Statement of Principles concerning ischaemic heart disease No. 89 of 2007

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Statement of Principles
concerning
 
ISCHAEMIC HEART DISEASE
No. 89 of 2007
 
for the purposes of the
 
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
           
Title
1.                  This Instrument may be cited as Statement of Principles concerning ischaemic heart disease No. 89 of 2007.
 
Determination
2.                  The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a)       revokes Instrument No. 53 of 2003, as amended by Instrument No. 9 of 2004, concerning ischaemic heart disease; and
(b)       determines in their place this Statement of Principles.
 
Kind of injury, disease or death
3.         (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 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 paragraph 3(b) above.
 
Basis for determining the factors
4.         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 under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
 
Factors that must be related to service
5.         Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
 
Factors
6.         The factor 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 is:
 
(a)               having hypertension before the clinical onset of ischaemic heart disease; or
 
(b)              having diabetes mellitus before the clinical onset of ischaemic heart disease; or
 
(c)              being obese for at least five years before the clinical onset of ischaemic heart disease; or
 
(d)              for males, having a waist to hip circumference ratio exceeding 1.0 for at least five years, before the clinical onset of ischaemic heart disease; or
 
(e)              for females, having a waist to hip circumference ratio exceeding 0.9 for at least five years, before the clinical onset of ischaemic heart disease; or
 
(f)               having dyslipidaemia before the clinical onset of ischaemic heart disease; or
 
(g)              where smoking has ceased prior to the clinical onset of ischaemic heart disease:
(i)                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 smoking cessation; or
(ii)             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 smoking cessation; or
(iii)           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
 
(h)              where smoking has not ceased prior to the clinical onset of ischaemic heart disease:
(i)                smoking an average of at least five cigarettes per day or the equivalent thereof in other tobacco products, for at least the one year before the clinical onset of ischaemic heart disease; or
(ii)             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
 
(i)                being in an atmosphere with a visible tobacco smoke haze in an enclosed space for at least 1000 hours before the clinical onset of ischaemic heart disease, where the last exposure to that atmosphere did not occur more than five years before the clinical onset of ischaemic heart disease; or
 
(j)                an inability to undertake any physical activity greater than three METs for at least the five years before the clinical onset of ischaemic heart disease; or
 
(k)              having hyperhomocysteinaemia before the clinical onset of ischaemic heart disease; or
 
(l)                having chronic renal disease before the clinical onset of ischaemic heart disease; or
 
(m)            having hypothyroidism before the clinical onset of ischaemic heart disease; or
 
(n)              inhaling or having cutaneous contact with products containing nitroglycerine or nitroglycol:
(i)                each day for at least 20 days within a consecutive period of 30 days, before the clinical onset of ischaemic heart disease; and
(ii)             where the last inhalation or contact occurred not more than 14 days before the clinical onset of ischaemic heart disease; or
 
(o)              having clinically significant depressive disorder for at least five years, 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 a combined oral contraceptive pill for at least the 21 days before the clinical onset of ischaemic heart disease; or
 
(r)               having a haematological disorder from the specified list of haematological disorders that are associated with a hypercoagulable state at the time of the clinical onset of ischaemic heart disease; or
 
(s)               using amphetamines or amphetamine-like compounds, within the 24 hours before the clinical onset of ischaemic heart disease; or
 
(t)                using a drug from the specified list within the 72 hours before the clinical onset of ischaemic heart disease; or
 
(u)              using a drug belonging to the nonsteroidal anti-inflammatory class of drugs, excluding aspirin, for a continuous period of at least seven days before the clinical onset of ischaemic heart disease, and where the last dose of the drug was taken within the seven days before the clinical onset of ischaemic heart disease; or
 
(v)               for angina, acute myocardial infarction or sudden death from ischaemic heart disease only:
(i)                experiencing a category 1A stressor within the 48 hours before the clinical onset of ischaemic heart disease; or
 
(ii)             experiencing a category 1B stressor within the 48 hours before the clinical onset of ischaemic heart disease; or
 
(iii)           experiencing the death of a significant other within the 12 months before the clinical onset of ischaemic heart disease; or
 
(iv)            having panic disorder within the 12 months before the clinical onset of ischaemic heart disease; or
 
(v)               having phobic anxiety with panic attack within the 12 months before the clinical onset of ischaemic heart disease; or
 
(w)             having hypertension before the clinical worsening of ischaemic heart disease; or
 
(x)              having diabetes mellitus before the clinical worsening of ischaemic heart disease; or
 
(y)              being obese for at least five years before the clinical worsening of ischaemic heart disease; or
 
(z)               for males, having a waist to hip circumference ratio exceeding 1.0 for at least five years, before the clinical worsening of ischaemic heart disease; or
 
(aa)           for females, having a waist to hip circumference ratio exceeding 0.9 for at least five years, before the clinical worsening of ischaemic heart disease; or
 
(bb)          having dyslipidaemia before the clinical worsening of ischaemic heart disease; or
 
(cc)          where smoking has ceased prior to the clinical worsening of ischaemic heart disease:
(i)              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 smoking cessation; or
(ii)           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 smoking cessation; or
(iii)         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
 
(dd)          where smoking has not ceased prior to the clinical worsening of ischaemic heart disease:
(i)               smoking an average of at least five cigarettes per day or the equivalent thereof in other tobacco products, for at least the one year before the clinical worsening of ischaemic heart disease; or
(ii)             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
(ee)          being in an atmosphere with a visible tobacco smoke haze in an enclosed space for at least 1000 hours before the clinical worsening of ischaemic heart disease, where the last exposure to that atmosphere did not occur more than five years before the clinical worsening of ischaemic heart disease; or
 
(ff)            an inability to undertake any physical activity greater than three METs for at least the five years before the clinical worsening of ischaemic heart disease; or
 
(gg)          having hyperhomocysteinaemia before the clinical worsening of ischaemic heart disease; or
 
(hh)          having chronic renal disease before the clinical worsening of ischaemic heart disease; or
 
(ii)             having hypothyroidism before the clinical worsening of ischaemic heart disease; or
 
(jj)             inhaling or having cutaneous contact with products containing nitroglycerine or nitroglycol:
(i)               each day for at least 20 days within a consecutive period of 30 days, before the clinical worsening of ischaemic heart disease; and
(ii)             where the last inhalation or contact occurred not more than 14 days before the clinical worsening of ischaemic heart disease; or
 
(kk)          having clinically significant depressive disorder for at least five years, before the clinical worsening of ischaemic heart disease; or
 
(ll)             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
 
(mm)     using the combined oral contraceptive pill for at least the 21 days before the clinical worsening of ischaemic heart disease; or
 
(nn)          having a haematological disorder from the specified list of haematological disorders that are associated with a hypercoagulable state, at the time of the clinical worsening of ischaemic heart disease; or
 
(oo)         using amphetamines or amphetamine-like compounds, within the 24 hours before the clinical worsening of ischaemic heart disease; or
 
(pp)          using a drug from the specified list within the 72 hours before the clinical worsening of ischaemic heart disease; or
 
(qq)          using a drug belonging to the nonsteroidal anti-inflammatory class of drugs, excluding aspirin, for a continuous period of at least seven days before the clinical worsening of ischaemic heart disease, and where the last dose of the drug was taken within the seven days before the clinical worsening of ischaemic heart disease; or
 
(rr)            for angina, acute myocardial infarction or sudden death from ischaemic heart disease only:
(i)                experiencing a category 1A stressor within the 48 hours before the clinical worsening of ischaemic heart disease; or
 
(ii)             experiencing a category 1B stressor within the 48 hours before the clinical worsening of ischaemic heart disease; or
 
(iii)           experiencing the death of a significant other within the 12 months before the clinical worsening of ischaemic heart disease; or
 
(iv)            having panic disorder within the 12 months before the clinical worsening of ischaemic heart disease; or
 
(v)               having phobic anxiety with panic attack within the 12 months before the clinical worsening of ischaemic heart disease; or
 
(ss)           inability to obtain appropriate clinical management for ischaemic heart disease.
 
Factors that apply only to material contribution or aggravation
7.         Paragraphs 6(w) to 6(ss) 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.
 
Inclusion of Statements of Principles
8.         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 as in force from time to time.
 
Other definitions
9.                  For the purposes of this Statement of Principles:
 
"a category 1A stressor" means one or more of the following severe traumatic events:
(a)               experiencing a life-threatening event;
(b)              being subject to a serious physical attack or assault including rape and sexual molestation; or
(c)              being threatened with a weapon, being held captive, being kidnapped, or being tortured;
 
"a category 1B stressor" means one of the following severe traumatic events:
(a)               being an eyewitness to a person being killed or critically injured;
(b)              viewing corpses or critically injured casualties as an eyewitness;
(c)              being an eyewitness to atrocities inflicted on another person or persons;
(d)              killing or maiming a person; or
(e)              being an eyewitness to or participating in, the clearance of critically injured casualties;
 
"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;
 
"a drug from the specified list" means:
(a)               cocaine;
(b)              D-lysergic acid diethylamide (LSD);
(c)              heroin;
(d)              marijuana; or
(e)              phencyclidine (angel dust);
 
"a haematological disorder from the specified list of haematological disorders that are associated with a hypercoagulable state" means:
(a)               antiphospholipid antibody syndrome;
(b)              disseminated intravascular coagulation;
(c)              heparin-induced thrombocytopaenia and thrombosis;
(d)              hyperproteinaemia;
(e)              hyperviscosity syndrome;
(f)               inherited coagulation protein disorders associated with hypercoagulability;
(g)              myeloproliferative disease;
(h)              primary or secondary polycythaemia;
(i)                primary or secondary thrombocytosis;
(j)                sickle-cell disease; or
(k)              thrombotic thrombocytopaenic purpura;
 
"a significant other" means a person who has a close family bond or a close personal relationship and is important or influential in one’s life;
 
"amphetamines or amphetamine-like compounds" means one of the following drugs:
(a)               3,4-methylenedioxymethamphetamine (ecstasy);
(b)              dextroamphetamine;
(c)              ephedrine;
(d)              methamphetamine;
(e)              methylphenidate (Ritalin);
(f)               phendimetrazine;
(g)              phentermine;
(h)              phenylpropanolamine; or
(i)                pseudoephedrine;
 
"an eyewitness" means a person who observes an incident first hand and can give direct evidence of it. This excludes a person exposed only to media coverage of the incident;
 
"being obese" means an increase in body weight by way of fat accumulation which results in a Body Mass Index (BMI) of thirty 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;
 
"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-TR" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.  Washington, DC, American Psychiatric Association, 2000.
 
"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)           serum triglyceride level greater than or equal to 2.0 mmol/L; or
(c)           having a high density lipoprotein cholesterol level less than 1.0 mmol/L;
 
"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), Fifth Edition, effective date of 1 July 2006, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 772 3;
 
"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 year 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 7300 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 7300 cigarettes, or 7.3 kg of smoking tobacco by weight. Tobacco products means either cigarettes, pipe tobacco or cigars smoked, alone or in any combination;
 
"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 7300 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 7300 cigarettes, or 7.3 kg of smoking tobacco by weight. Tobacco products means either cigarettes, pipe tobacco or cigars smoked, alone or in any combination;
 
"panic attack" means 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:
(a)               palpitations, pounding heart, or accelerated heart rate;
(b)              sweating;
(c)              trembling or shaking;
(d)              sensations of shortness of breath or smothering;
(e)              feeling of choking;
(f)               chest pain or discomfort;
(g)              nausea or abdominal distress;
(h)              feeling dizzy, unsteady, light headed or faint;
(i)                derealisation (feelings of unreality) or depersonalisation (being detached from oneself);
(j)                fear of losing control or going crazy;
(k)              fear of dying;
(l)                paraesthesias (numbness or tingling sensations); or
(m)            chills or hot flushes.
This definition is derived from DSM-IV-TR;
 
"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 under the VEA;
(b)     peacekeeping service under the VEA;
(c)          hazardous service under the VEA;
(d)          warlike service under the MRCA; or
(e)          non-warlike service under the MRCA;
 
"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
10.       This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
 
Date of effect
11.       This Instrument takes effect from 19 September 2007.
 
Dated this       fifth         day of              September           2007
 
 
The Common Seal of the                  )
Repatriation Medical Authority       )
was affixed to this instrument          )
in the presence of:                            )
 
KEN DONALD
CHAIRPERSON

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