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MAYFIELD v. SULLIVAN

January 31, 1990

JESSE D. MAYFIELD, Plaintiff
v.
LOUIS SULLIVAN, M.D., Defendant


James F. Holderman, United States District Judge.


The opinion of the court was delivered by: HOLDERMAN

JAMES F. HOLDERMAN, UNITED STATES DISTRICT JUDGE

 Plaintiff Jesse D. Mayfield instituted this action pursuant to 42 U.S.C. § 1383(c)(3) for review of the final decision of the Secretary of the Department of Health and Human Services (the "Secretary") denying plaintiff's application for social security disability insurance benefits. The parties have filed cross-motions for summary judgment. For the reasons stated, the Secretary's motion for summary judgment is denied and the case will be remanded for further consideration.

 BACKGROUND FACTS

 A. Medical Evidence.

 Plaintiff was admitted to Westlake Community Hospital on June 1, 1985 with chest pain which had begun the afternoon of the previous day. (Tr. 120.) Further examination revealed that plaintiff had experienced a myocardial infarction. While in the hospital Mr. Mayfield had resting electrocardiograms taken daily from June 2, 1985 through June 5, 1985 and again on June 10, 1985. (Tr. 213-217.) These electrocardiograms all displayed abnormal readings. An unsigned and undated interpretation of these at-rest electrocardiograms stated that the abnormality of the at-rest electrocardiograms rested in a:

 
QS pattern or Q wave amplitude at least 1/3 of R wave, and with a duration of 0.04 second or more. . . .

 (Tr. 210.) The interpretation also noted that certain ST/T changes indicated abnormalities. (Id.)

 Mr. Mayfield was released from the hospital on June 12, 1985 with instructions for rest and rehabilitation. Certain medications were prescribed. (Tr. 125.)

 After approximately 6 months off work, Mr. Mayfield returned to his job as a bus driver for the CTA. (Tr. 50.) On October 31, 1986 Mr. Mayfield, while he was driving a bus, experienced what he believed to be another heart attack. (Tr. 33, 50-51.) Mr. Mayfield testified at the administrative hearing in this matter that he believed he was experiencing another heart attack because he was ill, vomiting continuously, and was experiencing serious pain in his chest, in his head and on the left side of his face. (Tr. 51.) He was readmitted to Westlake Hospital. Laboratory tests revealed that Mr. Mayfield's cholesterol was slightly elevated, but that his electrolytes and cardiac enzymes were normal. At the hearing in this case Dr. Abramson, the administrative law judge's medical advisor, testified that although plaintiff's complaints leading to the 1986 hospitalization describe "something that sounds like a myocardial infarction," there was nothing in the record to indicate that plaintiff did suffer another heart attack at that time. (Tr. 60.)

 An electrocardiogram was taken of plaintiff's heart on November 3, 1986. (Tr. 169.) The interpretation of this test indicated that plaintiff's cardiac dimensions were within normal limits; the mitral valve anterior and posterior leaflets were within normal range; there was no sign of mitral stenosis or prolapse; the aortic valve recorded well within normal range. The posterior wall and septal wall were "minimally thickened." The report noted that this could have been a "normal variant." The report's conclusion was "normal echocardiography." (Tr. 169.)

 On November 5, 1986 plaintiff underwent a cardiac catheterization. This test revealed, inter alia, a "somewhat diseased" obtuse marginal branch, a "severely diseased" second obtuse marginal branch; a severely diseased first diagonal artery; a moderately severely diseased LAD artery; a severely diseased right coronary artery; an enlarged left ventricular cavity, and a moderately prolapsed posterior leaf of the mitral valve. (Tr. 171.)

 A Bruce Protocol Exercise Tolerance Test, conducted November 4, 1986 was stopped after 8 minutes of exercise because Mr. Mayfield was experiencing substernal chest pain with burning. During this test plaintiff was able to reach only 65% of his maximum heart rate before the test was stopped. (Tr. 140.) A subsequent Exercise ECG Interpretation of this treadmill test indicated that the test was negative at more than 5 METS and less than 10 METS. (Tr. 220.) *fn1" The interpretation indicated that Mr. Mayfield had achieved 8-9 METS during this treadmill test. (Id.)

 Another Bruce Protocol Exercise Tolerance Test was conducted on November 7, 1986. During this test plaintiff was able to exercise for only three minutes, but was able to achieve a heart rate of 156 beats per minute or 82% of his maximum heart rate. At this point the test was again stopped due to plaintiff's fatigue. The report of this test states that "no significant ST/T wave changes [were] noted during or post exercise. No cardiac arrhythmia [was] noted. Blood pressure remained within normal range." The report's conclusions were (1) that plaintiff had "normal cardiac function," and (2) that it had been a normal treadmill test for this level of exercise. A subsequent Exercise ECG Interpretation of the November 7, 1986 treadmill test indicated that the test was negative through completion of 10 METS. (Tr. 218.)

 A thallium stress test, probably conducted immediately following the 11/7/86 terminated Bruce Protocol exercise stress test, showed "no evidence of reversible or irreversible ischemia." (Tr. 172.) This report also noted: "incidentally, a comparison was made with previous study of July 25, 1985 and there is significant interval change." (Id.) No copy of the July 25, 1985 study is in the administrative record of this case, however, and the nature of the "significant interval change" is nowhere disclosed in the medical records. At the administrative hearing, Dr. Abramson found the results of the thallium stress test significant. He stated:

 
Now this Thallium stress test and this is what is interesting is that no defects are noted on this stress examination. No evidence of reversible or irreversible ischemia. And the impression was a normal Thallium stress exam. Now what is interesting is a statement below that[:] "Incidentally a comparison was made with the previous study of July the 25th, 1985." That was the time he had his heart attack -- his first heart attack and there is significant interval change.
 
In other words in 1985 there were definite signs of a myocardial infarction and now in 1986 these signs have disappeared which in my mind means that there is scar replacement, but of such minimal amount that the scan cannot pick it up.
 
In other words the area of absent profusion [sic?] is so small that it isn't picked up. But in any case the present Thallium stress test does not show the sign of an old infarction even though there is no question that he had an infarction.

 (Tr. 63-64.)

 Upon discharge, plaintiff's diagnosis was unstable angina and coronary artery disease. Mr. Mayfield was advised to consult a physician at the Foster G. McGaw Hospital of Loyola University regarding the possibility of bypass surgery.

 Plaintiff was admitted to Loyola on December 4, 1986, apparently to undergo angioplasty. The angioplasty was never performed. The daily progress notes from Mr. Mayfield's stay at Loyola indicate as follows:

 
Called re: variety of [tests?] done as output -- Bruce [test] to 10', stop [due to] fatigue, [without] EKG . . . HR 156. BP 150/82. In light of the above findings and the fact that myocardium in the area of one of the [?] is already infarcted, we do not believe that angioplasty is indicated at this time.

 (Tr. 198.) Thus, it is unclear whether the angioplasty was not performed because, as the ALJ apparently concluded, it was not necessary (Tr. 16), or whether, as plaintiff testified and the ALJ's medical advisor assumed, the angioplasty procedure itself might have traumatized a heart vessel that was completely occluded. (Tr. 49, 65.) In a letter dated July 20, 1988 (i.e. after the hearing on this matter had been concluded), plaintiff's treating physician wrote to counsel for the plaintiff and explained that bypass surgery had not been performed because the small caliper of Mr. Mayfield's arteries made the benefits of such a procedure dubious. (Tr. 259.)

 On May 18, 1987 a representative from the Bureau of Disability Determination Services contacted plaintiff's physician, Behrooz Eshaghy, M.D., for a report on plaintiff's condition. (Tr. 222.) Dr. Eshaghy reported that he last examined plaintiff on March 24, 1987 and that plaintiff's last three blood pressure readings (11/86, 1/87, and 3/87) had been 120/80. No end organ damage had been present. With regard to plaintiff's chest pain, the doctor reported:

 
The patient is having chest pain on occasion. This pain is of angina type. It is pressure like located under the chest radiating to the left shoulder. It lasts a few moments. I have not determined any precipitating factor and it occurs approximately 2 times a week. The pain is relieved by rest and Nitroglycerin.

 Finally, the administrative record was left open after the hearing on this case so that the plaintiff could submit the findings of certain tests that were scheduled to be taken shortly after the hearing. Plaintiff submitted the results of another Bruce Protocol exercise tolerance test ...


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