Atrial fibrillation and atrial flutter - Alcohol consumption Factor

The alcohol factor for atrial fibrillation requires consumption of at least 250 kilograms of alcohol within any 10 year period, within the 15 years immediately before the clinical onset of atrial fibrillation. This factor applies only in operational service cases.

As part of the investigation of this factor you will be asked to consider whether VEA service made a material contribution to the specified amounts for the relevant period.  In considering this question you should have regard to:

• Guideline for claims assessors on smoking and alcohol related conditions and military service [3] and also
• AN02/2000, an Advisory Note concerning Alcohol Habituation [4].

A material contribution by service can be made in a number of ways:

• an amount was consumed during service, as a causal result of service;
• an amount was consumed because of another medical condition, either during service or after service, or both.  For example: as part of alcohol dependence or alcohol abuse; or as part of another psychiatric condition; or as "self medication" for a medical condition.

The Repatriation Commission also agreed that arguments put to delegates that are outside the Guideline must still be considered for substance and medical and scientific support.  However the Commission did not agree that the temporal connection of service life with alcohol consumption is enough to establish ‘habit’ as the cause of alcohol use.

“Habituation” is often an argument advanced to connect service conditions with post service alcohol consumption.

A search by the RMA for sound medical scientific evidence bearing on "habituation" revealed only one epidemiological study (as at April 2000) that bears on the ‘habituation’ issue, that is, whether a “habit” of alcohol drinking continues from the service environment into the community after discharge from service.  In fact that paper suggested that not only was there no association with military service there is some evidence that military service produces the opposite effect.

Last reviewed for CCPS 16 July 2003.

Investigative Documents

Type	Title	PDF Format	Word Format
Claimant Report	Alcohol Consumption	CRD904.pdf [5]	CRD904.docx [6]
Claimant Report	Alcohol Consumption	CRV904.pdf [7]	CRV904.docx [8]
Medical Report	Alcohol Consumption	MR9244.pdf [9]	MR9244.docx [10]

Preliminary questions [14886]

25686 the veteran has consumed alcohol at some time.

10946  the veteran has established the causal connection between the alcohol consumption and operational service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10946]

10947 the veteran consumed at least 250 kg of alcohol within a 10 year period within the 15 years immediately before the clinical onset of the condition under consideration.

10949 operational service made a material contribution to the veteran's consumption of at least 250 kg of alcohol within a 10 year period within the 15 years immediately before the clinical onset of the condition under consideration.

10950 the veteran's consumption of at least 250 kg of alcohol within a 10 year period within the 15 years immediately before the clinical onset of the condition under consideration, which was materially contributed by operational service, was due to the veteran's serious default, wilful act or serious breach of discipline.

Atrial fibrillation and atrial flutter - Cardiac or thoracic surgery Factor

Thoracic surgery is surgery involving organs located in the thorax, or chest.  The thoracic cavity lies between the neck and the diaphragm, and contains the heart and lungs (cardiopulmonary system), the oesophagus, trachea, pleura, mediastinum, chest wall, and diaphragm. Therefore, in one sense, all cardiac surgery is also thoracic surgery.

Thoracic surgery treats diseased or injured organs and tissues in the thoracic cavity. General thoracic surgery deals specifically with disorders of the lungs and oesophagus.  Blunt chest trauma, reflux oesophagitis, oesophageal cancer, lung transplantation, lung cancer, and emphysema are just a few of the many clinical indications for thoracic surgery.

Cardiac surgery encompasses disorders of the heart, pericardium and great vessels, eg valve replacement, coronary bypass surgery, angioplasty (with stents), or transplant.

Clearly such surgery is a major event, and would be recorded in hospital records and doctor's notes.

Preliminary questions [14887]

14893 there is some evidence that cardiac or thoracic surgery may be a factor in the development of the condition under consideration.

10960 the veteran has undergone cardiac or thoracic surgery at some time.

10961 the veteran underwent cardiac or thoracic surgery within the 30 days immediately before the clinical onset of the condition under consideration.

10962  the veteran has established the causal connection between cardiac or thoracic surgery and VEA service for the clinical onset of atrial fibrillation.

10963   the veteran has established the causal connection between cardiac or thoracic surgery and operational service for the clinical onset of atrial fibrillation.

or

10964   the veteran has established the causal connection between cardiac or thoracic surgery and eligible service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10963]

10965 on operational service, the veteran underwent cardiac or thoracic surgery within the 30 days immediately before the clinical onset of the condition under consideration.

10966 the cardiac or thoracic surgery on operational service within the 30 days immediately before the clinical onset of the condition under consideration was due to the veteran's serious default, wilful act or serious breach of discipline.

or

10967 the veteran underwent cardiac or thoracic surgery within the 30 days immediately before the clinical onset of the condition under consideration for treatment of an illness or injury which is identifiable.

10968  the identified illness or injury for which cardiac or thoracic surgery was undergone is causally related to operational service.

Clinical onset and eligible service [10964]

10967 the veteran underwent cardiac or thoracic surgery within the 30 days immediately before the clinical onset of the condition under consideration for treatment of an illness or injury which is identifiable.

10969  the identified illness or injury for which cardiac or thoracic surgery was undergone is causally related to eligible service.

Atrial fibrillation and atrial flutter - Cardiomyopathy Factor

Cardiomyopathy is a non-inflammatory disorder of heart muscle, other than ischaemic or hypertensive disease, involving the myocardium [the middle layer of the heart wall] or the myocardium and the endocardium [the lining membranes of the cavities of the heart and the connective tissue bed on which it lies].

Cardiomyopathy is described as dilated, hypertrophic or restrictive, depending on the nature of the disease, and also as Primary cardiomyopathy or Secondary cardiomyopathy, depending on the cause of the disease.

Symptoms and signs

Symptoms and signs vary depending on the type of cardiomyopathy, but can include shortness of breath on exertion, fatigability, shortness of breath when lying down [orthopnoea], recurring acute distressing paroxysms of shortness of breath at night [paroxysmal nocturnal dyspnoea], oedema of the legs, palpitations, fainting spells, and angina pectoris,

If a veteran or member had cardiomyopathy he or she would have needed significant medical attention at some time, although medical attention may not have been sought until symptoms had been present for some time.  Such medical treatment would normally be recorded in doctors' notes and/or hospital records.  However, these records may have been destroyed or can no longer be obtained.  Therefore, if there is a reliable history of appropriate medical treatment at a particular time, this generally will be accepted, provided this is not negated by other evidence.  Seek medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to cardiomyopathy rather than to some other condition.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [34737]

34738 there is some evidence that cardiomyopathy may be a factor in the development of the condition under consideration.

34739  the veteran suffered from cardiomyopathy at some time.

19162 the veteran has suffered from primary cardiomyopathy at some time.

or

19291 the veteran has suffered from secondary cardiomyopathy at some time.

34740 the veteran suffered from cardiomyopathy at the time of the clinical onset of atrial fibrillation.

34741  the veteran has established the causal connection between the cardiomyopathy at the time of onset of atrial fibrillation and VEA service for the clinical onset of atrial fibrillation.

34742   the veteran has established the causal connection between the cardiomyopathy at the time of onset of atrial fibrillation and operational service for the clinical onset of atrial fibrillation.

or

34743   the veteran has established the causal connection between the cardiomyopathy at the time of onset of atrial fibrillation and eligible service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [34742]

34744  the cardiomyopathy is causally related to operational service.

Clinical onset and eligible service [34743]

34745  the cardiomyopathy is causally related to eligible service.

Atrial fibrillation and atrial flutter - Chronic bronchitis with pulmonary obstruction Factor

RMA definition

In the SOP for atrial fibrillation the RMA has defined chronic bronchitis with pulmonary obstruction to mean "a respiratory tract disorder with:

• excessive mucus production sufficient to cause cough and sputum production with expectoration for at least three months of each of at least two consecutive years which is not attributable to other respiratory diseases; and
• chronic expiratory obstruction on spirometric evaluation."

Note: In the SOP for atrial flutter the definition refers to "functional evaluation" rather than "spirometric evaluation".  However, the only functional evaluation of obstruction in chronic bronchitis is by spirometry so the definitions are essentially identical.

Establishing a history of chronic bronchitis with pulmonary obstruction

Chronic expiratory obstruction is evidenced by:

• a decrease in the person’s Forced Expiratory Volume in one second (FEV1) to 85% or less of the normal predicted value for a person of the same age, height and gender; and
• a ratio of FEV1 to Forced Vital Capacity (FVC) of 75% or less; which is not attributable to other disease; or
• specialist medical assessment indicative of a diagnosis of pulmonary obstruction, including evidence of significant irreversible small airways dysfunction as measured by FEF25-75 (Forced Expiratory Flow between 25% and 75% of the vital capacity), which is not attributable to other disease

A history of chronic bronchitis with pulmonary obstruction should be recorded in doctor’s notes and/or hospital records.  However, if these records cannot be obtained, a reliable history of appropriate symptoms or medical treatment at a particular time generally will be accepted, provided this is not negated by other evidence.  Seek medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to chronic bronchitis with pulmonary obstruction rather than to some other condition.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [34715]

19163 the veteran has suffered from chronic bronchitis with pulmonary obstruction at some time.

34716 the veteran suffered from chronic bronchitis with pulmonary obstruction at the time of the clinical onset of the condition under consideration.

34717  the veteran has established the causal connection between the chronic bronchitis with pulmonary obstruction and VEA service for the clinical onset of the condition under consideration.

34718   the veteran has established the causal connection between the chronic bronchitis with pulmonary obstruction and operational service for the clinical onset of the condition under consideration.

or

34719   the veteran has established the causal connection between the chronic bronchitis with pulmonary obstruction and eligible service for the clinical onset of the condition under consideration.

Clinical onset and operational service [34718]

34720  the chronic bronchitis with pulmonary obstruction is causally related to operational service.

Clinical onset and eligible service [34719]

34721  the chronic bronchitis with pulmonary obstruction is causally related to eligible service.

Atrial fibrillation and atrial flutter - Congenital heart disease Factor

Congenital heart disease is a defect of the heart and/or major great vessels produced by abnormalities at various stages of foetal development and present at birth, but which may not be diagnosed until later.

The incidence of such anomalies is 1/120 live births. The commonest congenital heart disease is the “hole in the heart”.  This term refers to the defects in the partitions (septums) that separate the two sides of the heart. There are two types – ventricular septal defect and atrial septal defect - in both cases oxygenated blood is forced from the left to the right side of the heart through a hole in the partition between the two sides. Too much blood passes into the lungs (via the pulmonary artery) and too little to the body tissues (via the aorta).

Congenital heart disease can also affect cardiac function in several other ways, depending on the nature of the disease. Routine history, physical examination, ECG, and chest X-ray are usually adequate for a specific diagnosis, with supportive and confirmatory data from echocardiography, cardiac catheterization, angiocardiography, and other laboratory data.

The diagnosis and history of a specific congenital heart disease should be recorded in doctor’s notes and/or hospital records.  However, these records may have been destroyed or can no longer be obtained.  Therefore, if there is a reliable history of appropriate symptoms or medical treatment at a particular time, this generally will be accepted, provided this is not negated by other evidence.  Seek medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to a congenital heart disease rather than to some other condition

Last reviewed for CCPS 16 July 2003.

Preliminary questions [19164]

14891 there is some evidence that congenital heart disease may be a factor in the development of the condition under consideration.

10779 the veteran has suffered from congenital heart disease at some time.

10780  congenital heart disease means a defect of the heart or the blood vessels near the heart that is present at birth.

10781 the veteran was suffering from the identified illness or injury, a congenital heart disease, at the time of the clinical onset of the condition under consideration.

10782  the veteran has established the causal connection between congenital heart disease and VEA service for the clinical onset of atrial fibrillation.

10783   the veteran has established the causal connection between congenital heart disease and operational service for the clinical onset of atrial fibrillation.

or

10784   the veteran has established the causal connection between congenital heart disease and eligible service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10783]

10785  the identified illness or injury, a congenital heart disease, is causally related to operational service.

Clinical onset and eligible service [10784]

10786  the identified illness or injury, a congenital heart disease, is causally related to eligible service.

Atrial fibrillation and atrial flutter - Congestive cardiac failure Factor

Definition

In the SOP for deep vein thrombosis the RMA has defined congestive cardiac failure as "congestion in the peripheral circulation or congestion of the lungs or both, due to reduced stroke volume".

Symptoms and signs

Cardiac failure results when the heart no longer can work efficiently.  It is characterised by breathlessness and abnormal sodium and water retention.  Common symptoms are shortness of breath on exertion, or at rest, or when lying down, oedema (excessive fluid) of the lower limbs, fatigue and weakness, or confusion.  Increased venous pressure is always present with congestive cardiac failure.

Determining the presence of congestive cardiac failure

The symptoms described above may also be due to several other medical illnesses or injuries, and therefore the diagnosis of cardiac failure should be confirmed by medical advice.  Cardiac failure may also be called congestive cardiac failure, right sided heart failure, left sided heart failure, or pulmonary oedema.  Any type of cardiac failure can be said to be a 'congestive cardiac failure' to some degree.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [19165]

25100 there is some evidence that congestive cardiac failure may be a factor in the development of the condition under consideration.

220       the veteran has a history of congestive cardiac failure.

8225     the congestive cardiac failure was caused by an illness or injury which is identifiable.

10934  the veteran has established the causal connection between the congestive cardiac failure and VEA service for the clinical onset of the condition under consideration.

10936   the veteran has established the causal connection between the congestive cardiac failure and eligible service for the clinical onset of the condition under consideration.

or

10935   the veteran has established the causal connection between the congestive cardiac failure and operational service for the clinical onset of the condition under consideration.

Clinical onset and operational service [10935]

10937 as a consequence of the identified illness or injury, the veteran suffered from congestive cardiac failure within the 30 days immediately before the clinical onset of the condition under consideration.

1159     the identified illness or injury which caused the congestive cardiac failure is causally related to operational service.

Clinical onset and eligible service [10936]

10938 as a consequence of the identified illness or injury, the veteran suffered from congestive cardiac failure at the time of the clinical onset of the condition under consideration.

1163     the identified illness or injury which caused the congestive cardiac failure is causally related to eligible service.

Atrial fibrillation and atrial flutter - Emphysema Factor

RMA definition

In the SOP for Chronic bronchitis and emphysema the RMA defines emphysema as "a bilateral and diffuse respiratory tract disorder which is characterised by distension of airspaces distal to the terminal bronchiole with destruction of alveolar septa, and without obvious fibrosis. This definition excludes isolated emphysematous bleb and surgical, traumatic, unilateral, focal or localised emphysema, and Swyer-James syndrome (also known as MacLeod's syndrome or hyperlucent lung syndrome)."

Establishing a history of emphysema

Specific spirometric or other evidence is not required.  Spirometry results will generally be available (either provided or obtained for assessment purposes).  If that spirometry does not show the usual obstructive pattern associated with emphysema, ie FEV1 £ 85% of predicted and FEV₁/FVC) ratio £ 75%, then the diagnosis should not be confirmed without other evidence in support and further investigation should be undertaken.

A history of emphysema should be recorded in doctor’s notes and/or hospital records.  However, if these records cannot be obtained, a reliable history of appropriate symptoms or medical treatment at a particular time generally will be accepted, provided this is not negated by other evidence.  Seek medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to emphysema rather than to some other condition.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [34722]

3819     the veteran has had emphysema at some time.

34723 the veteran suffered from emphysema at the time of the clinical onset of the condition under consideration.

34724  the veteran has established the causal connection between the emphysema and VEA service for the clinical onset of the condition under consideration.

34725   the veteran has established the causal connection between the emphysema and operational service for the clinical onset of the condition under consideration.

or

34726   the veteran has established the causal connection between the emphysema and eligible service for the clinical onset of the condition under consideration.

Clinical onset and operational service [34725]

34727  the emphysema is causally related to operational service.

Clinical onset and eligible service [34726]

34728  the emphysema is causally related to eligible service.

Atrial fibrillation and atrial flutter - Hypertension Factor

Definition

Hypertension is high blood pressure.  Hypertension was also sometimes called hyperpiesia or hyperpiesis up until the 1950's.  Blood pressure is usually recorded as two figures - the top figure records the systolic pressure and the lower figure records the diastolic pressure (eg 130/80 records a systolic pressure of 130 and a diastolic pressure of 80).

Note:  The definition means that hypertension cannot be diagnosed on the basis of one elevated blood pressure reading.  There must be a number of high readings.  When treatment is given, blood pressure readings may return to normal.  However, a person with 'normal' blood pressure readings can still be suffering from hypertension if he or she is undergoing treatment for hypertension.

Establishing the onset of hypertension

This disease is significant and, if it has been detected, it will have been documented by a medical officer.  However, doctors' notes and hospitals' records may have been destroyed or can no longer be obtained.  If this is the case, the person's statement that hypertension was detected at a particular time should generally be accepted, However, if these records cannot be obtained, a reliable history of hypertension at a particular time will generally be accepted, unless there is contradictory evidence.  Obtain medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to hypertension rather than to some other condition.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [14888]

317       the veteran has hypertension.

10940 the hypertension was present at the time of the clinical onset of atrial fibrillation.

10939  the veteran has established the causal connection between the hypertension and operational service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10939]

334        the hypertension is causally related to operational service.

Atrial fibrillation and atrial flutter - Hyperthyroidism Factor

In the Statement of Principles for atrial fibrillation the RMA has defined hyperthyroidism as “thyrotoxicosis or subclinical hyperthyroidism”.

Subclinical hyperthyroidism is simply an excess of thyroid hormones without clinical manifestations, ie where symptoms and signs are not apparent or detectable by clinical examination.

Note:  While goitre, covered by a SOP, is a clinical manifestation of hyperthyroidism, goitre is not a cause of atrial fibrillation.  Therefore, the goitre SOP should not be used for propagation purposes when considering the hyperthyroidism factor in atrial fibrillation.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [34730]

34729 there is some evidence that hyperthyroidism may be a factor in the development of the condition under consideration.

28996 the veteran has suffered from hyperthyroidism at some time.

34731 the veteran suffered from hyperthyroidism at the time of the clinical onset of atrial fibrillation.<hotword

34732  the veteran has established the causal connection between the hyperthyroidism at the time of onset of atrial fibrillation and VEA service for the clinical onset of atrial fibrillation.

34733   the veteran has established the causal connection between the hyperthyroidism at the time of onset of atrial fibrillation and operational service for the clinical onset of atrial fibrillation.

or

34734   the veteran has established the causal connection between the hyperthyroidism at the time of onset of atrial fibrillation and eligible service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [34733]

34735  the hyperthyroidism is causally related to operational service.

Clinical onset and eligible service [34734]

34736  the hyperthyroidism is causally related to eligible service.

Atrial fibrillation and atrial flutter - Inability to obtain appropriate clinical management for atrial fibrillation Factor

Appropriate clinical management of atrial fibrillation may involve correction of the precipitating factor and the use of drugs and/or electrical shock to slow the ventricular rate and to convert to sinus rhythm.

Inability to obtain appropriate clinical management

Investigative Documents

Type	Title	PDF Format	Word Format
Medical Report	Inability to Obtain Appropriate Cinical Management	GQACM.pdf [11]	GQACM.docx [12]

Preliminary questions [14869]

11109  the condition under consideration has been accepted on the basis of inability to obtain appropriate clinical management for the condition under consideration.

7066     there is some evidence that an inability to obtain appropriate clinical management for the condition under consideration may be a factor in the worsening of the condition under consideration.

7334     the clinical onset of the condition under consideration occurred after the end of the veteran's last period of VEA service.

7335     the condition under consideration permanently worsened.

7378     the veteran was unable to obtain appropriate clinical management for the condition under consideration at some time.

7379     the inability to obtain appropriate clinical management for the condition under consideration contributed to the clinical worsening of the condition under consideration.

11234   the veteran has established the causal connection between the inability to obtain appropriate clinical management for the condition under consideration and VEA service for the clinical worsening of the condition under consideration.

11235  the veteran has established the causal connection between the inability to obtain appropriate clinical management for the condition under consideration and operational service for the clinical worsening of the condition under consideration.Ê

or

11236  the veteran has established the causal connection between the inability to obtain appropriate clinical management for the condition under consideration and eligible service for the clinical worsening of the condition under consideration.

Clinical worsening and operational service [11235]

7384     the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, during operational service.

21084 the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, during operational service, as a causal result of operational service.

7387     the veteran's inability to obtain appropriate clinical management for the condition under consideration during operational service was due to the veteran's serious default, wilful act or serious breach of discipline.

or

7389     the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, because of an illness or injury which is identifiable.

7390     the identified illness or injury which prevented the veteran from obtaining appropriate clinical management for the condition under consideration is causally related to operational service.

7392     the clinical onset of the condition under consideration occurred prior to that part of operational service to which the identified illness or injury that prevented the veteran from obtaining appropriate clinical management for the condition under consideration is causally related.

Clinical worsening and eligible service [11236]

7385     the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, during eligible service.

7386     the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, during eligible service, as a causal result of eligible service.

7388     the veteran's inability to obtain appropriate clinical management for the condition under consideration during eligible service was due to the veteran's serious default, wilful act or serious breach of discipline.

or

7389     the veteran was unable to obtain appropriate clinical management for the condition under consideration, which contributed to the clinical worsening of the condition under consideration, because of an illness or injury which is identifiable.

7391     the identified illness or injury which prevented the veteran from obtaining appropriate clinical management for the condition under consideration is causally related to eligible service.

7393     the clinical onset of the condition under consideration occurred prior to that part of eligible service to which the identified illness or injury that prevented the veteran from obtaining appropriate clinical management for the condition under consideration is causally related.

Atrial fibrillation and atrial flutter - Ischaemic heart disease Factor

Definition

Note that coronary atherosclerosis that has not resulted in angina, an infarct or some other cardiac disability is not covered by the RMA SOP definition.

Establishing a history of ischaemic heart disease

Ischaemic heart disease is a cardiac disability which arises from an imbalance between the supply and myocardial demand for oxygen.  This imbalance results from coronary atheroma [also called coronary atherosclerosis and coronary artery disease] or coronary vasospasm.  NB - the presence of coronary artery disease [as may be shown by an angiogram] does not establish the presence of ischaemic heart disease, unless there is some cardiac disability such as angina.

If a veteran or member had ischaemic heart disease he or she would most likely have sought medical attention at some time.  Such medical treatment would normally be recorded in doctors' notes and/or hospital records.  However, if these records cannot be obtained, a reliable history of appropriate symptoms and/or medical treatment at a particular time generally will be accepted, provided this is not negated by other evidence.  Seek medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to ischaemic heart disease rather than to some other illness or injury.

19161 the veteran has suffered from ischaemic heart disease at some time.

34711 the veteran suffered from ischaemic heart disease at the time of the clinical onset of the condition under consideration.

34712  the veteran has established the causal connection between the ischaemic heart disease and VEA service for the clinical onset of the condition under consideration.

34713   the veteran has established the causal connection between the ischaemic heart disease and operational service for the clinical onset of the condition under consideration.

or

34714   the veteran has established the causal connection between the ischaemic heart disease and eligible service for the clinical onset of the condition under consideration.

Clinical onset and operational service [34713]

30360  the ischaemic heart disease is causally related to operational service.

Clinical onset and eligible service [34714]

30361  the ischaemic heart disease is causally related to eligible service.

Atrial fibrillation and atrial flutter - Myocarditis Factor

Myocarditis means inflammation of the muscular walls of the heart.

Viral infection is by far the most common cause of myocarditis and the most common viral infection is Coxsackie B virus.  Other causes are radiation, chemicals, hypersensitivity to drugs, or physical agents.  Bacterial causes are usually complications of infective endocarditis.  Chagas disease (Trypanosoma cruzi) and Lyme’s disease (Borrelia burgdorferi) are also causes.  Giant cell myocarditis is associated with thymoma, systemic lupus erythematosus or thyrotoxicosis.

Signs and symptoms

Myocarditis can be asymptomatic with only temporary abnormal ECG readings.  Where damage to the heart muscle occurs this can lead to signs of heart failure and cardiac arrhythmia.

Establishing onset

In mild cases the disease is self-limiting and goes away on its own.  In more severe cases the complications of heart failure or arrhythmia require treatment.  If a veteran or member had myocarditis he or she may have needed significant medical attention at that time.  Such medical treatment would normally be recorded in doctors' notes and/or hospital records.  However, if these records have been destroyed or can no longer be obtained and there is a reliable history of myocarditis at a particular time, this generally will be accepted, unless there is contradictory evidence.  Obtain medical advice if it is unclear whether the claimed symptoms and treatment at that time can be attributed to myocarditis rather than to some other condition

14890 there is some evidence that myocarditis may be a factor in the development of the condition under consideration.

14895 the veteran has had myocarditis at some time.

14896  the veteran has established the causal connection between myocarditis and VEA service for the clinical onset of atrial fibrillation.

14898   the veteran has established the causal connection between myocarditis and eligible service for the clinical onset of atrial fibrillation.

or

14897   the veteran has established the causal connection between myocarditis and operational service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [14897]

14899 the veteran was suffering from myocarditis within the 30 days immediately before the clinical onset of the condition under consideration.

14901  the myocarditis is causally related to operational service.

Clinical onset and eligible service [14898]

14900 the veteran was suffering from myocarditis at the time of the clinical onset of the condition under consideration.

14903  the myocarditis is causally related to eligible service.

Atrial fibrillation and atrial flutter - Pericarditis Factor

Pericarditis is an inflammation of the pericardium. The pericardium is the fibroserous sac that surrounds the heart and the roots of the great vessels, comprising an external layer of fibrous tissue and an inner serous layer. The base of the pericardium is attached to the central tendon of the diaphragm.

Chronic pericarditis is symptomless but acute pericarditis causes chest pain, shortness of breath, fever, pericardial rub, ECG changes or X-ray changes.

There are many causes of pericarditis.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [14885]

14892 there is some evidence that pericarditis may be a factor in the development of the condition under consideration.

10941 the veteran has suffered from pericarditis at some time.

10942 the veteran suffered from pericarditis as a consequence of an illness or injury which is identifiable.

10943 as a consequence of the identified illness or injury, the veteran suffered from pericarditis within the 30 days immediately before the clinical onset of the condition under consideration.

10944  the veteran has established the causal connection between the pericarditis and operational service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10944]

10945  the identified illness or injury which caused the pericarditis is causally related to operational service.

Atrial fibrillation and atrial flutter - Strenuous physical activity Factor

RMA definition

Strenuous physical activity means physical activity greater than 11 METs, where a “MET” is a unit of measurement of the level of physical exertion. 1 MET=3.5ml of oxygen/kg of body weight per minute or, 1.0 kcal/kg of body weight per hour, or resting metabolic rate.

Further information

In general, physical activity greater then 11METs would only be regularly engaged in by athletes participating in regular and long term competitive (vigorous) sporting activities.  For example, competitive tennis might involve 10-13 METs whereas social tennis would be only 6-7 METs; jogging and running might be anywhere from 9 METs to 11-12 METs depending how fast someone was going.

MET ratings for common activities

Last reviewed for CCPS 16 July 2003.

Investigative Documents

Type	Title	PDF Format	Word Format
Claimant Report	Strenuous Physical Activity - Atrial Fibrillation	CR9227.pdf [13]	CR9227.docx [14]

Preliminary questions [14889]

14894 there is some evidence that strenuous physical activity may be a factor in the development of the condition under consideration.

10956  the veteran has established the causal connection between strenuous physical activity and operational service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [10956]

10970 the veteran undertook strenuous physical activity for an average duration of at least three hours per week for a minimum of 40 weeks per year during each year for at least five consecutive years.

10971 the veteran undertook strenuous physical activity for an average duration of at least three hours per week for a minimum of 40 weeks per year during each year for at least five consecutive years before the clinical onset of the condition under consideration.

10972 where the veteran undertook strenuous physical activity for an average duration of at least three hours per week for a minimum of 40 weeks per year during each year for at least five consecutive years and that activity has ceased, the clinical onset of atrial fibrillation occurred within five years of cessation.

10973 the veteran's operational service made a material contribution to the reasonable hypothesis Statement of Principles requirements for undertaking strenuous physical activity before the clinical onset of atrial fibrillation.

Atrial fibrillation and atrial flutter - Valvular heart disease Factor

Valvular heart disease means any dysfunction or abnormality of one or more of the heart’s four valves ie aortic, mitral, tricuspid or pulmonic valves.

Valvular heart disease would have needed significant medical attention at some time, although medical attention may not have been sought until symptoms had been present for some time.  Such medical treatment would normally be recorded in doctors' notes and/or hospital records.  Seek medical advice if it is unclear whether claimed symptoms and treatment at a particular time can be attributed to valvular heart disease rather than to some other condition.

Valvular heart disease can be congenital, or may be due to other medical conditions such as rheumatic fever. Valvular heart disease can involve:

• mitral stenosis (MS) which produces dyspnoea (shortness of breath) and cough with exertion, excitement, fever, severe anaemia or pregnancy. Almost always caused by previous rheumatic fever;
• mitral regurgitation (MR) causing fatigue, exertional dyspnoea and orthopnoea (dysnoea when lying down). Also known as Mitral Insufficiency or Mitral Incompetence;
• mitral valve prolapse (MVP) is usually asymptomatic and is also known as Systolic Click Murmur Syndrome, Barlow’s syndrome, Click Late Systolic Murmur Syndrome, Billowing Mitral Valve Syndrome or Ballooned Valve Syndrome;
• aortic stenosis (AS) which may exist for many years before producing symptoms of dysnoea on exertion, angina pectoris (chest pain) and exertional syncope (fainting). Almost always considered congenital unless there is concomitant rheumatic fever;
• aortic regurgitation (AR) with awareness of the patient's own heartbeat, exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea and diaphoresis (perspiration). Also known as Aortic Incompetence or Aortic Insufficiency;
• tricuspid stenosis (TS) which usually is associated with rheumatic fever and a preceding mitral stenosis - many patients initially have symptoms of pulmonary congestion;
• tricuspid regurgitation (TR) is usually seen in the late stages of heart failure due to rheumatic heart disease with severe pulmonary hypertension.  The neck veins are distended and there may be marked hepatomegaly (enlargement of the liver), ascites (accumulation of fluid in the abdominal cavity), pleural effusions (fluid in the chest) and oedema (excessive fluid). Also known as Tricuspid Incompetence or Isufficiency;
• pulmonic valve stenosis is a congenital condition.

Last reviewed for CCPS 16 July 2003.

Preliminary questions [14867]

14870 the veteran has suffered from valvular heart disease at some time.

14871  valvular heart disease means any dysfunction or abnormality of one or more of the heart's four valves ie aortic, mitral, tricuspid or pulmonic valves.

14872 the veteran suffered from the identified illness or injury, a valvular heart disease, at the time of the clinical onset of atrial fibrillation.

14873  the veteran has established the causal connection between the identified illness or injury, a valvular heart disease, and VEA service for the clinical onset of atrial fibrillation.

14874   the veteran has established the causal connection between the identified illness or injury, a valvular heart disease, and operational service for the clinical onset of atrial fibrillation.

or

14875   the veteran has established the causal connection between the identified illness or injury, a valvular heart disease, and eligible service for the clinical onset of atrial fibrillation.

Clinical onset and operational service [14874]

14876  the identified illness or injury, a valvular heart disease, is causally related to operational service.

Clinical onset and eligible service [14875]

14877  the identified illness or injury, a valvular heart disease, is causally related to eligible service.