Statement of Principles concerning ischaemic heart disease No. 53 of 2003 (Cth)

Case

Statement of Principles

concerning

ISCHAEMIC HEART DISEASE

Instrument No. 53 of 2003 as amended

made under section 196B(2) of the

Veterans’ Entitlements Act 1986

This compilation was prepared on 2 November 2005
taking into account Amendment of Statement of Principles concerning ISCHAEMIC HEART DISEASE (Instrument No. 9 of 2004)

Prepared by the Repatriation Medical Authority Secretariat, Brisbane


Revocation and Determination

of

Statement of Principles

concerning

ISCHAEMIC HEART DISEASE

Veterans’ Entitlements Act 1986

1. The Repatriation Medical Authority under subsection 196B(2) of the Veterans’ Entitlements Act 1986 (the Act):

(a)       revokes Instrument No.38 of 1999; and

(b)       determines in its place the following Statement of Principles.

Kind of injury, disease or death

2.         (a)        This Statement of Principles is about ischaemic heart disease and death from ischaemic heart disease.

(b)For the purposes of this Statement of Principles, “ischaemic heart disease” means a cardiac disability characterised by insufficient blood flow to the muscle tissue of the heart due to atherosclerosis, thrombosis or vasospasm of the coronary arteries.

(c)Ischaemic heart disease attracts an ICD-10-AM code in the range I20 to I25.

(d)In the application of this Statement of Principles, the definition of “ischaemic heart disease” is that given at para 2(b) above.

Basis for determining the factors

3.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that ischaemic heart disease and death from ischaemic heart disease can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces.

Factors that must be related to service

4.         Subject to clause 6, at least one of the factors set out in clause 5 must be related to any relevant service rendered by the person.

Factors

5.         The factors that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting ischaemic heart disease or death from ischaemic heart disease with the circumstances of a person’s relevant service are:

(a)the presence of hypertension before the clinical onset of ischaemic heart disease; or

(b)suffering from diabetes mellitus before the clinical onset of ischaemic heart disease; or

(c)being obese before the clinical onset of ischaemic heart disease; or

(d)the presence of dyslipidaemia before the clinical onset of ischaemic heart disease; or

(e)where smoking has ceased prior to the clinical onset of ischaemic heart disease,

  1. smoking at least one pack year but less than five pack years of cigarettes or the equivalent thereof, in other tobacco products, and the clinical onset of ischaemic heart disease has occurred within five years of cessation; or

  2. smoking at least five pack years but less than 20 pack years of cigarettes or the equivalent thereof, in other tobacco products, and the clinical onset of ischaemic heart disease has occurred within 15 years of cessation; or

  3. smoking at least 20 pack years of cigarettes or the equivalent thereof, in other tobacco products before the clinical onset of ischaemic heart disease; or

    (f)where smoking has not ceased prior to the clinical onset of ischaemic heart disease,

  4. smoking at least five cigarettes per day or the equivalent thereof, in other tobacco products, for a period of at least one year immediately before the clinical onset of ischaemic heart disease; or

  5. smoking at least one pack year of cigarettes or the equivalent thereof, in other tobacco products, before the clinical onset of ischaemic heart disease; or

    (g)immersion in an atmosphere with a visible tobacco smoke haze in an enclosed space for at least 1 000 hours before the clinical onset of ischaemic heart disease, provided the last exposure to that atmosphere did not end more than five years before the clinical onset of ischaemic heart disease; or

    (h)an inability to undertake any physical activity greater than 3 METs for at least the five years immediately before the clinical onset of ischaemic heart disease; or

    (i)the presence of hyperhomocystinaemia before the clinical onset of ischaemic heart disease; or

    (j)suffering from chronic renal disease before the clinical onset of ischaemic heart disease; or

    (k)suffering from hypothyroidism before the clinical onset of ischaemic heart disease; or

    (l)inhaling or having cutaneous contact with products containing nitroglycerine or nitroglycol,

  6. each day for at least 20 days within a consecutive period of 30 days; and

  7. where the last inhalation or contact occurred not more than two weeks before the clinical onset of ischaemic heart disease; or

    (m)suffering from clinically significant depressive disorder for at least five years before the clinical onset of ischaemic heart disease; or

    (n)for angina, acute myocardial infarction or sudden death from ischaemic heart disease only, suffering from panic disorder or phobic anxiety with panic attack, within the 12 months immediately before the clinical onset of ischaemic heart disease; or

    (o)for angina, acute myocardial infarction or sudden death from ischaemic heart disease only, experiencing a severe stressor immediately before the clinical onset of ischaemic heart disease; or

    (p)undergoing a course of therapeutic radiation involving the mediastinum or the chest wall region overlying the heart before the clinical onset of ischaemic heart disease; or

    (q)using the combined oral contraceptive pill at the time of the clinical onset of ischaemic heart disease; or

    (r)the presence of hypertension before the clinical worsening of ischaemic heart disease; or

    (s)suffering from diabetes mellitus before the clinical worsening of ischaemic heart disease; or

    (t)being obese before the clinical worsening of ischaemic heart disease; or

    (u)the presence of dyslipidaemia before the clinical worsening of ischaemic heart disease; or

    (v)where smoking has ceased prior to the clinical worsening of ischaemic heart disease,

  8. smoking at least one pack year but less than five pack years of cigarettes or the equivalent thereof, in other tobacco products, and the clinical worsening of ischaemic heart disease has occurred within five years of cessation; or

  9. smoking at least five pack years but less than 20 pack years of cigarettes or the equivalent thereof, in other tobacco products, and the clinical worsening of ischaemic heart disease has occurred within 15 years of cessation; or

  10. smoking at least 20 pack years of cigarettes or the equivalent thereof, in other tobacco products before the clinical worsening of ischaemic heart disease; or

    (w)where smoking has not ceased prior to the clinical worsening of ischaemic heart disease,

  11. smoking at least five cigarettes per day or the equivalent thereof, in other tobacco products, for a period of at least one year immediately before the clinical worsening of ischaemic heart disease; or

  12. smoking at least one pack year of cigarettes or the equivalent thereof, in other tobacco products, before the clinical worsening of ischaemic heart disease; or

    (x)immersion in an atmosphere with a visible tobacco smoke haze in an enclosed space for at least 1 000 hours before the clinical worsening of ischaemic heart disease, provided the last exposure to that atmosphere did not end more than five years before the clinical worsening of ischaemic heart disease; or

    (y)an inability to undertake any physical activity greater than 3 METs for at least the five years immediately before the clinical worsening of ischaemic heart disease; or

    (z)the presence of hyperhomocystinaemia before the clinical worsening of ischaemic heart disease; or

    (za)suffering from chronic renal disease before the clinical worsening of ischaemic heart disease; or

    (zb)suffering from hypothyroidism before the clinical worsening of ischaemic heart disease; or

    (zc)inhaling or having cutaneous contact with products containing nitroglycerine or nitroglycol,

  13. each day for at least 20 days within a consecutive period of 30 days; and

  14. where the last inhalation or contact occurred not more than two weeks before the clinical worsening of ischaemic heart disease; or

    (zd)suffering from clinically significant depressive disorder for at least five years, before the clinical worsening of ischaemic heart disease; or

    (ze)for angina, acute myocardial infarction or sudden death from ischaemic heart disease only, suffering from panic disorder or phobic anxiety with panic attack, within the 12 months before the clinical worsening of ischaemic heart disease; or

    (zf)for angina, acute myocardial infarction or sudden death from ischaemic heart disease only, experiencing a severe stressor immediately before the clinical worsening of ischaemic heart disease; or

    (zg)undergoing a course of therapeutic radiation involving the mediastinum or the chest wall region overlying the heart before the clinical worsening of ischaemic heart disease; or

    (zh)using the combined oral contraceptive pill at the time of the clinical worsening of ischaemic heart disease; or

    (zi)inability to obtain appropriate clinical management for ischaemic heart disease.

    Factors that apply only to material contribution or aggravation

    6.Paragraphs 5(r) to 5 (zi) apply only to material contribution to, or aggravation of, ischaemic heart disease where the person’s ischaemic heart disease was suffered or contracted before or during (but not arising out of) the person’s relevant service; paragraph 8(1)(e), 9(1)(e), 70(5)(d) or 70(5A)(d) of the Act refers.

    Inclusion of Statements of Principles

    7.         In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles.

    Other definitions

    8.For the purposes of this Statement of Principles:

    “a course of therapeutic radiation” means one or more fractions (treatment portions) of ionising radiation administered with the aim of achieving palliation or cure with gamma rays, x-rays, alpha particles or beta particles;

    “being obese” means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of 30 or greater.

    The BMI = W/H2 and where:

    W is the person’s weight in kilograms and

    H is the person’s height in metres;

    “chronic renal disease” means irreversible kidney damage which leads to impaired renal function;

    “cigarettes per day or the equivalent thereof, in other tobacco products” means either cigarettes, pipe tobacco or cigars, alone or in any combination where one tailor made cigarette approximates one gram of tobacco; or one gram of cigar, pipe or other smoking tobacco by weight;

    “clinically significant” means sufficient to warrant ongoing management, which may involve regular visits (for example, at least monthly), to a psychiatrist, counsellor or General Practitioner;

    “death from ischaemic heart disease” in relation to a person includes death from a terminal event or condition that was contributed to by the person’s ischaemic heart disease;

    “DSM-IV” means the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders;

    “dyslipidaemia” generally means evidence of a persistently abnormal lipid profile after the accurate evaluation of serum lipids following a 12 hour overnight fast, and estimated on a minimum of two occasions as a:

(a)      total serum cholesterol level greater than or equal to 5.5 mmol/L; or

(b)      fasting serum triglyceride level greater than or equal to 2.0 mmol/L together with high density lipoprotein cholesterol level less than 0.9 mmol/L;

Note: the source for this definition is: NHF Australia, Guide to Plasma Lipids for Doctors; Current Therapeutics, Vol 33 Supplement 1, 1992.

“experiencing a severe stressor” means, the person experienced, witnessed or was confronted with, an event or events that involved actual or threat of death or serious injury, or a threat to the person’s or other people’s physical integrity, which event or events might evoke intense fear, helplessness or horror.

In the setting of service in the Defence Forces, or other service where the Veterans’ Entitlements Act applies, events that qualify as severe stressors include:

  1. threat of serious injury or death; or

    (ii)engagement with the enemy; or

    (iii)witnessing casualties or participation in or observation of casualty clearance, atrocities or abusive violence;

    “hyperhomocystinaemia” means a condition characterised by an excess of homocystine in the blood;

    “hypothyroidism” means a disease state characterised by a reduction in circulating thyroid hormones;

    “ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification (ICD-10-AM), Third Edition, effective date of 1 July 2002, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 413 9;

    “MET” means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute or, 1.0 kcal/kg of body weight per hour, or resting metabolic rate;

    “pack years of cigarettes or the equivalent thereof in other tobacco products” means a calculation of consumption where one pack year of cigarettes equals twenty tailor made cigarettes per day for a period of one calendar year, or 7 300 cigarettes.  One tailor made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight.  One pack year of tailor made cigarettes equates to 7 300 cigarettes, or 7.3kg of smoking tobacco by weight.  Tobacco products means either cigarettes, pipe tobacco or cigars smoked, alone or in any combination;

    “panic attack” means a condition, as defined in DSM-IV, meeting the following criteria:

    the person has experienced a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

  1. palpitations, pounding heart, or accelerated heart rate; or

    (2)sweating; or

    (3)trembling or shaking; or

    (4)sensations of shortness of breath or smothering; or

    (5)feeling of choking; or

    (6)chest pain or discomfort; or

    (7)nausea or abdominal distress; or

    (8)feeling dizzy, unsteady, light headed or faint; or

    (9)derealisation (feelings of unreality) or depersonalisation (being detached from oneself); or

    (10)fear of losing control or going crazy; or

    (11)fear of dying; or

    (12)paresthesias (numbness or tingling sensations); or

    (13)chills or hot flushes;

    “phobic anxiety” means a psychiatric condition which significantly limits an individual’s normal routine, occupational and social activities by excessive or unreasonable persistent fears brought on by the presence or anticipation of certain situations or objects.  The exposure to the stimulus invariably provokes an immediate anxiety response such as a panic attack and the response is recognised as being excessive or unreasonable by the affected individual;

    “relevant service” means:

    (a)  operational service; or

    (b)  peacekeeping service; or

    (c)hazardous service;

    “sudden death” means death within one hour of onset of acute symptoms;

    “terminal event” means the proximate or ultimate cause of death and includes:

    (a)pneumonia;

    (b)respiratory failure;

    (c)cardiac arrest;

    (d)circulatory failure; or

    (e)cessation of brain function.

    Application

    9. This Instrument applies to all matters to which section 120A of the Act applied.


    Notes to Statement of Principles concerning ischaemic heart disease (Instrument No. 53 of 2003)

    The Statement of Principles concerning ischaemic heart disease (Instrument No. 53 of 2003) in force under section 196B(2) of the Veterans’ Entitlements Act 1986, as shown in this compilation is amended as indicated in the Tables below.

    Table of Instruments

Title

Date of notification
in Gazette or FRLI registration

Date of
commencement

Application, saving or
transitional provisions

Statement of Principles concerning ischaemic heart disease (Instrument No. 53 of 2003)

19 November 2003

(see Gazette 2003, No. GN46)

 19 November 2003
Amendment of Statement of Principles concerning ischaemic heart disease (Instrument No. 9 of 2004)

31 March 2004

(see Gazette 2004, No. GN13)

 31 March 2004

Table of Amendments

ad. = added or inserted      am. = amended      rep. = repealed      rs. = repealed and substituted

Provision affected

How affected

Paragraph 5 – ‘factors (h) and (y)’...............................

rs. Instrument  No.9 of 2004

Paragraph 8 – ‘an inability to undertake more than a mildly strenuous level of physical activity’................

rep. Instrument  No.9 of 2004

Paragraph 8 – ‘MET’........... ad. Instrument  No.9 of 2004
Paragraph 8 – ‘chronic renal disease’..................

rs. Instrument  No.9 of 2004

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