Blue Book listing 4.04
Ischemic Heart Disease and SSDI: How Listing 4.04 Works
SSA evaluates ischemic heart disease under listing 4.04, which asks for objective proof that your symptoms come from reduced blood flow to the heart while on prescribed treatment. That proof can come from exercise or stress imaging, coronary angiography with qualifying measurements, or repeated hospitalizations within 12 months.
Coronary artery disease, chronic angina, a past heart attack and repeat stenting all reach Social Security through one Blue Book listing: 4.04, ischemic heart disease. The medical rules are the same whether you apply for SSDI (Social Security Disability Insurance), which depends on your work history, or SSI (Supplemental Security Income), which depends on income and assets.
SSA rewrote this listing in a final rule published July 2, 2026. The revised version applies to new applications filed on or after October 30, 2026 and to claims pending on or after that date. It now has five paragraphs, A through E, and includes coronary physiology measurements called FFR and iFR. Below we cover each paragraph, the RFC (residual functional capacity) route when the numbers fall short, and the cardiac records that decide the file.
SSA Blue Book listing
4.04
Heart and lungs
The criteria are set out below in plain language.
Federal Register, Revised Medical Criteria for Evaluating Cardiovascular Disorders (July 2, 2026)
What does it take to meet heart disease listing 4.04?
Listing 4.04 starts with a threshold: you must have symptoms due to myocardial ischemia, meaning heart muscle starved of oxygenated blood, while on a regimen of prescribed treatment. Beyond that, you need one of five findings.
- A, an exercise test. Inability to perform an exercise tolerance test at a workload of 5 METs or less, with findings that an acceptable medical source interprets as positive for ischemia.
- B, stress imaging. An ischemic response on stress testing with medically appropriate imaging, showing either at least two reversible or fixed regional perfusion defects plus transient ischemic dilatation or a resting left ventricular ejection fraction under 50 percent, or at least two reversible or fixed regional wall motion abnormalities plus a drop in ejection fraction during testing or a resting ejection fraction under 50 percent.
- C, three ischemic episodes. Three separate ischemic episodes, each requiring unplanned hospitalization, inpatient or observation status, within a consecutive 12-month period.
- D, angiography. Coronary artery disease documented by angiography obtained independently of the disability claim, with one of four findings, set out in the next section.
- E, three longer hospitalizations. Three hospitalizations for exacerbations or complications of ischemic heart disease within a consecutive 12-month period, at least 30 days apart, each lasting at least 48 hours, counting emergency department hours immediately before admission.
SSA's rule explains that planned staged interventions are a single event and do not by themselves satisfy paragraph E.
How angiography, FFR and iFR meet the heart disease listing
Paragraph D is built on the catheterization report, and it offers four ways in.
- FFR. A fractional flow reserve of 0.80 or less in a proximal or mid segment of a coronary artery that is not amenable to revascularization.
- iFR. An instantaneous wave-free ratio of 0.89 or less in a proximal or mid segment of an artery not amenable to revascularization.
- Prior bypass surgery with continuing signs of ischemia on prescribed treatment, plus 50 percent or more narrowing of a nonbypassed left main artery; 70 percent or more in the proximal or mid segment of another nonbypassed artery; 50 percent or more in the proximal or mid segments of at least two nonbypassed arteries; or 70 percent or more of a bypass graft.
- A resting ejection fraction under 50 percent while medically stable, with signs of ischemia on prescribed treatment, plus 50 percent or more narrowing of the nonbypassed left main artery, 70 percent in the proximal or mid segment of another nonbypassed artery, or 50 percent or more in the proximal or mid segments of at least two.
The FFR and iFR criteria apply only to a proximal or mid segment artery that is not amenable to revascularization, as SSA defines that term in 4.00E9c(ii), so the report or a cardiology note should address whether revascularization is possible. Location matters as well: several criteria count only narrowing in the proximal or mid segment of an artery.
Narrowing in the coronary arteries of a transplanted heart is evaluated under its own new listing, 4.16 for cardiac allograft vasculopathy, which our FAQ below covers.
The RFC route for heart disease disability claims
A stress test number alone should not stand in for an RFC.
Many people with coronary disease do not hit an exact 4.04 number, and the claim does not end there. SSA then sets your RFC, which SSR 96-8p defines as the most you can still do in sustained work on a regular and continuing basis, meaning 8 hours a day, 5 days a week, or an equivalent schedule. For ischemic heart disease, the RFC turns on how much exertion brings on ischemia, and how quickly.
Exertional angina maps onto SSA's exertional categories. Under SSR 83-10, light work involves lifting no more than 20 pounds at a time and standing or walking, off and on, for about 6 hours of an 8-hour day. Sedentary work involves lifting no more than 10 pounds, with standing or walking that generally totals no more than about 2 hours. When a cardiology note records chest pain after one flight of stairs or a short walk, that note speaks directly to whether you can sustain 6 hours on your feet.
Breathlessness and fatigue belong in the RFC discussion too. Federal regulation 20 CFR 404.1529 lists fatigue, shortness of breath and weakness among the symptoms SSA weighs, along with the type, dosage, effectiveness and side effects of your medication, so beta blockers, nitrates and other anti-anginal drugs belong in that record. A stress test number alone should not stand in for an RFC.
Medical evidence that decides a heart disease claim
Every paragraph of 4.04 depends on objective testing tied to ischemia. For a 4.04 claim, the records that matter first are:
- Full exercise test reports, including the METs reached, the reason the test stopped and the interpreting physician's reading, not only the one-line impression.
- Nuclear perfusion, stress echocardiogram or other stress imaging reports that count the defects or wall motion abnormalities and state the ejection fraction at rest and during testing.
- Catheterization reports giving percent narrowing vessel by vessel and segment by segment, any FFR or iFR values, and the cardiologist's note on whether revascularization is possible.
- Hospital records for each admission, with emergency department arrival time, admission and discharge dates, inpatient or observation status, and whether the stay was planned or unplanned.
- Cardiology office notes recording how often chest pain occurs, what brings it on and how often you use nitroglycerin.
Timing matters in cardiac files. SSA's rules say a longitudinal record covering at least 3 months of observation and treatment is usually necessary, unless the agency can decide on the evidence it already has. The angiogram for paragraph D must have been obtained independently of the disability evaluation, which in practice means it was done as part of your care.
Why do heart disease disability claims get denied?
The first pattern to check for is a test that was done but never read against the listing. A stress report that omits the workload reached, or an imaging study that does not count the perfusion defects or report the resting ejection fraction, leaves SSA without the number paragraphs A and B depend on.
A second pattern to check for is hospital stays that do not fit the rules. Paragraph C counts only unplanned admissions, and paragraph E needs stays of at least 48 hours, at least 30 days apart. Planned staged interventions are a single event under the rule, so a planned second stage does not count as a separate event toward paragraph E. A third is a catheterization report that gives percentages without naming the segment, or an FFR or iFR value with no note on whether the artery is amenable to revascularization. A fourth is a thin treatment history, since listing 4.04 is written for someone on a regimen of prescribed treatment.
If your claim has already been denied on one of these grounds, our guide to a disability denial explains the next filing. Coronary disease often travels with other cardiac problems, so our pages on heart failure disability claims and recurrent arrhythmia claims may also apply to your file.
Heart Disease Disability Claim Questions
Does one heart attack with a stent count toward listing 4.04?
A single heart attack does not satisfy paragraph C on its own. Paragraph C needs three separate episodes requiring unplanned hospitalization within a consecutive 12-month period, which SSA defines as 12 consecutive months, all or part of which falls within the period it is considering. A single event can still support a claim through stress testing, angiography with FFR or iFR, or the RFC route.
Can a chemical stress test be used for listing 4.04?
Yes, for paragraph B. That paragraph accepts an ischemic response on exercise or pharmacological stress testing, the drug-induced test used when you cannot exercise on a treadmill, as long as the study includes medically appropriate imaging. Paragraph A is different: it depends on an exercise tolerance test, so it is not available from a drug-induced study.
How does Social Security evaluate heart disease after a heart transplant?
Listing 4.09 considers you disabled for 1 year from the date of a heart transplant, and SSA then evaluates what remains. Narrowing in the transplanted heart's arteries falls under the new listing 4.16, cardiac allograft vasculopathy, when imaging documents it along with a cardiac index or output under 2 l/min/m2, an ejection fraction of 45 percent or less, right atrial pressure over 12 mmHg, or wedge pressure over 15 mmHg.
Sources: Federal Register, Revised Medical Criteria for Evaluating Cardiovascular Disorders (July 2, 2026); SSR 96-8p, Assessing Residual Functional Capacity; SSR 83-10, Exertional Levels of Work; 20 CFR 404.1529, Evaluation of Symptoms.
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