QSWZ and Repatriation Commission - [2014] AATA 482

Administrative Appeals Tribunal
ADMINISTRATIVE APPEALS TRIBUNAL             )
  )        No: 2011/1799
Veterans' Appeals Division  )
Re: QSWZ
Applicant

And: Repatriation Commission
Respondent
CORRIGENDUM TO DECISION
TRIBUNAL:             Miss E A Shanahan, Member
DATE:   24 July 2014
PLACE:                  Melbourne

The Tribunal directs the Registrar, pursuant to sub 43AA(1) of the Administrative Appeals Tribunal Act 1975, to alter the text of the decision as follows:

On page 1, replace war-caused with defence-caused;

On page 6, paragraph 16, replace war-caused with defence-caused; and

On page 17, paragraph 59, delete or as defined, war-caused.

..........[sgd].........................................................
Member
[2014] AATA 482

Division VETERANS' APPEALS DIVISION

File Number(s)

2011/1799

Re

QSWZ

APPLICANT

And

Repatriation Commission

RESPONDENT

Decision

Tribunal
Miss E A Shanahan, Member

Date 16 July 2014

Place Melbourne
The Tribunal sets aside the decision under review and substitutes its decision that the applicant’s paroxysmal atrial fibrillation is war-caused.

...[sgd].....................................................................
Miss E A Shanahan, Member
VETERANS’ AFFAIRS – Disability Pension – eligible service – cardiac arrhythmias variously diagnosed – prolonged strenuous high level endurance physical activity – eventual diagnosis paroxysmal atrial fibrillation – satisfaction of Statement of Principles – decision set aside.
Legislation
Veterans’ Entitlement Act 1986
Secondary Materials
Statement of Principles Instrument No 20 of 2003 concerning atrial fibrillation
Statement of Principles Instrument No 50 of 2014 concerning atrial fibrillation and atrial flutter
REASONS FOR DECISION
Miss E A Shanahan, Member
16 July 2014

QSWZ (the Veteran) lodged a claim for acceptance of a cardiac condition as being related to service. The claim was lodged on 6 April 2010. The Veteran has received payment at 80 per cent of the general disability pension rate since 30 October 2002 for numerous accepted medical conditions which are prominently musculoskeletal in nature. The claim of 6 April 2010 was described as being for multifocal ventricular ectopic beats and non-sustained ventricular tachycardia.
The claim was rejected by a delegate of the Repatriation Commission (the Commission) on 2 July 2010. The Veteran lodged an application for review of this decision by the Veterans’ Review Board (the Board) on 26 July 2010. The Board affirmed the delegate’s decision on 9 February 2011 having found that the medical material before it:
... does not raise the required causal connection between the applicant’s multifocal ventricular ectopic beats and non-sustained ventricular tachycardia and the defence service as required by the Act.
The Board noted there was no Statement of Principles (SoP) applicable to the cardiac rhythm abnormalities mentioned above. The Veteran lodged an application for review by the Administrative Appeals Tribunal on 11 May 2011.
The hearing of this matter commenced on 27 May 2013 but was adjourned at the request of the Commission’s representative Mr Adrian Crowe, an advocate with the Department of Veterans’ Affairs (the Department), in order to obtain a more definitive investigation and expert opinion regarding the Veteran’s cardiac arrhythmia. The hearing resumed and was completed on 16 June 2014. On both occasions the Veteran was self-represented and Mr Crowe appeared for the Commission. The Veteran gave evidence before the Tribunal.
The Tribunal was provided with the documents pursuant to s 37 of the Administrative Appeals Tribunal Act 1975 (the T-documents). Both parties tendered further documentation, a list of which is appended to this decision.
background to the application
The Veteran served in the Royal Australian Army (the Army) from 27 January 1967 until 31 January 2000. He attained the rank of Lieutenant Colonel on 1 January 1984. Following his retirement from service he continued as a member of the Army Standby Reserve. His eligible service dates from 7 December 1972 to 30 January 2000.
On completion of his secondary education the Veteran enrolled at the Royal Military College in Duntroon (Duntroon) where he studied engineering. At school he had been very active in sport, playing representational sport. His training at Duntroon also required him to maintain a high level of fitness. He has never smoked cigarettes or tobacco, nor does he drink alcohol. While the Veteran trained as an engineer, he spent most of his time in field activities, that being his preference.
While his level of daily exercise was extremely high throughout his service, it increased to a maximum between 1977 and 1987. In 1977 he was training in anticipation of qualifying for the Special Air Service (SAS) selection course which was conducted over three weeks in mid-1978. Less than 25 per cent of participants in this selection course completed the training successfully. The Veteran gave evidence that during his SAS training he was in the top activity scale of all participants. The Veteran served in the SAS between 1979 and 1980 and during this time his level of training was at extremes. For example, during this period he spent three months in the Pilbara region trekking for consecutive days carrying very heavy packs; exercises on Rottnest Island simulating a rescue of a senior politician taking place over 48 hours of continual physical activity and without any sleep. He stated that on numerous occasions he exercised to a point of exhaustion. He was also the subject of medical research relating to the effects of strenuous exercise and sleep deprivation.
Between 1981 and 1982 the Veteran was based at divisional headquarters and was an instructor, training staff in outdoor activities. He had been the Royal Military College Alpine instructor from 1977 to 1978 and was again an Alpine instructor between 1989 and 1993. During this period, he climbed Mount Kilimanjaro and Mount Kenya in Africa and spent two months in the Himalayas in the same year. He also participated in mountain exercises in the Sierra Nevada mountains in the United States of America on numerous occasions.
In 1984 the Veteran undertook parachute training which included high altitude parachuting. In all, he undertook approximately 130 parachute descents, frequently in non‑ideal conditions.
In the late 1980s the Veteran noticed that he occasionally experienced a sudden onset of episodes of total exhaustion during what he considered to have been physical activities well within his usual range. In October 1990 he requested that the Army Medical Service investigate these episodes, despite being reassured that all was well. He eventually insisted and was referred to Dr Simon O’Connor, a cardiologist at the Royal Canberra Hospital. This referral was for the performance of an exercise test. It appears that Dr O’Connor was under the impression that the exercise test was to ensure that the Veteran could train to his maximum workload, despite having no cardiac symptoms or risk factors. Dr O’Connor noted atrial ectopic beats but considered them to be a normal variant. The Veteran was reassured that he could continue to train to his desired level.
The Veteran continued to experience these episodes of extreme exhaustion on strenuous physical exertion and further electrocardiograms (ECGs) done over the years showed various changes. For example, in 1993 an ECG showed nonspecific STT wave changes and P waves suggestive of left atrial hypertrophy. A further ECG in November 1998 showed sinus rhythm and unifocal ventricular premature beats. This ECG had been performed in the course of his investigation of a febrile illness characterised by chest pain, night sweats and temperatures to 39^oC. The chest pain had been pleuritic in nature. The treating physician, Dr Beinart, considered the Veteran to be suffering from an acute viral illness.
An ECG performed on 24 May 2001 revealed sinus bradycardia with an incomplete right bundle branch block (rate 46 beats per minute). However, there is no formal report on any of these in-service ECGs.
Following his retirement from active service, the Veteran obtained employment at a local TAFE institution as an instructor in outdoor recreational activities.
The Veteran noted that the episodes of extreme exhaustion increased in frequency from 2006 onwards. In 2009 he purchased and wore a heart rate monitor while exercising. He noted that his resting and exercise heart rate varied from 36 and 155 beats per minute but on occasions the monitor would read up to 225 beats per minute. As a result of these observations, he requested further cardiological assessment. His general practitioner, Dr Gladman, arranged for 24-hour ambulatory ECG monitoring of the Veteran (Holter monitoring). This revealed frequent ventricular ectopic beats including bigeminy and trigeminy, frequent supra ventricular ectopic beats and runs of tachycardia up to 115 beats per minute and a heart rate between 30 and 199.
The Veteran attended Dr Jan du Plooy, a cardiologist, who performed further testing in the form of a stress ECG according to the Bruce protocol, a cardiac ultrasound (Echo) and various biochemical tests. Dr du Plooy made a diagnosis of episodes of non-sustained ventricular tachycardia with a structurally normal heart. He noted that the Veteran’s atrial P wave activity commenced in the left atrium. No abnormality was detected on cardiac ultrasound nor was there any evidence of ischaemic heart disease on the stress-testing ECG.
Dr du Plooy was not able to exclude an infiltrative process such as amyloid or sarcoidosis which could account for the finding of bilateral atrial enlargement and considered it likely these changes were probably secondary to the Veteran’s strenuous exercise program. Further investigation was to be performed depending on the Veteran’s progress. Dr du Plooy’s report formed the basis of the Veteran’s application for an increase in a disability pension and an acceptance of his cardiac arrhythmia as being war‑caused within the meaning of the Veterans’ Entitlement Act 1986 (the Act).
Following the rejection of his claim and the affirmation of this rejection by the Board the Veteran sought further medical opinion in relation to the diagnosis of his cardiac arrhythmia. With the assistance of Mr Crowe, further opinions were obtained from a cardiologist, Dr Richard Hillock in Adelaide and, some 12 months later, from Professor Jonathan Kalman of the Department of Cardiology, Royal Melbourne Hospital.
Dr Hillock performed a series of investigations including an MRI of the Veteran’s heart which led to a diagnosis of exercise-related focal atrial tachycardia with high frequency broad complex beats most likely due to aberrant atrial ectopics with a normal myocardial MRI except for a mildly dilated left atrium.
Professor Kalman’s investigations, which included seven-day Holter monitoring, revealed frequent atrial and ventricular ectopic beats with brief runs of non-sustained atrial tachycardia and a 17-hour period of atrial fibrillation which was associated with a rapid ventricular response rate of up to 210 beats per minute. Professor Kalman assumed these had occurred during physical exertion. The Veteran’s exercise stress test also showed bursts of atrial tachycardia and ventricular ectopy including non-sustained ventricular tachycardia. Professor Kalman considered these changes to be due to aberrant electrophysiological conduction in the heart. Professor Kalman was of the opinion that it would be reasonable to do an electrophysiological study with a view to ablating the Veteran’s abnormal atrial focus which he considered to be sited near the coronary sinus. The Veteran was to consider Professor Kalman’s recommendations.
The Veteran subsequently underwent CT coronary angiography to exclude underlying ischaemic heart disease as the cause of his paroxysmal atrial fibrillation and atrial tachycardia. The CT coronary angiogram proved to be difficult to interpret due to motion artefact resulting from the Veteran having numerous ventricular ectopic beats. Within these limitations, Professor Kalman found the Veteran to have moderate stenosis of the proximal left anterior descending coronary artery but no hemodynamically significant stenosis in the circumflex coronary artery or the dominant right coronary artery.
Given the inconclusive nature of the CT angiogram, the Veteran underwent coronary angiography performed by Associate Professor Roderic Warren, an interventional cardiologist at the Royal Melbourne Hospital. This angiogram confirmed the presence of stenosis in the left anterior descending coronary artery extending from the origin of the diagonal and involving the diagonal branch which has a 50 per cent narrowing. There was no significant disease in the circumflex or right coronary artery. Left ventricular function was normal.
The schematic representation of the angiogram which accompanied the report indicates that the 40 per cent narrowing of the left anterior descending and that of the first diagonal (at 50 per cent) are of considerable length.
The Veteran continues to pursue strenuous exercise on a regular basis but has reduced the extent of such exercise to mainly bicycle riding over distances of 60 to 80 kilometres. These bicycle rides are on average at a speed of 28 to 38 kilometres per hour. The Veteran also indulges in mountain bike riding at a competitive level. He does not walk long distances because of his bilateral knee osteoarthritis. He is no longer able to perform manual work on his farm and has not been employed since 2005 when he ceased being an outdoor recreational instructor at TAFE. He did not feel that it was safe for him to conduct bush recreational activities with students given that he might suffer an episode of cardiac arrhythmia.
EVIDENCE BEFORE THE TRIBUNAL
The Veteran’s evidence has been summarised under BACKGROUND TO THE APPLICATION.
However, by the first day of hearing in May 2013 a diagnosis of non‑sustained atrial tachycardia with episodic atrial fibrillation had been made by Professor Kalman, following the seven-day Holter ECG monitoring study.
In May 2103 there was in existence a Statement of Principles concerning atrial fibrillation (Instrument No. 20 of 2003 (the 2003 SoP)). This particular instrument related to matters decided on the balance of probabilities. The only factors identified which might be applicable to the Veteran’s claim were factors 5(b) and (c). Factor 5(b) relates to ischaemic heart disease and factor 5(c) to the occurrence to myocarditis. Both conditions are required to be present at the time of clinical onset of atrial fibrillation which was defined in the SoP to include paroxysmal atrial fibrillation.
The Commission requested an adjournment to pursue further investigations of these two factors. By the time of the resumed hearing on 16 June 2014, the Repatriation Medical Authority had determined a further SoP relating to atrial fibrillation and atrial flutter (Instrument No. 50 of 2014 (the 2014 SoP)). Neither the Veteran nor Mr Crowe had been aware of this 2014 SoP. The 2014 SoP expanded the factors that must exist before it could be said, on the balance of probabilities, that the atrial fibrillation was connected to the circumstances of an individual’s relevant service. This instrument came into force on 7 May 2014. The relevant factor in the 2014 SoP that could apply to the Veteran’s claim was factor 6(o) relating to:
... strenuous, high level, endurance physical activity greater than six METs, for an average of at least 20 hours per week for a continuous period of at least five years before the clinical onset of atrial fibrillation or atrial flutter, and where strenuous physical activity has ceased, the clinical onset of atrial fibrillation or atrial flutter has occurred within ten years of cessation. ...
In light of the requirements of factor 6(o) of the 2014 SoP, the Veteran was asked to outline his physical activity on a weekly basis during the period which he regarded as his highest level of training, that is from 1977 until 1987.
The Veteran gave evidence that his typical exertion activities during a week in the period between the late 1970s and 1990 involved:
·playing squash at a competitive level for one hour, once a week;
·running 10 kilometres in one hour on four days of the week, the run involving lots of hill climbing;
·cycling to and from work at speeds of up to 30 to 40 kilometres per hour with each trip taking 40 minutes on average;
·weight training to improve aerobic capacity for one to one and a half hours, three times per week; and
·exercising for up to eight hours, per weekend.
In winter months he indulged in:
·long distance cross- country skiing; and his holidays included high level all day hiking; and
In the summer:
· bushwalking and rock climbing.
· kayaking in the sea, rivers and Lake Hume.
At weekends, and now during the week, he would cycle for 60 to 150 kilometres over a period of several hours at a speed of 20 to 30 kilometres per hour. He now restricts his long rides to 60 to 80 kilometres.
Mr Crowe requested the Veteran expand on his answers to the questions, as on his calculations a typical week’s strenuous exercise totalled 16 to 17 hours. The Veteran stated that the hours he had provided related to his recorded times of physical training and exertion and had not included the day-to-day activities that he was required to perform in the Army, particularly as an instructor between 1981 and 1984, in addition to his relentless SAS training and two years’ service in the SAS.
documentary evidence before the tribunal
The medical reports which are of the greatest importance have been referred to under BACKGROUND TO THE APPLICATION. It is documented in the Veteran’s medical records that he complained of symptoms of extreme exhaustion on occasions of strenuous physical activity and requested a referral to a cardiologist in early October 1990. The reporting cardiologists, in particular Professor Kalman, have referred to this long-standing symptom, noting also that it had increased in severity particularly since the mid-2000s.
Atrial ectopic activity has been documented in ECGs, both in his service record and in Dr O’Connor’s report of 5 December 1990.
Twenty-four hour ambulatory ECG monitoring was performed on the Veteran on several occasions. The first of these was conducted on 9 February 2010; the second study was performed at the request of Dr Hillock on 8 February 2012; and a third seven-day Holter monitoring examination was conducted early in 2013 by Professor Kalman. As previously stated, all showed frequent atrial ectopic beats; and in 2013 an episode of atrial fibrillation lasting for 17 hours was captured on day three of the seven-day Holter monitoring. This atrial fibrillation was associated with rapid ventricular response rates, that is, ventricular tachycardia at rates up to 210 beats per minute. Professor Kalman had presumed that this episode occurred during physical exertion but appears not to have asked the Veteran if this was in fact the case.
In February 2012 Dr Hillock in his report to Dr Gladman made a diagnosis of exercise related focal atrial tachycardia but felt it was quite possible that the Veteran was having episodes of paroxysmal atrial fibrillation which had not been captured in the 24-hour Holter monitoring. He determined to await developments and treat the Veteran with a small dose of Flecainide. Dr Hillock did provide the Veteran with information regarding radiofrequency ablation of ectopic sites of atrial activity. Dr Hillock confirmed his diagnosis of atrial ectopy and atrial tachycardia of unknown cause in a letter to the Commission on 7 May 2012. He did however express the opinion that atrial tachycardia is more frequent in highly trained populations with dilated atria such as had been found in the Veteran.

Professor Kalman has provided copies of his letters to Dr Gladman and to the Commission via Mr Crowe but has not expressed an opinion regarding the aetiology of the Veteran’s paroxysmal atrial fibrillation. Professor Kalman has recommended that the Veteran undergo electrophysiological studies with a view to radiofrequency ablation of any abnormal atrial focus of ectopic activity and/or fibrillation.
The Board’s decision has been referred to earlier in this decision. It was considering the claim in terms of ventricular ectopy and non-sustained ventricular tachycardia and could not find any medical evidence to support any relationship between this diagnosis and the Veteran’s eligible service. It has now been shown that this diagnosis was incomplete, the proper diagnosis being paroxysmal atrial fibrillation and atrial tachycardia.
As the various reports came to hand, Mr Crowe sought the opinion of Dr Simon Spedding, an Adelaide based Exercise and Sport Medicine Physician and Medical Advisor to the Department. In his opinion of 24 May 2013, Dr Spedding concluded that there was insufficient medical evidence to reach a diagnosis; that the demonstrated ECG abnormalities had not been linked causally to the Veteran’s symptoms; and he suggested that the presence of ischaemic heart disease be excluded as arrhythmias such as atrial fibrillation may be a feature and the presenting symptom of myocardial ischaemia.
Following completion of the Veteran’s investigation by Professor Kalman, Dr Spedding provided a further opinion on 1 April 2014. In the opinion he interpreted the results of the CT angiogram and the interventional angiogram as being in conflict, questioning why Professor Kalman had not reported on the angiogram performed by Associate Professor Warren. The Tribunal finds this criticism unfounded as the specialists involved are from three different areas of cardiology who work as a team and it was clear from the CT angiogram report that the Veteran’s frequent ectopic beats (both atrial and ventricular) resulted in a technically poor quality study, hence the need to have Associate Professor Warren perform a standard interventional angiogram by arterial catheterisation.
relevant legislation
Section 7 of the Act defines eligible war-service and s 9 provides that:
... an injury suffered by a veteran shall be taken to be a war‑caused injury, or a disease contracted by a veteran shall be taken to be a war‑caused disease, if:
...
(b)the injury suffered, or disease contracted, by the veteran arose out of, or was attributable to, any eligible war service rendered by the veteran;
(2)For the purposes of this Act, where any incapacity of a veteran was, in the opinion of the Commission, due to an accident that would not have occurred, or due to a disease that would not have been contracted, but for his or her having rendered eligible war service or but for changes in the veteran’s environment consequent upon his or her having rendered eligible war service:
...
(b)if the incapacity was due to a disease—the incapacity shall be deemed to have arisen out of that disease and that disease shall be deemed to be a war‑caused disease contracted by the veteran.
Section 13 of the Act addresses Eligibility for pension and s 13(1)(d) states:
(d)in the case of the incapacity of the veteran—pension by way of compensation to the veteran; in accordance with this Act.
Section 15 of the Act provides for Application for increases in pension.
The standard of proof attracted by a veteran claiming a pension relating to eligible service is provided in s 120(4) of the Act, which states:
(4)Except in making a determination to which subsection (1) or (2) applies, the Commission shall, in making any determination or decision in respect of a matter arising under this Act or the regulations, including the assessment or re‑assessment of the rate of a pension granted under Part II or Part IV, decide the matter to its reasonable satisfaction.
As the Veteran’s claim in relation to his cardiac arrhythmia was lodged after 1 June 1994, the Tribunal is required to apply s 120B and the SoPs made by the Repatriation Medical Authority.
The 2003 and 2014 SoPs have been identified as potentially relevant to this claim. Clause 2 of the 2003 SoP defines atrial fibrillation as:
... a paroxysmal, persistent or permanent arrhythmia arising in the atria of the heart, causing disorganised atrial activity and an irregularly irregular ventricular response.
The definition provided in the 2014 SoP has been expanded and now reads:
3. ...
(b)"atrial fibrillation" means a paroxysmal, persistent or permanent cardiac arrhythmia, in which normal and regular electrical impulses generated by the sinoatrial node are overwhelmed by disorganised, rapid, and irregular atrial activation, leading to irregular conduction of impulses to the ventricles, and an irregular ventricular rate and rhythm;
In the 2003 SoP, the factors that must be related to service and that are arguably applicable to the Veteran’s claim are factors 5(b), (c) and (d), which state:
...
(b)suffering from ischaemic heart disease at the time of the clinical onset of atrial fibrillation; or
(c)suffering from myocarditis at the time of the clinical onset of atrial fibrillation; or
(d)suffering from cardiomyopathy at the time of the clinical onset of atrial fibrillation; or
The 2014 SoP contains the same factors in 6(b), (c) and (d), but in addition factor 6(h) and 6(o) which provide for;
(h)having pericarditis within the one month before the clinical onset of atrial fibrillation or atrial flutter; or
…
(o)undertaking strenuous, high level, endurance physical activity greater than six METs, for an average of at least 20 hours per week for a continuous period of at least five years before the clinical onset of atrial fibrillation or atrial flutter, and where strenuous physical activity has ceased, the clinical onset of atrial fibrillation or atrial flutter has occurred within ten years of cessation; or ...
The Fifth Edition of the Guide to the Assessment of Rates of Veterans’ Pensions (the Guide) defines the term MET as metabolic effort tolerance. It is normally measured in terms of one MET being equal to the consumption of 3.5 millilitres of oxygen per kilogram of bodyweight per minute. While the Guide recommends exercise testing be deployed to measure high levels of METs, examples are provided to inform medical practitioners and includes estimations relating to the type of activities the Veteran routinely engaged in.
Seven to eight METs are generated:
·in very heavy exercise.
·jogging at eight kilometres per hour ;
·carrying heavy objects (30 kilograms) on level ground;
Eight to nine METs are required for;
·running at nine kilometres per hour;
·skiing (cross country);
·calisthenics;
·squash (non-competitive);
Ten plus METs are generated by;
·running quickly (10 kilometres per hour);
·cycling quickly (25 kilometres per hour);
·carrying loads of 10 kilograms up a gradient;
·football (any code);
THE VETERAN’S submissions
The Veteran contends that his high level of strenuous exercise encouraged by and expected by his service in the Army has resulted in the development of paroxysmal atrial tachycardia and paroxysmal atrial fibrillation, presenting as debilitating, severe exhaustion on strenuous exertion commencing in October 1990 and continuing thereafter at an increasing frequency, particularly more common after 2005/2006.
The Veteran submits that he meets factor 5(b) of the 2003 SoP in that he has ischaemic heart disease; and/or factor 5(c) in that he may have suffered from myocarditis during service when he contracted several viral infections, the exact nature of which remains unknown. He also contends that he satisfies factor 6(o) of the 2014 SoP, in relation to strenuous high level endurance physical activities for 20 hours per week for a continuous period of greater than five years before the clinical onset of paroxysmal atrial fibrillation.
The respondent’s submissions
Mr Crowe conceded that the onset of the Veteran’s cardiac arrhythmia, presenting symptomatically as sudden onset extreme exhaustion on exertion, was October 1990. Mr Crowe accepted that the Veteran was a credible witness and that he told the truth in the giving of his evidence. It was also accepted that if in the decade from 1977 to 1987 the Veteran was involved in a very high level of activity which met the required METs level, he would fulfil the time requirements of the SoP.
However, Mr Crowe submitted that some of the episodes referred to in the Veteran’s evidence and submissions, in particular those in the 1990s in Africa and Nepal when he was mountain climbing, were outside the nominated 10-year period of 1977 to 1987, and in fact occurred after the onset of his symptoms. Mr Crowe submitted that, on his calculations prior to the Veteran expanding on his daily activities, the Veteran’s level of six or more MET activities only reached 16 to 17 hours.
tribunal’s deliberations
The Veteran first sought investigation and treatment of the symptom of episodic severe and debilitating exhaustion of acute onset in the setting of very strenuous exercise in 1990. This symptom has persisted for nearly 25 years. He denies any accompanying symptoms of dizziness, chest pain, faintness, sweating or syncope all of which may be present in paroxysmal atrial fibrillation or paroxysmal atrial tachycardia.
In 1990 he was noted to have frequent atrial ectopic beats but this was considered by Dr O’Connor to be a normal variant of no concern. The Veteran accepted the advice given and continued his (what many might consider excessive) exercise regime and rationalised his episodes of exhaustion as due to poor fitness or the ageing process. As the episodes of exhaustion increased in frequency he monitored his heart rate during exercise and found that at times it reached 225 beats per minute; whereas, his normal peak exercise heart rate was in the order of 160 to 170 beats per minute. He had commenced these monitoring observations in approximately 2009. Eventually, this led to further medical opinion being sought.
An ECG performed on 9 September 1993 was interpreted as showing left atrial hypertrophy; the ECG performed on 28 April 1997 was said to be normal; and in 1998 an ECG revealed unifocal ventricular premature beats (also known as ventricular extra systolic beats). The Veteran’s medical board examination of 8 September 1998 described him as being MAGNIFICENTLY FIT! Two months later he presented with a petechial haemorrhagic rash, fever arthralgia and chest pain. This was apparently diagnosed as a viral illness not involving his heart, on the basis of a normal chest x-ray and cardiac enzymes.
From early 2010 to 2014 investigation of the Veteran’s episodic severe exhaustion and cardiac arrhythmia has been undertaken by three cardiologists, Dr du Plooy in 2010, Dr Hillock in 2011 and 2012 and Professor Kalman in 2013 and 2014. These investigations have ultimately provided the diagnosis of atrial tachycardia and paroxysmal atrial fibrillation.
Dr Hillock expressed the opinion that atrial tachycardia or atrial ectopics were seen more frequently in highly trained populations with dilated atria. The Tribunal notes that the cardiac MRI to which Dr Hillock refers reported left atrial dilatation, although the ECG of 9 February 2012 showed bilateral dilatation. In contrast, the ECG of 1993 was interpreted as showing left atrial hypertrophy based on high voltage P waves. The episodic nature of the Veteran’s symptoms was such that prolonged Holter monitoring over a period of many days was essential in reaching a definitive diagnosis. It may well be that had this type of monitoring occurred at a much earlier date the correct diagnosis would have been made.
There is insufficient medical evidence before the Tribunal to support the contention that the Veteran suffered from myocarditis or pericarditis in the month immediately preceding the development of his symptoms, although it has been documented that he has experienced viral illnesses.
CT angiography and invasive angiography have revealed that the Veteran has moderate coronary artery disease, involving the left anterior descending coronary artery and its first diagonal branch. These stenoses have been estimated to be 40 and 50 per cent respectively and thus not haemodynamically significant. It is noted that the Veteran does not have a medical history of angina and his left ventricular myocardial function is considered to be normal. Thus, there is insufficient evidence to support a myocardial ischaemic basis for his arrhythmia although micro-ischaemia may lead to fibrosis, which in turn can provide a site of aberrant electrical activity.
The respondent has conceded that the Veteran’s clinical onset of symptoms, that is, the symptoms of arrhythmia occurred in October 1990. The respondent does not challenge the Veteran’s credit and the Tribunal agrees that the Veteran is a witness of truth. The Tribunal accepts his evidence to its reasonable satisfaction that between 1977 and 1987 his exercise regime coupled with the highly demanding physical requirements of his service in preparing for and then serving as an officer in SAS from 1977 to 1980, and thereafter as an instructor at headquarters and the Royal Military College until 1987 and beyond, satisfies factor 6(o) of the 2014 SoP. Therefore, it is more probable than not that the Veteran’s paroxysmal atrial fibrillation has arisen from his relevant eligible service, as provided for by the Act.
The Tribunal sets aside the decision under review and in substitution decides that the Veteran’s paroxysmal atrial fibrillation is service related and compensable. The matter is remitted to the Commission for determination of any increase in pension resulting from the acceptance of this condition as service related or as defined, war-caused.

I certify that the preceding 59 (fifty -nine) paragraphs are a true copy of the reasons for the decision herein of Miss E A Shanahan, Member.
........[sgd]................................................................
Associate
Dated 16 July 2014

Date(s) of hearing 27 May 2013 and 16 June 2014

Applicant In person

Advocate for the Respondent Adrian Crowe, Department of Veterans' Affairs
APPENDIX
Applicant’s Exhibits
A1Statement from the Veteran dated 27 July 2011
A2Correspondence with Mersina Stratos, including instance of Ventricular Tachycardia of 30 October 2011
A3Correspondence between Mersina Stratos and the Veteran dated 10 November 2011
A4SA Heart report dated 9 February 2012
A5 Letter from Richard Hillock to Dr Gladman dated 24 February 2012
A6Referral letter for appointment with Dr Hillock including Alfred Radiology report dated 25 January 2011
A7 Emails from the respondent to the Veteran and Tribunal re the Veteran’s Holter ECG Report dated 8 February 2012
A8 To Whom It May Concern letter from Dr Gladman in relation to the Veteran dated 23 May 2013
A9 Respondent’s letter to Professor Kalman dated 31 May 2013
A10Medical report from Professor Kalman with enclosures from Associate Professor Warren and radiologist, Subodh Joshi

Respondent’s Exhibits
R1 T-Docs
R2 Referral letter sent by respondent to Dr Hillock dated 16 January 2012
R3 Letter from respondent to Dr Hillock dated 14 March 2012
R4 Dr Hillock's reply dated 7 May 2012 to respondent's letters
R5 Minute from respondent to Dr Spedding dated 25 October 2011
R6Minute from Dr Spedding dated 7 November 2011 in reply to respondent's minute.
R7Minute from respondent to Dr Spedding dated 24 May 2013
R8Dr Spedding's reply dated 24 May 2013 to respondent's minute.
R9 Medical report of Dr Spedding dated 30 July 2013
R10Medical report of Dr Spedding dated 1 April 2014

Division	VETERANS' APPEALS DIVISION
File Number(s)	2011/1799
Re	QSWZ
APPLICANT
And	Repatriation Commission
RESPONDENT

Tribunal	Miss E A Shanahan, Member
Date	16 July 2014
Place	Melbourne

Date(s) of hearing	27 May 2013 and 16 June 2014
Applicant	In person
Advocate for the Respondent	Adrian Crowe, Department of Veterans' Affairs