Overview
In This Section |
This section contains the following topics:
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1. Rating Principles for Heart Conditions
Introduction |
This topic contains miscellaneous cardiovascular concepts and principles, including
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Change Date |
April 18, 2019
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III.iv.4.G.1.c. Manifestations of Advanced Arteriosclerotic Disease in Service |
When service connection (SC) for a cardiovascular condition is claimed, the mere identification of arteriosclerotic disease upon routine examination early in service isnot a basis for SC.
Manifestation of lesions or symptoms of chronic disease will establish pre-service existence under 38 CFR 3.303(c) if objective evidence shows manifestation
Important:
Note: Under 38 CFR 3.6(a), inactive duty for training qualifies as active service if an individual becomes disabled or dies from an acute myocardial infarction (MI), a cardiac arrest, or a cerebrovascular accident occurring during such training.
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III.iv.4.G.1.d. Documentation of MI |
38 CFR 4.104, diagnostic code (DC) 7006 requires documentation of an MI by laboratory tests. Health providers may rely on a variety of diagnostic tests to document MI.
If an assessment of an MI appears to have been made without diagnostic testing or if there is a question about whether the assessment was supported by appropriate testing, obtain clarification from the Department of Veterans Affairs (VA) examiner or other provider.
Reference: For more information on evaluating medical evidence, see M21-1, Part III, Subpart iv, 5.A.3.
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III.iv.4.G.1.e. Effective Dates and Liberalizing Changes Affecting SC for IHD |
IHD became a condition presumptively associated with herbicide exposure effective August 31, 2010. This was a liberalizing change of law.
Therefore, unless an earlier effective date is available under the provisions of 38 CFR 3.816, consider the application of 38 CFR 3.114(a) when granting presumptive SC for IHD related to herbicide exposure under the provisions of 38 CFR 3.307(a)(6) and 38 CFR 3.309(e).
References: For more information on
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III.iv.4.G.1.f. Considering Cardiovascular Conditions Subsequent to Amputation |
Grant SC on a secondary basis for the following conditions that develop subsequent to the service-connected (SC) amputation of one lower extremity at or above the knee, or SC amputations of both lower extremities at or above the ankles:
References: For more information on
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III.iv.4.G.1.i. Considering Co-existing Heart Conditions and Supraventricular Arrhythmia |
Separate evaluations are warranted for supraventricular arrhythmia under 38 CFR 4.104, DC 7010 and other types of heart disease rated using the general rating formula for heart conditions (involving metabolic equivalents (METs), ejection fraction, etc.) even if there is common etiology for the supraventricular arrhythmia and heart disease.
Note: When questions arise as to whether a single or separate evaluations may be assigned for co-existing cardiovascular disabilities, such as arrhythmias and other cardiovascular diseases, consider whether the criteria for evaluating the disability and/or the symptoms of the disability are separate and distinct and apply38 CFR 4.14 and any other condition-specific guidance.
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2. Evaluating Heart Conditions
Introduction |
This topic contains information about applying the evaluation criteria for heart conditions, including
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Change Date |
January 25, 2018
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III.iv.4.G.2.a. Definition: MET |
One Metabolic Equivalent (MET) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute.
The level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation of cardiovascular conditions under the DCs listed in M21-1, Part III, Subpart iv, 4.G.2.b.
References: For more information on
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III.iv.4.G.2.b. METs Requirements and Exceptions |
METs testing is required to evaluate cardiovascular conditions under 38 CFR 4.104, DCs 7000 – 7007, 7011, and 7015 – 7020, except when
Important: If LVEF testing is not of record, evaluate on alternative criteria unless the examiner states that LVEF test is necessary because the available medical evidence does not sufficiently reflect the Veteran’s cardiovascular disability.
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III.iv.4.G.2.e. Using LVEF for Evaluation of Cardiovascular Disorders |
Physicians may document the finding of LVEF percentage with a numerical range, rather than an exact number (for example, 50-55 percent). Under generally accepted medical standards this clinically represents a LVEF falling between the two numbers and not including the endpoints.
Refer to the following table for information on how to interpret LVEF ranges stated in medical reports when making decisions on evaluation of cardiovascular conditions.
Note: This table provides general rating guidelines. Always follow guidance on concepts and principles for evaluation of evidence, and consider the reasonable doubt rule as appropriate.
References: For more information on
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III.iv.4.G.2.f. Documentation of Cardiac Hypertrophy, Dilatation, or Need for Continuous Medication |
According to 38 CFR 4.100(a), objective evidence must show the following information for rating purposes when evaluating the cardiovascular conditions listed under 38 CFR 4.104, DCs 7000 – 7007, 7011, and 7015 – 7020:
Note: Cardiac hypertrophy and/or dilatation must be documented by ECG, echocardiogram, or X-ray.
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III.iv.4.G.2.g. Aspirin as Continuous Medication |
Aspirin is a medication that may be medically recommended for control of a cardiovascular disability such as an ischemic stroke, angina, or coronary artery bypass graft.
When considering a compensable evaluation based on need for continuous medication as provided in M21-1, Part III, Subpart iv, 4.G.2.f, aspirin treatment must be medically required for care of the SC cardiovascular disorder.
To satisfy the requirement of “continuous” medication the evidence must show an ongoing regimen – not periodic, irregular use.
Take care not to incorrectly conclude that an aspirin treatment regimen is necessary simply because aspirin appears on a current medication list. A medication list may not contain enough information to conclude:
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III.iv.4.G.2.h. Evaluation of Nephritis and Cardiovascular Disabilities |
38 CFR 4.115 states that separate ratings cannot be assigned for disability from disease of the heart and any form of nephritis.
Reference: For more information on the limits on separate evaluation of nephritis and cardiovascular conditions, see M21-1, Part III, Subpart iv, 4.I.1.h.
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3. Rating Principles for Hypertension
Introduction |
This topic contains information about on concepts and principles relating to hypertension, including
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Change Date |
January 25, 2018
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III.iv.4.G.3.a. Definitions: Hypertension and Isolated Systolic Hypertension |
Two types of hypertensive vascular disease are defined in 38 CFR 4.104, DC 7101, Note 1.
Hypertension means elevated diastolic blood pressure is predominantly 90mm or greater.
Isolated systolic hypertension means that systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm.
Note: Use of the term “hypertension” in reports or in VA guidance will most often be used as a synonym for any type of hypertensive vascular disease.
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III.iv.4.G.3.b. Blood Pressure Readings Required for SC of Hypertension |
Subject to the exception below, SC for hypertensive vascular disease requires current blood pressure readings (obtained during the claim period) which meet the regulatory definition of either
Exception: Current readings meeting the regulatory standards for the definitions above are not required if
Notes:
References: For more information on
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III.iv.4.G.3.c. Confirmation With Multiple Blood Pressure Readings |
In addition to the definitional requirements for a diagnosis of hypertension or isolated systolic hypertension 38 CFR 4.104, DC 7101 provides a second criterion that must be met for a diagnosis to be acceptable.
Subject to the exceptions below, a diagnosis of hypertension (or isolated systolic hypertension) must be confirmed by blood pressure readings taken two or more times on at least three different days.
The rulemaking for the regulation stated that the purpose of this requirement, was to “assure that the existence of hypertension is not conceded based solely on readings taken on a single, perhaps unrepresentative, day.”
Exceptions:
Important: The decision maker must critically evaluate the evidence to ensure the in-service diagnosis was based on blood pressure readings in accordance with 38 CFR 4.104, DC 7101 and M21-1, Part III, Subpart iv, 4.G.3.b in claims for SC for hypertension where
If the evidence is unclear, medical clarification and/or a medical opinion may be warranted.
References: For more information on
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III.iv.4.G.3.d. Pre-Hypertension |
Pre-hypertension is generally defined as systolic pressure between 120mm and 139mm and diastolic pressure from 80mm to 89mm.
Pre-hypertension is not a disability for VA purposes.
If the VA examination (or evidence used in lieu of a VA examination) contains only a diagnosis of pre-hypertension based on readings that do not meet the definition of hypertension or isolated systolic hypertension, do not
Exception: Clarification may be required if a current diagnosis of “pre-hypertension” is made where readings exist in the record that meet the regulatory definition of hypertension. This may indicate
References: For more information on:
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III.iv.4.G.3.e. Predominant Blood Pressure in Evaluations of Hypertension |
Every level of evaluation specified under 38 CFR 4.104, DC 7101 requires consideration of the predominant (most common or prevailing) blood pressure. Blood pressure may fluctuate depending on a number of variables and disability evaluations must be based on valid evidence demonstrating representative disability.
Generally the regulation requires analysis of predominant current readings— readings from the period during which an effective date can be assigned.
When current predominant blood pressure readings are non-compensable, a 10-percent evaluation may be assigned if
Important: Do not assign a 10-percent evaluation based upon a showing of one of the two conjunctive criteria above by invoking the benefit of the doubt rule (38 CFR 3.102 and 38 CFR 4.3 or 38 CFR 4.7). When either criterion is simply not shown (for example, the claimant is using prescribed anti-hypertensive medication but diastolic pressure has never been predominantly 100 or greater) the evidence is not in relative equipoise on whether a 10-percent evaluation is appropriate and the disability picture does not more nearly approximate the 10-percent criteria.
However, 38 CFR 3.102, 38 CFR 4.3, and 38 CFR 4.7 may be applicable to whether the evidence supports each criterion, namely
Use the table below to assist in analyzing predominant blood pressure.
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III.iv.4.G.3.f. Long Term Effects of Hypertension |
Hypertension may
If the hypertension is of sufficient degree to cause significant impairment of circulation to the organ, symptoms will manifest in accordance with the
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If additional arteriosclerotic manifestations are subsequently diagnosed in a Veteran with SC hypertension, grant SC on a secondary basis through the relationship to hypertension for any of the following:
Important: A claim for benefits is required to adjudicate a secondary SC claim for any of the arteriosclerotic manifestations.
Notes:
Reference: For more information on secondary SC, see M21-1, Part IV, Subpart ii, 2.B.5.
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III.iv.4.G.3.h. Effective Dates of Arteriosclerotic Manifestations Granted Secondary to Hypertension |
The effective date of any grant of SC for arteriosclerotic manifestations secondary to hypertension is the date of claim or date entitlement arose, whichever is later.
Important: Arteriosclerotic manifestations are not considered a worsening of hypertension. Therefore do not apply
Neither of those regulations provides a basis for an effective earlier than the default rule above.
References: For more information on
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III.iv.4.G.3.i. Separately
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Evaluate hypertension separately from hypertensive heart disease and other types of heart disease. Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation.
Notes:
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III.iv.4.G.3.j. Prohibition on Separate Evaluation of Hypertension and Renal Dysfunction from Nephritis or Nephropathy |
38 CFR 4.115 prohibits assignment of separate evaluations for renal dysfunction from nephritis and for hypertension except where
The same prohibition and exceptions apply to a separate evaluation of renal dysfunction from nephropathy and hypertension but the basis is the prohibition against pyramiding in 38 CFR 4.14 rather than 38 CFR 4.115. As is explained in more detail in M21-1, Part III, Subpart iv, 4.I.3.s there is a close relationship between hypertension and nephropathy and hypertension is considered in the renal dysfunction criteria.
References: For more information on
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III.iv.4.G.3.k. Evaluating Rheumatic Heart Disease Coexisting With Hypertensive or Arteriosclerotic Heart Disease |
Accepted medical principles do not concede an etiological relationship between rheumatic heart disease and either hypertensive or arteriosclerotic heart disease. Therefore, do not extend secondary SC to systemic manifestations or arteriosclerosis in areas remote from the heart if the Veteran is SC for rheumatic heart disease.
If a Veteran who is SC for rheumatic heart disease develops hypertensive or arteriosclerotic heart disease after the applicable presumptive period following military discharge, request a medical opinion to determine which condition is causing the current signs and symptoms.
Note: If the examiner is unable to separate the effects of one type of heart disease from another, the effects must be rated together.
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4. Residuals of Cold Injuries
Introduction |
This topic contains information about residuals of cold injury, including
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Change Date |
November 29, 2016
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III.iv.4.G.4.a. General Effects of Injury Due to Cold |
Injury due to exposure to extremely cold temperatures causes structural and functional disturbances of
The physical effects of exposure may be acute or chronic, with immediate or latent manifestations.
Examples: Exposure to
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III.iv.4.G.4.b. Long-Term Effects of Exposure to Cold |
The fact that the immediate effects of cold injury may have been characterized as “acute” or “healed” does not preclude development of disability at the original site of injury many years later.
There does not need to be continuity of symptoms following a cold injury. Typically symptoms may last for days up to a week or two after the cold injury. Unless there was a loss (such as part of a hand or foot) this is followed by a long symptom free period, after which signs and symptoms may reoccur.
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III.iv.4.G.4.c. Chronic Effects of Exposure to Cold |
Veterans with a history of cold injury may experience the following signs and symptoms at the site of the original injury:
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III.iv.4.G.4.d. Granting SC for Residuals of Cold Injuries |
Grant SC for the residuals of cold injury if
Notes:
Reference: For more information on reasonable doubt, see 38 CFR 3.102.
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III.iv.4.G.4.e. Considering Circumstances of Service in Cold Injury Cases |
Consider the circumstances of service as provided in 38 U.S.C. 1154(a) and 38 CFR 3.303(a), even if STRs are not positive for a claimed cold injury. Also as provided in 38 U.S.C. 1154(b) and 38 CFR 3.304(d) in cases involving cold injuries related to documented combat service, satisfactory lay evidence of service conditions will be accepted if consistent with the circumstances, conditions, or hardships of combat service even if there is no official documentation in service records.
For example, the Battle of the Bulge (Ardennes/Rhineland) in the winter of 1944/1945 during World War II was known for its extreme cold. If participation in the Battle of the Bulge is confirmed by the DD Form 214, Certificate of Release or Discharge from Active Duty, or personnel records, concede exposure to extreme cold. If the Veteran engaged in combat with the enemy and the circumstances of service are consistent with claimed service in the Battle of the Bulge, concede exposure to extreme cold.
Afford an examination if the circumstances are consistent with exposure to extreme cold, proving an event in service, and the criteria for a necessary examination are otherwise met.
Reference: For more information on determining whether an examination is necessary, see
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III.iv.4.G.4.f. Considering Cold Injuries Incurred During the Chosin Reservoir Campaign |
The Chosin Reservoir Campaign was conducted during the Korean War, October 1950 through December 1950, in temperatures of –20ºF or lower. Many participants in this campaign suffered from frostbite for which they received no treatment and, as a result, there may be no STRs to directly support their claims for frostbite.
If the Veteran’s participation in the Chosin Reservoir Campaign is confirmed, concede exposure to extreme cold under the provisions of 38 U.S.C. 1154(a).
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III.iv.4.G.4.g. Granting SC for Cold Injuries Incurred During the Chosin Reservoir Campaign |
Grant SC under the provisions of 38 CFR 3.303(a) and 38 CFR 3.304(d) if
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III.iv.4.G.4.h. Evaluations of Cold Injuries |
Cold injuries are evaluated under 38 CFR 4.104, DC 7122.
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III.iv.4.G.4.i. Separate Evaluations for Residuals of Cold Injuries |
The following separately diagnosed residuals of cold injuries should be evaluated under the appropriate DC:
All other disabilities separately diagnosed as the residual effect of a cold injury should be separately evaluated unless they are used to support an evaluation under 38 CFR 4.104, DC 7122. Examples of such disabilities include, but are not limited to
Note: Separately evaluate each part (e.g., hand, foot, ear, nose) affected by cold injuries and then combine in accordance with 38 CFR 4.25 and 38 CFR 4.26.
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III.iv.4.G.4.j. X-ray Findings in Cold Injury Cases |
For appropriate evaluation of cold injuries under the criteria of 38 CFR 4.104, DC 7122, it is very important that there be medical evidence addressing whether or not x-ray abnormalities (specifically osteoporosis, subarticular punched out lesions, or osteoarthritis) exist.
The Cold Injury Residuals Disability Benefits Questionnaire instructs that the x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) must be confirmed by x-rays. Once these abnormalities have been documented no further imaging studies are indicated. This means that x-ray studies do not have to be completed on each and every subsequent examination after the specified abnormalities have been documented.
The DBQ asks the examiner whether x-rays have been performed and if so to provide the date of the studies.
If an examination is necessary for evaluation purposes, x-ray studies were not performed as part of the examination, and the specified x-ray abnormalities have not been previously documented, return the examination.
References: For more information on
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