38 CFR § 4.104 - Schedule of ratings - cardiovascular system.

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§ 4.104 Schedule of ratings - cardiovascular system.

Diseases of the Heart

[Unless otherwise directed, use this general rating formula to evaluate diseases of the heart.]

Rating
Note (1): Evaluate cor pulmonale, which is a form of secondary heart disease, as part of the pulmonary condition that causes it.
Note (2): One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, a medical examiner may estimate the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms.
Note (3): For this general formula, heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope.
GENERAL RATING FORMULA FOR DISEASES OF THE HEART:
Workload of 3.0 METs or less results in heart failure symptoms 100
Workload of 3.1-5.0 METs results in heart failure symptoms 60
Workload of 5.1-7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging) 30
Workload of 7.1-10.0 METs results in heart failure symptoms; or continuous medication required for control 10
7000 Valvular heart disease (including rheumatic heart disease),
7001 Endocarditis, or
7002 Pericarditis:
During active infection with cardiac involvement and for three months following cessation of therapy for the active infection 100
Thereafter, with diagnosis confirmed by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization, use the General Rating Formula.
7003 Pericardial adhesions.
7004 Syphilitic heart disease:
Note: Evaluate syphilitic aortic aneurysms under DC 7110 (Aortic aneurysm: Ascending, thoracic, abdominal).
7005 Arteriosclerotic heart disease (coronary artery disease).
Note: If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, request a medical opinion as to which condition is causing the current signs and symptoms.
7006 Myocardial infarction:
During and for three months following myocardial infarction, confirmed by laboratory tests 100
Thereafter, use the General Rating Formula.
7007 Hypertensive heart disease.
7008 Hyperthyroid heart disease:
Rate under the appropriate cardiovascular diagnostic code, depending on particular findings.
For DCs 7009, 7010, 7011, and 7015, a single evaluation will be assigned under the diagnostic code that reflects the predominant disability picture.
7009 Bradycardia (Bradyarrhythmia), symptomatic, requiring permanent pacemaker implantation:
For one month following hospital discharge for implantation or re-implantation 100
Thereafter, use the General Rating Formula.
Note (1): Bradycardia (bradyarrhythmia) refers to conduction abnormalities that produce a heart rate less than 60 beats/min. There are five general classes of bradyarrhythmia: Sinus bradycardia, including sinoatrial block; atrioventricular (AV) junctional (nodal) escape rhythm; AV heart block (second or third degree) or AV dissociation; atrial fibrillation or flutter with a slow ventricular response; and, idioventricular escape rhythm.
Note (2): Asymptomatic bradycardia (bradyarrhythmia) is a medical finding only. It is not a disability subject to compensation.
7010 Supraventricular tachycardia:
Confirmed by ECG, with five or more treatment interventions per year 30
Confirmed by ECG, with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control 10
Note (1): Examples of supraventricular tachycardia include, but are not limited to: Atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia.
Note (2): For the purposes of this diagnostic code, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief.
7011 Ventricular arrhythmias (sustained):
For an indefinite period from the date of inpatient hospital admission for initial medical therapy for a sustained ventricular arrhythmia; or, for an indefinite period from the date of inpatient hospital admission for ventricular aneurysmectomy; or, with an automatic implantable cardioverter-defibrillator (AICD) in place 100
Note: When inpatient hospitalization for sustained ventricular arrhythmia or ventricular aneurysmectomy is required, a 100-percent evaluation begins on the date of hospital admission with a mandatory VA examination six months following hospital discharge. Evaluate post-surgical residuals under the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination.
7015 Atrioventricular block:
Benign (First-Degree and Second-Degree, Type I):
Evaluate under the General Rating Formula.
Non-Benign (Second-Degree, Type II and Third-Degree):
Evaluate under DC 7018 (implantable cardiac pacemakers).
7016 Heart valve replacement (prosthesis):
For an indefinite period following date of hospital admission for valve replacement 100
Thereafter, use the General Rating Formula.
Note: Six months following discharge from inpatient hospitalization, disability evaluation shall be conducted by mandatory VA examination using the General Rating Formula. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination.
7017 Coronary bypass surgery:
For three months following hospital admission for surgery 100
Thereafter, use the General Rating Formula.
7018 Implantable cardiac pacemakers:
For one month following hospital discharge for implantation or re-implantation 100
Thereafter:
Evaluate as supraventricular tachycardia (DC 7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC 7015).
Minimum 10
Note: Evaluate automatic implantable cardioverter-defibrillators (AICDs) under DC 7011.
7019 Cardiac transplantation:
For a minimum of one year from the date of hospital admission for cardiac transplantation 100
Thereafter:
Evaluate under the General Rating Formula.
Minimum 30
Note: One year following discharge from inpatient hospitalization, determine the appropriate disability rating by mandatory VA examination. Apply the provisions of § 3.105(e) of this chapter to any change in evaluation based upon that or any subsequent examination.
7020 Cardiomyopathy.
Diseases of the Arteries and Veins
7101 Hypertensive vascular disease (hypertension and isolated systolic hypertension):
Diastolic pressure predominantly 130 or more 60
Diastolic pressure predominantly 120 or more 40
Diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more 20
Diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication for control 10
Note (1): Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm.
Note (2): Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation.
Note (3): Evaluate hypertension separately from hypertensive heart disease and other types of heart disease.
7110 Aortic aneurysm: Ascending, thoracic, or abdominal:
Evaluate at 100 percent if the aneurysm is any one of the following: Five centimeters or larger in diameter; symptomatic (e.g., precludes exertion); or requires surgery 100
Otherwise 0
Evaluate non-cardiovascular residuals of surgical correction according to organ systems affected.
Note: When surgery is required, a 100-percent evaluation begins on the date a physician recommends surgical correction with a mandatory VA examination six months following hospital discharge. Evaluate post-surgical residuals under the General Rating Formula. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter.
7111 Aneurysm, any large artery:
If symptomatic; or, for the period beginning on the date a physician recommends surgical correction and continuing for six months following discharge from inpatient hospital admission for surgical correction 100
Following surgery: Evaluate under DC 7114 (peripheral arterial disease).
Note: Six months following discharge from inpatient hospitalization for surgery, determine the appropriate disability rating by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter.
7112 Aneurysm, any small artery:
Asymptomatic 0
Note: If symptomatic, evaluate according to body system affected. Following surgery, evaluate residuals under the body system affected.
7113 Arteriovenous fistula, traumatic:
With high-output heart failure 100
Without heart failure but with enlarged heart, wide pulse pressure, and tachycardia 60
Without cardiac involvement but with chronic edema, stasis dermatitis, and either ulceration or cellulitis:
Lower extremity 50
Upper extremity 40
Without cardiac involvement but with chronic edema or stasis dermatitis:
Lower extremity 30
Upper extremity 20
7114 Peripheral arterial disease:
At least one of the following: Ankle/brachial index less than or equal to 0.39; ankle pressure less than 50 mm Hg; toe pressure less than 30 mm Hg; or transcutaneous oxygen tension less than 30 mm Hg 100
At least one of the following: Ankle/brachial index of 0.40-0.53; ankle pressure of 50-65 mm Hg; toe pressure of 30-39 mm Hg; or transcutaneous oxygen tension of 30-39 mm Hg 60
At least one of the following: Ankle/brachial index of 0.54-0.66; ankle pressure of 66-83 mm Hg; toe pressure of 40-49 mm Hg; or transcutaneous oxygen tension of 40-49 mm Hg 40
At least one of the following: Ankle/brachial index of 0.67-0.79; ankle pressure of 84-99 mm Hg; toe pressure of 50-59 mm Hg; or transcutaneous oxygen tension of 50-59 mm Hg 20
Note (1): The ankle/brachial index (ABI) is the ratio of the systolic blood pressure at the ankle divided by the simultaneous brachial artery systolic blood pressure. For the purposes of this diagnostic code, normal ABI will be greater than or equal to 0.80. The ankle pressure (AP) is the systolic blood pressure measured at the ankle. Normal AP is greater than or equal to 100 mm Hg. The toe pressure (TP) is the systolic blood pressure measured at the great toe. Normal TP is greater than or equal to 60 mm Hg. Transcutaneous oxygen tension (TcPO2) is measured at the first intercostal space on the foot. Normal TcPO2 is greater than or equal to 60 mm Hg. All measurements must be determined by objective testing.
Note (2): If AP, TP, and TcPO2 testing are not of record, evaluate based on ABI unless the examiner states that an AP, TP, or TcPO2 test is needed in a particular case because ABI does not sufficiently reflect the severity of the veteran's peripheral arterial disease. In all other cases, evaluate based on the test that provides the highest impairment value
Note (3): Evaluate residuals of aortic and large arterial bypass surgery or arterial graft as peripheral arterial disease.
Note (4): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable.
7115 Thrombo-angiitis obliterans (Buerger's Disease):
Lower extremity: Rate under DC 7114.
Upper extremity:
Deep ischemic ulcers and necrosis of the fingers with persistent coldness of the extremity, trophic changes with pains in the hand during physical activity, and diminished upper extremity pulses 100
Persistent coldness of the extremity, trophic changes with pains in the hands during physical activity, and diminished upper extremity pulses 60
Trophic changes with numbness and paresthesia at the tips of the fingers, and diminished upper extremity pulses 40
Diminished upper extremity pulses 20
Note (1): These evaluations involve a single extremity. If more than one extremity is affected, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable.
Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities).
7117 Raynaud's syndrome (also known as secondary Raynaud's phenomenon or secondary Raynaud's):
With two or more digital ulcers plus auto-amputation of one or more digits and history of characteristic attacks 100
With two or more digital ulcers and history of characteristic attacks 60
Characteristic attacks occurring at least daily 40
Characteristic attacks occurring four to six times a week 20
Characteristic attacks occurring one to three times a week 10
Note (1): For purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for Raynaud's syndrome as a whole, regardless of the number of extremities involved or whether the nose and ears are involved.
Note (2): This section is for evaluating Raynaud's syndrome (secondary Raynaud's phenomenon or secondary Raynaud's). For evaluation of Raynaud's disease (primary Raynaud's), see DC 7124.
7118 Angioneurotic edema:
Attacks without laryngeal involvement lasting one to seven days or longer and occurring more than eight times a year, or; attacks with laryngeal involvement of any duration occurring more than twice a year 40
Attacks without laryngeal involvement lasting one to seven days and occurring five to eight times a year, or; attacks with laryngeal involvement of any duration occurring once or twice a year 20
Attacks without laryngeal involvement lasting one to seven days and occurring two to four times a year 10
7119 Erythromelalgia:
Characteristic attacks that occur more than once a day, last an average of more than two hours each, respond poorly to treatment, and that restrict most routine daily activities 100
Characteristic attacks that occur more than once a day, last an average of more than two hours each, and respond poorly to treatment, but that do not restrict most routine daily activities 60
Characteristic attacks that occur daily or more often but that respond to treatment 30
Characteristic attacks that occur less than daily but at least three times a week and that respond to treatment 10
Note: For purposes of this section, a characteristic attack of erythromelalgia consists of burning pain in the hands, feet, or both, usually bilateral and symmetrical, with increased skin temperature and redness, occurring at warm ambient temperatures. These evaluations are for the disease as a whole, regardless of the number of extremities involved.
7120 Varicose veins:
Evaluate under diagnostic code 7121.
7121 Post-phlebitic syndrome of any etiology:
With the following findings attributed to venous disease:
Massive board-like edema with constant pain at rest 100
Persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration 60
Persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration 40
Persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema 20
Intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery 10
Asymptomatic palpable or visible varicose veins 0
Note: These evaluations are for involvement of a single extremity. If more than one extremity is involved, evaluate each extremity separately and combine (under § 4.25), using the bilateral factor (§ 4.26), if applicable.
7122 Cold injury residuals:
With the following in affected parts:
Arthralgia or other pain, numbness, or cold sensitivity plus two or more of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome 30
Arthralgia or other pain, numbness, or cold sensitivity plus one of the following: Tissue loss, nail abnormalities, color changes, locally impaired sensation, hyperhidrosis, anhydrosis, X-ray abnormalities (osteoporosis, subarticular punched-out lesions, or osteoarthritis), atrophy or fibrosis of the affected musculature, flexion or extension deformity of distal joints, volar fat pad loss in fingers or toes, avascular necrosis of bone, chronic ulceration, carpal or tarsal tunnel syndrome 20
Arthralgia or other pain, numbness, or cold sensitivity 10
Note (1): Separately evaluate amputations of fingers or toes, and complications such as squamous cell carcinoma at the site of a cold injury scar or peripheral neuropathy, under other diagnostic codes. Separately evaluate other disabilities diagnosed as the residual effects of cold injury, such as Raynaud's syndrome (which is otherwise known as secondary Raynaud's phenomenon), muscle atrophy, etc., unless they are used to support an evaluation under diagnostic code 7122.
Note (2): Evaluate each affected part (e.g., hand, foot, ear, nose) separately and combine the ratings in accordance with §§ 4.25 and 4.26.
7123 Soft tissue sarcoma (of vascular origin) 100
Note: A rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, rate on residuals.
7124 Raynaud's disease (also known as primary Raynaud's):
Characteristic attacks associated with trophic change(s), such as tight, shiny skin 10
Characteristic attacks without trophic change(s) 0
Note (1): For purposes of this section, characteristic attacks consist of intermittent and episodic color changes of the digits of one or more extremities, lasting minutes or longer, with occasional pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved.
Note (2): Trophic changes include, but are not limited to, skin changes (thinning, atrophy, fissuring, ulceration, scarring, absence of hair) as well as nail changes (clubbing, deformities).
Note (3): This section is for evaluating Raynaud's disease (primary Raynaud's). For evaluation of Raynaud's syndrome (also known as secondary Raynaud's phenomenon, or secondary Raynaud's), see DC 7117.
(Authority: 38 U.S.C. 1155)
[62 FR 65219, Dec. 11, 1997, as amended at 63 FR 37779, July 14, 1998; 71 FR 52460, Sept. 6, 2006; 79 FR 2100, Jan. 13, 2014; 82 FR 50804, Nov. 2, 2017; 86 FR 54093, Sept. 30, 2021; 86 FR 62095, Nov. 9, 2021]

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