Listing 4.02 in 2026: How SSA Evaluates Chronic Heart Failure, the 30 Percent Ejection Fraction Rule, the 2.5 cm Wall Plus 4.5 cm Atrium Path, and the 5 METs Exercise Test That Wins at Step 3

Published June 12, 2026 by Anthony Albert, Benefits Research Director

Chronic heart failure (CHF) affects roughly 6.7 million American adults, and about 1 in 4 of those will end up filing a Social Security disability claim at some point. The listing that decides those cases at Step 3 is 4.02. People miss it constantly because they look at the wrong number on their echo report, or because they don't realize that 4.02 has not one but two boxes that both have to be checked.

The A part of 4.02 is about the structure or pump function of your heart. Either your left ventricle is dilated and weak (systolic failure with ejection fraction 30 percent or less), or your left ventricle is stiff and the left atrium is enlarged (diastolic failure with wall plus septum thickness of 2.5 cm or greater and a left atrium of 4.5 cm or greater).

The B part is about what that heart failure actually does to your functional capacity. There are three ways to satisfy B. You can have persistent symptoms so bad that exercise testing would be dangerous. You can have three or more acute heart failure episodes in a 12-month period. Or you can fail at 5 METs of exercise on a stress test.

You need both A and B. If you only have A (the ejection fraction is low but you function fine), SSA doesn't approve at Step 3. If you only have B (you're in the ER twice a week but your echo looks ok), SSA doesn't approve at Step 3 either. The two pieces have to line up.

This article walks through how 4.02 actually works in 2026. It covers what counts as "chronic" heart failure, what kind of imaging SSA needs, the period of stability rule that wrecks a lot of files, the exclusion for cor pulmonale, the 5 METs exercise tolerance test rules under 4.00D4, and the difference between meeting 4.02 and qualifying for an RFC-based win at Step 5. It ends with worked examples from California and Texas showing how the same diagnosis (heart failure with reduced ejection fraction) can win or lose depending on what else is in the file.

Where 4.02 Lives in the Listings

Listing 4.02 sits inside the 4.00 Cardiovascular section of the Blue Book at 20 CFR Part 404, Subpart P, Appendix 1. The 4.00 section also covers 4.04 (ischemic heart disease), 4.05 (recurrent arrhythmias), 4.06 (symptomatic congenital heart disease), 4.09 (heart transplant), 4.10 (aneurysm of aorta or major branches), 4.11 (chronic venous insufficiency), and 4.12 (peripheral arterial disease). Each has its own structure, but 4.02 is the workhorse listing because CHF is so common.

Important crossover: if your heart failure is caused by chronic lung disease (cor pulmonale), SSA evaluates you under Listing 3.09 (chronic pulmonary hypertension), not 4.02. The Blue Book at 4.00D1b is explicit about this. If your CHF comes from atherosclerosis, cardiomyopathy, hypertension, valvular disease, or congenital disease, it stays under 4.02. For more on the respiratory listings and how 3.09 differs, see our breakdown on Listing 3.02 chronic respiratory disorders.

What "Chronic" Means in Chronic Heart Failure

The 4.00D2b definition matters because SSA doesn't approve people for one bad day. To meet 4.02, your medical history and physical exam have to describe ongoing symptoms and signs of pulmonary or systemic congestion (fluid in the lungs, swelling in the legs, jugular venous distention) or limited cardiac output (fatigue, dyspnea, exercise intolerance), combined with abnormal cardiac imaging.

If you've only had one acute episode of heart failure and it was triggered by a fixable cause (a one-time arrhythmia, eating too much salt, going to high altitude), and once that was treated your heart went back to normal, you don't have chronic heart failure for SSA purposes. The listing requires a persistent pattern.

"Persistent" under 4.00A3b means the longitudinal record shows the required finding(s) is present or expected to be present for a continuous 12-month period with few exceptions. That's the durational hurdle.

4.02A: Imaging Showing Systolic or Diastolic Dysfunction

Part A is the imaging path. You need either A1 (systolic) or A2 (diastolic), not both.

4.02A1: Systolic Failure

Systolic failure means the left ventricle can't squeeze hard enough to push out a normal volume of blood. There are two ways to prove it on imaging:

• Left ventricular end diastolic dimension (LVEDD) greater than 6.0 cm. This means your left ventricle is dilated. A normal LVEDD is around 3.5 to 5.5 cm. Once it stretches past 6.0 cm, the ventricle has lost its ability to contract efficiently. OR
• Ejection fraction (EF) of 30 percent or less. EF is the percentage of blood the left ventricle pumps out with each beat. A normal EF is 55 to 70 percent. An EF below 50 is mildly reduced, below 40 is moderately reduced, below 30 is severely reduced. That 30 percent threshold is the SSA bright line.

Either one of those qualifies. You don't need both. An EF of 28 percent with normal LVEDD still hits 4.02A1.

The measurement has to be made during a "period of stability" (not during an acute heart failure episode). The reason: in acute CHF, the LV can dilate temporarily from fluid overload, and EF can drop transiently from acute insult. SSA wants the steady-state value. If your only echo was done in the ER during a flare, your representative needs to get a follow-up echo done at a stable visit.

4.02A2: Diastolic Failure

Diastolic failure (also called heart failure with preserved ejection fraction, or HFpEF) is the inability of the left ventricle to relax and fill properly. The pump function looks normal on echo (EF stays at 50 to 70 percent), but the ventricle is too stiff to fill, so blood backs up into the lungs. You can be just as sick with diastolic failure as with systolic failure.

SSA's diastolic path requires three findings, all on the same imaging study, during a period of stability:

• Left ventricular posterior wall thickness plus septal thickness totaling 2.5 cm or greater.
• Enlarged left atrium with diameter 4.5 cm or greater.
• Normal or above-normal EF.

The wall thickness measurement is just the LV posterior wall plus the interventricular septum, added together. Normal is around 1.6 to 1.9 cm combined. Once it hits 2.5 cm, the ventricle is significantly hypertrophied. Normal left atrium is 2.7 to 3.8 cm. Once it stretches to 4.5 cm, you have chronic pressure backup.

All three measurements show up on any standard echocardiogram report. Most cardiologists report them automatically. If your echo report is missing one (some labs only report LA volume index rather than LA diameter), the radiologist can re-read the images and provide the missing measurement.

4.02B: Functional Limitation

You hit A. Now you need one of three B paths.

4.02B1: Persistent Symptoms with ETT Contraindicated

4.02B1 applies when your heart failure is so severe that an exercise tolerance test (ETT) would be dangerous. A medical consultant (preferably one experienced in cardiovascular disease) has to conclude that the test would present a significant risk. The symptoms have to "very seriously limit the ability to independently initiate, sustain, or complete activities of daily living."

This is the path for people who can barely walk across the room, who get short of breath putting on shoes, who can't shower without sitting down halfway through. The ETT would push them into pulmonary edema or cardiac arrest, so it's contraindicated. SSA accepts this on the medical consultant's judgment without requiring you to actually take the test.

Practical reality: not every DDS medical consultant is willing to call an ETT contraindicated unless the file already screams it. They want hospitalization records, repeated ER visits, severe NYHA class IV documentation, and a cardiologist's note saying so. If your cardiologist hasn't written it down, ask for a statement.

4.02B2: Three Acute CHF Episodes in 12 Months

4.02B2 is the hospitalization-based path. You need three or more separate episodes of acute congestive heart failure within a consecutive 12-month period. Each episode has to include:

• Evidence of fluid retention from clinical and imaging assessments (chest X-ray showing pulmonary edema, jugular venous distention noted in the exam, lower extremity edema documented).
• Acute extended physician intervention such as hospitalization OR emergency room treatment for 12 hours or more.
• Separation between episodes by "periods of stabilization" of at least 2 weeks, during which there's objective evidence of clearing of pulmonary edema or pleural effusions, and you returned to (or were medically considered able to return to) your prior level of activity.

The 12-hour ER rule matters. A lot of CHF patients get bumped from observation to discharge in 4 to 6 hours after diuresis. That doesn't count for 4.02B2 even though it's a real heart failure episode. Only ER visits of 12 hours or longer, or full admissions, qualify.

The "period of stabilization" rule also matters. If you bounce back into the ER 5 days after a discharge, that second visit doesn't count as a separate episode. SSA treats it as a continuation of the first episode. You need 14 days clear of pulmonary edema between visits for them to count as separate.

4.02B3: Failure at 5 METs on Exercise Tolerance Test

4.02B3 is the stress test path. You take an exercise tolerance test (treadmill or bicycle, usually) and you can't reach 5 METs of workload because of any of the following:

• 3.B.a: Dyspnea, fatigue, palpitations, or chest discomfort.
• 3.B.b: Three or more consecutive premature ventricular contractions (ventricular tachycardia), or increasing frequency of ventricular ectopy with at least 6 PVCs per minute.
• 3.B.c: Decrease of 10 mm Hg or more in systolic pressure below the baseline or below the preceding systolic pressure measured during exercise, due to left ventricular dysfunction, despite increasing workload.
• 3.B.d: Signs attributable to inadequate cerebral perfusion, such as ataxic gait or mental confusion.

What's 5 METs? One MET is the energy cost of sitting quietly. 5 METs is roughly the effort of brisk walking on a flat surface (3 to 4 mph), climbing two flights of stairs at a moderate pace, mowing the lawn with a push mower, or vacuuming a house. If you can't get to 5 METs without your heart giving out, you can't sustain even sedentary work.

The 10 mm Hg drop rule (4.02B3c) is technical but matters. Normally, systolic blood pressure rises during exercise. A drop of 10 mm Hg below baseline (the standing pre-exercise reading) or below the preceding exercise reading is a sign that the failing left ventricle can't keep up with the workload. The drop has to be "due to left ventricular dysfunction" and "despite an increase in workload." SSA's 4.00D4d note clarifies that an early drop in BP can sometimes happen from drugs or deconditioning rather than from LV dysfunction, so the rest of the test context matters.

The Period of Stability Rule

This wrecks more 4.02 cases than any other rule. SSA requires that the imaging measurements (LVEDD, EF, wall thickness, LA diameter) be made during a period of stability, not during an acute heart failure episode.

Why? Because in acute CHF, everything looks worse. The LV is acutely dilated from fluid overload. EF can transiently crash. Wall measurements get distorted by fluid in the pericardium. After diuresis and stabilization, the numbers can shift back toward baseline.

SSA wants the steady-state value. If your only echo was done in the ER when you came in with acute pulmonary edema, that's not enough. You need a follow-up echo done at least 2 weeks after the acute episode resolved, at an outpatient visit, when you're back at your stable baseline. POMS DI 22021.001 reinforces this.

Practical move: if your file only has acute-phase imaging, ask your cardiologist to order a follow-up echo at your next stable visit. Most insurance covers a yearly echo for CHF patients anyway.

What Counts as Appropriate Imaging

4.00D2a lists the acceptable imaging modalities:

• Chest X-ray (limited use for measurements but supports the diagnosis).
• Echocardiography (M-Mode, 2-dimensional, and Doppler). The most common.
• Radionuclide studies (MUGA scan, nuclear stress test imaging).
• Cardiac catheterization with ventriculography.
• Cardiac MRI (acceptable as "appropriate medically acceptable imaging" under 4.00A3d).

Echocardiography is the workhorse because it's non-invasive, widely available, and reports all four measurements (LVEDD, EF, wall thickness, LA diameter) on a single study. Cardiac MRI gives more precise measurements but is rarely ordered for CHF unless there's a specific question (suspected cardiomyopathy, amyloidosis, sarcoidosis).

NYHA Functional Classes and SSA

The New York Heart Association (NYHA) functional classification (Class I through IV) is what cardiologists use to describe how symptomatic you are. SSA doesn't formally use NYHA in 4.02, but DDS medical consultants pay attention to it, and it correlates loosely with the 4.02B paths:

NYHA III or IV are the ranges where 4.02 wins live. NYHA I or II usually require building an RFC-based Step 5 win, not a Step 3 listing win.

What If You Don't Meet 4.02

Most CHF claims don't win at Step 3. The EF is reduced but not at or below 30, the wall thickness is borderline, the hospitalizations are too few, the stress test wasn't done or got stopped early for non-cardiac reasons. That's where Step 4 and Step 5 come in.

Your RFC under SSR 96-8p captures what you can still do despite the disease. CHF RFCs typically include:

• Exertional limits: sedentary or light work only, no lifting above 10 to 20 pounds, no prolonged standing or walking.
• Postural limits: limited bending, stooping, climbing.
• Environmental limits: no exposure to temperature extremes (cold air triggers vasoconstriction and worsens CHF), no exposure to fumes.
• Mental/concentration limits: secondary to fatigue or cardiac cachexia.
• Off-task time: from medication side effects (diuretic bathroom needs, blood pressure swings) or unscheduled rest needs.

Combined with the grid rules at 20 CFR 404 Appendix 2, a sedentary RFC plus the right vocational profile (age 50 plus, limited education, no transferable skills) can win at Step 5 even when 4.02 is missed. For more on how RFC and grid rules work together, see SSR 96-8p RFC assessment and borderline age and grid rules.

How Long the 4.02 Win Lasts

CHF generally doesn't improve. Once the LV remodels (dilates and weakens), it stays that way. Some patients with new-onset CHF on guideline-directed medical therapy can recover EF (this is called "reverse remodeling"), but it's not guaranteed. For most claimants, SSA assigns Medical Improvement Possible (MIP) and schedules CDRs on a 3 to 5 year cycle. If you've had heart transplant under 4.09, you're presumptively disabled for at least 1 year post-transplant. For more on CDRs, see our deep-dive on CDR and medical improvement.

Worked Example 1: California Systolic CHF Win Under 4.02A1 + B2

Worked Example 2: Texas Diastolic CHF, 4.02A2 Met, 4.02B Failed, Step 5 Win

Common Mistakes Claimants Make

• Relying on a single acute-phase echo. SSA wants stable-baseline imaging. Get a follow-up echo at a stable visit before relying on the numbers.
• Ignoring the 12-hour ER rule. Short ER visits with 4-hour bumps don't count for 4.02B2. Only admissions or ER stays of 12 hours or more count.
• Confusing EF percent with ejection fraction reduction. SSA uses absolute EF (the percentage measured on the echo), not "percent reduction from normal." EF of 35 doesn't meet 4.02A1. EF of 30 or 28 or 22 does.
• Using a stress test stopped early for non-cardiac reasons. If you stopped the treadmill because your knees hurt, that's not 4.02B3 territory. The stop has to be cardiac (dyspnea, chest pain, arrhythmia, BP drop, cerebral perfusion signs).
• Missing the LA diameter on the echo report. Some labs report only LA volume index, not LA diameter. SSA's 4.02A2 specifically uses LA diameter at or above 4.5 cm. If your report doesn't have it, the radiologist can re-read and provide it.
• Forgetting that A and B both have to be met. A great EF reading alone doesn't win 4.02. You need the functional B leg too.

What to Do Before Filing

1. Get a stable-baseline echo within the last 6 to 12 months. Confirm the report shows LVEDD, EF, LV posterior wall thickness, septal thickness, and LA diameter.
2. Pull all ER visit records and hospital admissions from the past 12 months. Highlight which ones lasted 12 hours or more, which ones had documented pulmonary edema, and what the gaps between them looked like.
3. If you've had a stress test, request the full report (not just the conclusion). SSA wants to see METs achieved, reason for termination, ECG findings during exercise, and blood pressure readings throughout.
4. If you haven't had a stress test and your cardiologist agrees it would be high-risk, ask for a written note saying so. That's what B1 needs.
5. Get a current NYHA classification documented by your cardiologist.

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