the third type. Atrial fibrillation is constant, but paroxysms are difficult to stop or cannot be stopped at all with medications. Progressive heart failure, conditions such as syncope, and attacks of MES are also determined.

Hemodynamic disorders of functional significance may be associated not only with forms of NRS, but also with the condition of the arteries (cerebral, coronary) and myocardium, which can be worsened by the development of cardiosclerosis and atherosclerosis.

Contraindications for working conditions

In the process of registering disability due to arrhythmia, the question of working conditions often arises at the ITU commission. Sometimes an improperly equipped workplace can cause the development of an underlying disease, which is further complicated by heart rhythm disturbances. The same applies to rheumatism, coronary heart disease, varicose veins, etc.

Some professions are associated with risk, and with continuous employment in such a field of activity, ventricular arrhythmias and asystole may develop. This applies to such professions as a driver, crane operator, pilot, railway or aeroflot dispatcher. This also includes all work that, to one degree or another, depends on extremes.

During MSE, the patient’s ability to work is necessarily determined. To do this, the condition is often assessed based on the underlying disease, for example, rheumatism or coronary artery disease. A more complex situation occurs in the presence of only rhythm and conduction disturbances. Then the categories of patients who have been diagnosed with mild and moderate severity of arrhythmia are considered able to work:

Mild degree - in patients, attacks of arrhythmia manifest themselves in a mild degree, that is, the clinical picture is poorly expressed.
Moderate degree - the clinical manifestations are moderate, and there are no predisposing factors to the progression of the disease from working conditions.

In case of severe severity, disability of the third group is issued. Such patients, as a rule, have “a whole bunch of diseases,” among which heart failure is often pronounced. Arrhythmias play a secondary role in examining a patient. Some forms may still increase the risk of developing atrial fibrillation or cardiac arrest.

Contraindicated working conditions:

1. Working conditions contraindicated in case of the underlying disease that caused NSR and conductivity (IHD, rheumatism, and others). 2. The presence or risk of ventricular arrhythmias and asystole: work that poses a danger to others and the patient in the event of its sudden cessation (driver, pilot, railway and aeroflot dispatcher, work at height and in extreme conditions).

In most cases of NSD, the ability of patients to work is determined by the underlying disease that was their cause. Difficulties in MSE, as a rule, arise more often when the only manifestation of the pathological process is a violation of rhythm and conduction.

Able-bodied:

1. Insignificant (mild) rhythm disturbances. 2. Average severity of rhythm disturbances with the exception of contraindicated labor factors.

Reduced ability to work (limited ability to work - disability group III): 1. Severe degree of rhythm disturbance. Heart rhythm and conduction disturbances, as a rule, do not have independent significance in permanent disability and are considered in combination with the underlying disease that caused their occurrence. It should be taken into account that NSR and severe conduction may contribute to the progression of heart failure and indicate a high risk of sudden death.

The greatest difficulties arise when it is necessary to assess the ability to work and rationally employ patients with continuous electrical cardiac stimulation (PECS).

This method is currently widely used for the treatment of the following NSR and conduction: acquired complete A-B block in the presence of MES attacks and a heart rate of less than 40 beats per minute; congenital permanent A-B block with a heart rate less than 50 beats per minute; A-B blockade of the second degree (Mobitz II); blockade of both bundle branches; sick sinus syndrome, tachybradcardia syndrome; supraventricular paroxysmal tachycardia and atrial fibrillation, resistant to drug therapy; WPW syndrome.

Registration of disability with an implanted pacemaker

There are certain indications according to which patients with an implanted pacemaker can be referred for MSA.

1. Re-examination of those patients who have had a permanent pacemaker installed.

2. Registration of a disability group for those patients who are of working age. In this case, at least one reason from the following must be determined for which the disability should be registered

the patient cannot work at his previous job because there are absolute contraindications;
after implantation of a permanent pacemaker, attacks of arrhythmia are observed, significantly worsening hemodynamics;
after implantation, complications appeared that require long-term treatment to eliminate;
the patient is absolutely dependent on the pacemaker;
the course of the underlying disease worsened greatly.

3. After successful implantation and a normal prognostic value, the period of temporary disability can be extended for the following reasons:

after the operation, complications arose in the form of pleurisy, pericarditis, etc.;
the heart rhythm disturbance is assessed as moderate, and its treatment requires long-term medication;
signs of heart failure appeared in the initial stage.

Indications for referral to MSE for patients with implanted pacemakers:

1. To extend the duration of VUT in cases of effective pacemaker implantation and a favorable clinical and labor prognosis with: - the presence of complications in the postoperative period (pleurisy, pericarditis, etc.); - heart rhythm disturbances of moderate severity (for example, ventricular extrasystole more than 6-8 per minute, parasystole, etc.), requiring active and long-term drug therapy; — presence of signs of the initial stage of heart failure; disorders of psychological adaptation to ECS requiring psychotherapeutic correction.

2. To determine the disability group for persons of working age: - the presence of absolute medical contraindications to the continuation of the previous professional activity and the need, in connection with this, to transfer to another job with a reduction in volume, qualifications or a change in profession; — ineffectiveness of PEX, as a result of which attacks of NSR and conduction persist, which is accompanied by significant dysfunction of the cardiovascular system; — presence of complications of PEX requiring long-term treatment; - absolute dependence of the patient on PEX; - worsening of the underlying disease.

3. Re-examination of disabled people with PEX.

What is ITU?

Medical and social examination (MSE) is an examination at the state level of a person’s needs for social protection, for which the degree of restrictions in the activity of vital organs is assessed, which led to persistent impairment of the functions of the whole organism.

Patients are referred to MSE by treatment and preventive institutions that are subordinate to the Ministry of Health. Medical and social expert commissions created on the basis of the same state medical institutions take part in determining disability. The commission is headed by the chief physician, who is approved for the position by the head of the health department of the city administration.

Video: Rules for referral to ITU

Contraindicated working conditions (absolute):

1. Work associated with being in conditions of strong static charges, magnetic fields and pronounced effects of microwave fields. 2. Work related to electrolytes and under conditions of exposure to strong induction of thermal and light radiation from stoves and radiators. 3. Work related to the maintenance of existing powerful electrical installations. 4. Work in conditions of severe vibration. 5. Work associated with constant or episodic significant physical stress throughout the entire working day, at a prescribed pace, and in a forced body position. 6. Work associated with potential danger to others due to its sudden cessation by patients.

Patients should be considered able to work if they are effectively treated with a permanent pacemaker: the disappearance of previously existing PSR and conductivity, significant or complete regression of HF phenomena, and the absence of complications in the postoperative period. As a result, in such patients, after 1.5-2 months, the quality of life improves, a normal psychological reaction is established, the required level of physical activity is achieved, and they can resume their professional activities in professions of mental or light physical labor. A necessary condition for the restoration of working capacity is the patient’s independence from the pacemaker: the emergence of his own heart rhythm after suppression of the pacemaker.

Disability criteria for patients with pacemaker

Third group. Against the background of a normally performed operation and an improvement in the patient’s quality of life, the following is observed: a positive bicycle ergometry test, a moderate hemodynamic disturbance, and a determination of persistent rejection of the implanted device, expressed in a change in personality. Also, after implantation of an pacemaker and the development of arrhythmia, they are given disability in the event of a change in place of work with an expected reduction in the load of production work, a change in profession or qualifications.

Second group. The operation to implant a permanent pacemaker was ineffective: previously identified arrhythmias persist; There is interference between the rhythms of the patient’s own and the pacemaker, and severe coronary or heart failure has appeared.

4.50 Aug. rating ( 89 % score) – 6 votes – ratings

Disability criteria

Group III: after the operation, there is an improvement in the general condition of the patients, but they have: a) a positive VEM test; b) moderate disorders of the circulatory system; c) the presence of a persistent psychopathological reaction to pacemaker implantation with personality changes; d) the need for employment in non-contraindicated working conditions, with a decrease in the volume of production activities, qualifications or a change in profession.

Group II: ineffectiveness of surgical treatment using the PEX method: a) previous NSR and conductivity are preserved; b) interference of ECS and own rhythms; c) pronounced manifestations of coronary and heart failure (angina pectoris class III—IV, heart failure stage IIB—III); d) absolute dependence on the ECS.

What examinations do you need to undergo before ITU?

Patients referred for medical and social examination must first undergo a series of studies, including the following types of diagnostics:

Electrocardiography in a calm state.
Echocardiography or integral rheography.
Bicycle ergometry with a threshold power of about 75 W.
Holter (24-hour) monitoring of cardiac activity.
X-ray of the chest organs.
Advisory opinion of doctors of a narrow specialty (psychotherapist).