ࡱ> {}zq` y7bjbjqPqP 4l::.nnnnnnn&0&0&08^0$0_J*:1L2(t2t2t2356PIIIIIII$KhM$Jn63366Jnnt2t2hJ$>$>$>6nt2nt2FI$>6I$>$>nBpnnEt2.1 k-&0t9.E El/J0_JNEhPX;tP@EPnE$66$>66666JJ=X666_J6666 &0&0nnnnnn Section E. Cardiovascular System Conditions  PRIVATE INFOTYPE="OTHER" Overview In this SectionThis section contains the following topics: TopicTopic NameSee Page20Heart Conditions4-E-221Residuals of Cold Injuries4-E-7 20. Heart Conditions  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about heart conditions, including definition of the term congenital heart defect definition of the term arteriosclerotic heart disease granting service connection for arteriosclerotic heart disease rating hypertension considering a diagnosis of pre-hypertension considering the long term effects of hypertension granting service connection arteriosclerotic manifestations due to hypertension effects of rheumatic heart disease rheumatic heart disease coexisting with hypertensive or arteriosclerotic heart disease, and considering conditions subsequent to amputation. Change DateAugust 3, 2009 a. Definition: Congenital Heart DefectCongenital heart defects include common heart conditions due to prenatal influences, such as patent foramen ovale patent ductus arteriosus coarctation of the aorta, and intraventricular septal defect. b. Definition: Arteriosclerotic Heart DiseaseArteriosclerotic heart disease, also diagnosed as ischemic heart disease and coronary heart disease, is a disease of the heart caused by the diminution of blood supply to the heart muscle due to narrowing of the cavity of one or both coronary arteries due to the accumulation of fatty material on the inner lining of the arterial wall.Continued on next page styleref "Map Title"20. Heart Conditions, Continued c. Granting Service Connection for Arteriosclerotic Heart DiseaseGrant service connection for any sudden development during service of coronary occlusion or thrombosis. Notes: The mere identification of coronary heart disease upon routine examination early in service is not a basis for service connection. Under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_6.DOC" 38 CFR 3.6(a), inactive duty for training qualifies as active service if an individual becomes disabled or dies from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. d. Rating Hypertension Evaluate hypertension separately from hypertensive heart disease and other types of heart disease. Evaluate hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, or the elevation of systolic or diastolic blood pressure due to nephritis, as part of the condition causing it rather than by a separate evaluation. However, a separate evaluation for hypertension may be awarded when the sole renal disability is the absence of a kidney, or the requirement of regular dialysis. Notes: The cause of hypertension is unknown in the vast majority of cases. Do not establish service connection for hypertension if the evidence does not contain readings specified in  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_104.DOC" 38 CFR 4.104, Diagnostic Code 7101, Note 1. Reference: For more information on hypertension and nephritis, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_115.DOC" 38 CFR 4.115.Continued on next page  STYLEREF "Map Title" 20. Heart Conditions, Continued e. Considering a Diagnosis of Pre-HypertensionPre-hypertension is not considered a ratable disability for VA purposes. When an examiner diagnoses pre-hypertension based on readings not recognized under  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_104.DOC" Diagnostic Code 7101, do not return the medical examination report for clarification, or establish service connection for hypertension based on this diagnosis.  f. Considering Long Term Effects of Hypertension Hypertension may exist for years without causing symptoms so increase the cardiac load as to result in hypertrophy of the cardiac muscle or cardiac dilation and decompensation, if sufficiently severe, and cause arteriosclerosis of uneven distribution that often involves the vessels of one organ to a greater degree than those of the rest of the body, in cases where hypertension is long-standing. If the hypertension is of sufficient degree to cause significant impairment of circulation to the organ, symptoms will manifest in accordance with the organ involved, and degree of impairment.Continued on next page  STYLEREF "Map Title" 20. Heart Conditions, Continued g. Granting Service Connection for Arteriosclerotic Manifestations Due to HypertensionIf any of the following arteriosclerotic manifestations are diagnosed in a veteran with service-connected (SC) hypertension, grant service connection through the relationship to hypertension: symptoms and signs in the brain that warrant a diagnosis of cerebral arteriosclerosis or thrombosis with hemiplegia nephrosclerosis of the kidneys with impairment of renal function, or myocardial damage or coronary occlusion of the heart. Notes: Arteriosclerosis occurs with advancing age without preexisting hypertension, and may occur in some younger individuals who are predisposed to arterial changes. The existence of arteriosclerosis does not imply or indicate previous hypertension. h. Effects of Rheumatic Heart DiseaseChronic rheumatic heart disease results from single or repeated attacks of rheumatic fever that produce valvular disease, manifested by rigidity and deformity of the cusps fusion of the commissures, or shortening and fusion of the chordae tendineae. The earliest evidence of organic valvular disease is a significant murmur, and hemodynamically significant valvular lesions found on x-ray, fluoroscopy, and electrocardiogram (ECG) study, since these reveal the earliest stages of specific chamber enlargement. Note: Grant service connection for an aortic valve insufficiency that manifests without other cause after an in-service case of rheumatic fever.Continued on next page  STYLEREF "Map Title" 20. Heart Conditions, Continued i. Rheumatic Heart Disease Coexisting With Hypertensive or Arteriosclerotic Heart DiseaseAccepted medical principles do not concede an etiological relationship between rheumatic heart disease and either hypertensive or arteriosclerotic heart disease. If a veteran who is SC for rheumatic heart disease develops hypertensive or arteriosclerotic heart disease after the applicable presumptive period following military discharge, request a medical opinion to determine which condition is causing the current signs and symptoms. Notes: If the examiner is unable to separate the effects of one type of heart disease from another, the effects must be rated together. Do not extend service connection to systemic manifestations or arteriosclerosis in areas remote from the heart, since medically there is no recognized etiological relationship between rheumatic heart disease and later developing hypertensive or arteriosclerotic changes. j. Considering Conditions Subsequent to AmputationGrant service connection on a secondary basis for the following conditions that develop subsequent to the SC amputation of one lower extremity at or above the knee, or SC amputations of both lower extremities at or above the ankles: ischemic heart disease, or other cardiovascular disease, including hypertension. Reference: For more information on proximate results or secondary conditions, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_310.DOC" 38 CFR 3.310(b). 21. Residuals of Cold Injuries  PRIVATE INFOTYPE="OTHER"  IntroductionThis topic contains information about residuals of cold injury, including the general effects of injury due to cold long-term effects of exposure to cold the chronic effects of exposure to cold granting service connection for residuals of cold injuries considering cold injuries incurred during the Chosin Reservoir Campaign, and granting service connection for cold injuries incurred during the Chosin Reservoir Campaign. Change DateDecember 29, 2007 a. General Effects of Injury Due to ColdInjury due to exposure to extremely cold temperatures causes structural and functional disturbances of small blood vessels cells nerves skin, and bone. The physical effects of exposure may be acute or chronic, with immediate or latent manifestations. Examples: Exposure to damp cold temperatures (around freezing) cause frostnip and immersion or trench foot. dry cold, or temperatures well below freezing, cause frostbite with, in severe cases, loss of body parts, such as fingers, toes, earlobes, or the tip of the nose. b. Long-Term Effects of Exposure to ColdThe fact that the immediate effects of cold injury may have been characterized as acute or healed does not preclude development of disability at the original site of injury many years later.Continued on next page styleref "Map Title"21. Residuals of Cold Injuries, Continued c. Chronic Effects of Exposure to ColdVeterans with a history of cold injury may experience the following signs and symptoms at the site of the original injury: chronic fungal infection of the feet disturbances of nail growth hyperhidrosis chronic pain of the causalgia type abnormal skin color or thickness cold sensitization joint pain or stiffness Raynauds phenomenon weakness of hands or feet night pain weak or fallen arches edema numbness paresthesias breakdown or ulceration of cold injury scars vascular insufficiency, indicated by edema, shiny, atrophic skin, or hair loss, and increased risk of developing conditions, such as peripheral neuropathy squamous cell carcinoma of the skin, at the site of the scar from a cold injury, or arthritis or other bone abnormalities, such as osteoporosis, or subarticular punched-out lesions. Continued on next page styleref "Map Title"21. Residuals of Cold Injuries, Continued d. Granting Service Connection for Residuals of Cold InjuriesGrant service connection for the residuals of cold injury if the cold injury was incurred during military service, and an intercurrent nonservice-connected (NSC) cause cannot be determined. Notes: The fact that an NSC systemic disease that could produce similar findings is present, or that other areas of the body not affected by cold injury have similar findings, does not necessarily preclude service connection for residual conditions in the cold-injured areas. When considering the possibility of intercurrent cause, always resolve reasonable doubt in the veterans favor. Reference: For more information on reasonable doubt, see  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_102.DOC" 38 CFR 3.102. e. Considering Cold Injuries Incurred During the Chosin Reservoir Campaign The Chosin Reservoir Campaign was conducted during the Korean War, October 1950 through December 1950, in temperatures of 20F or lower. Many participants in this campaign suffered from frostbite for which they received no treatment and, as a result, there may be no service treatment records (STRs) to directly support their claims for frostbite. If the veterans participation in the Chosin Reservoir Campaign is confirmed, concede exposure to extreme cold under the provisions of HYPERLINK "http://straylight.law.cornell.edu/uscode/html/uscode38/usc_sec_38_00001154----000-.html"38 U.S.C. 1154(a). f. Granting Service Connection for Cold Injuries Incurred During the Chosin Reservoir Campaign Grant service connection under the provisions of  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC" 38 CFR 3.303(a) and  HYPERLINK "http://www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC" 38 CFR 3.304(d) if the veteran has a disability which is diagnosed as a residual of cold injury, and there are no other circumstances to which this disability may be attributed.     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