Statement of Principles concerning hypertension (Reasonable Hypothesis) (No. 21 of 2022) (Cth)

Statement of Principles concerning HYPERTENSION (Reasonable Hypothesis) (No. 21 of 2022) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 4 March 2022

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:

Professor Terence Campbell AM Chairperson

Contents 1 Name 2 Commencement 3 Authority 4 Repeal 5 Application 6 Schedules 7 Kind of injury, disease or death to which this Statement of Principles relates 8 Basis for determining the factors 9 Factors that must exist 10 Relationship to service 11 Factors referring to an injury or disease covered by another Statement of Principles Schedule 1 - Dictionary 1 Definitions Schedule 2 - Drugs 1 Specified Drugs

1 Name This is the Statement of Principles concerning hypertension (Reasonable Hypothesis) (No. 21 of 2022). 2 Commencement This instrument commences on 4 April 2022. 3 Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning hypertension No. 63 of 2013 (Federal Register of Legislation No. F2013L01652) made under subsections 196B(2) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Schedules Any item in a Schedule to this Instrument has effect according to its terms. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about hypertension and death from hypertension. Meaning of hypertension (2) For the purposes of this Statement of Principles, hypertension: (a) means persistently elevated blood pressure, where that persistent elevation in blood pressure has been diagnosed by a medical practitioner and evidenced by: (i) a usual clinic blood pressure reading of greater than or equal to 140 mmHg systolic or greater than or equal to 90 mmHg diastolic, or equivalent levels using ambulatory blood pressure measurement; or (ii) a usual home blood pressure reading of greater than or equal to 135 mmHg systolic or greater than or equal to 85 mmHg diastolic; or (iii) for persons aged under 18 years, a usual systolic or diastolic blood pressure reading of greater than or equal to the 95th centile for age and sex; or (iv) the regular administration of antihypertensive therapy to reduce blood pressure; and (b) excludes temporary elevations in blood pressure from conditions such as acute renal failure, neurogenic hypertension, eclampsia, pre-eclampsia, gestational hypertension and medications. Note: equivalent levels using ambulatory blood pressure measurement is defined in the Schedule 1 - Dictionary. (3) While hypertension attracts ICD‑10‑AM code I10 or I15, in applying this Statement of Principles the meaning of hypertension is that given in subsection (2). (4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4. Death from hypertension (5) For the purposes of this Statement of Principles, hypertension, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's hypertension. Note: terminal event is defined in the Schedule 1 - Dictionary. 8 Basis for determining the factors The Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that hypertension and death from hypertension 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 MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary. 9 Factors that must exist At least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting hypertension or death from hypertension with the circumstances of a person's relevant service: (1) being overweight or obese for at least the 5 years before the clinical onset of hypertension; Note: being overweight or obese is defined in the Schedule 1 - Dictionary. (2) consuming an average of at least 250 grams of alcohol per week for a continuous period of at least the 6 months before the clinical onset of hypertension; Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink. (3) consuming an average of at least 9 grams (150 millimoles) of salt per day for at least the 1 year before the clinical onset of hypertension; Note: Sodium-containing medications may contribute to daily salt intake. Sodium-containing medications include the effervescent or soluble version of standard medicines, such as acetaminophen, ascorbic acid, aspirin, calcium carbonate, ibuprofen, sodium bicarbonate and zinc sulphate. (4) having renal artery stenosis at the time of the clinical onset of hypertension; Note: Causes of renal artery stenosis include renal artery atherosclerotic disease and fibromuscular dysplasia. (5) having a solid organ, stem cell or bone marrow transplant before the clinical onset of hypertension; (6) having diabetes mellitus for at least the 5 years before the clinical onset of hypertension; (7) having chronic kidney disease at the time of the clinical onset of hypertension; Note: chronic kidney disease is defined in the Schedule 1 - Dictionary. (8) having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical onset of hypertension; Note: specified list of endocrine disorders is defined in the Schedule 1 - Dictionary. (9) having sleep apnoea at the time of the clinical onset of hypertension; (10) having extrinsic compression of the renal parenchyma from a haematoma or mass at the time of the clinical onset of hypertension; (11) having: (a) an aneurysm of the renal artery; or (b) an arteriovenous fistula involving the blood supply of the kidney; or (c) an arteriovenous malformation involving the blood supply of the kidney; before the clinical onset of hypertension; (12) having a clinically significant disorder of mental health as specified at the time of the clinical onset of hypertension; Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 – Dictionary. (13) having gout or hyperuricaemia at the time of the clinical onset of hypertension; Note: hyperuricaemia is defined in the Schedule 1 – Dictionary. (14) taking a drug specified in the Schedule 2 - Drugs of this Instrument, where that drug cannot be ceased or substituted, for a continuous period of at least the 28 days before the clinical onset of hypertension; (15) taking a drug from the Specified List 1 of drugs at the time of the clinical onset of hypertension; Note: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary. (16) having glucocorticoid therapy as specified before the clinical onset of hypertension, and if the glucocorticoid therapy as specified has ceased or decreased before the clinical onset of hypertension, then that onset occurred within 30 days of cessation or reduction of therapy; Note: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary. (17) taking medroxyprogesterone acetate or megestrol acetate for a malignant disease or human immunodeficiency virus infection: (a) for at least 28 days before the clinical onset of hypertension; and (b) if treatment has ceased before the clinical onset of hypertension, then that onset occurred within 30 days of cessation; (18) inability to undertake any physical activity greater than 3 METs for at least the 1 year before the clinical onset of hypertension; Note: MET is defined in the Schedule 1 - Dictionary. (19) being exposed to arsenic as specified before the clinical onset of hypertension; Note: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary. (20) undergoing a course of therapeutic radiation for cancer, where the whole body was in the field of radiation, at least 1 year before the clinical onset of hypertension; (21) having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the whole body at least 1 year before the clinical onset of hypertension; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. (22) inhaling, ingesting or having cutaneous contact with the phenoxy acid herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) or 2,4,5-trichlorophenoxyacetic acid (2,4,5-T): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and if that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation; (23) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and if that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation; Note: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary. (24) inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl: (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and if that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation; Note: inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl is defined in the Schedule 1 – Dictionary. (25) inhaling ambient, chronically polluted air as specified for at least 1 year, within the 2 years before the clinical onset of hypertension; Note: ambient, chronically polluted air as specified is defined in the Schedule 1 – Dictionary. (26) being overweight or obese for at least the 5 years before the clinical worsening of hypertension; Note: being overweight or obese is defined in the Schedule 1 - Dictionary. (27) consuming an average of at least 250 grams of alcohol per week for a continuous period of at least the 6 months before the clinical worsening of hypertension; Note: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink. (28) consuming an average of at least 9 grams (150 millimoles) of salt per day for at least the 1 year before the clinical worsening of hypertension; Note: Sodium-containing medications may contribute to daily salt intake. Sodium-containing medications include the effervescent or soluble version of standard medicines, such as acetaminophen, ascorbic acid, aspirin, calcium carbonate, ibuprofen, sodium bicarbonate and zinc sulphate. (29) having renal artery stenosis at the time of the clinical worsening of hypertension; Note: Causes of renal artery stenosis include renal artery atherosclerotic disease and fibromuscular dysplasia. (30) having a solid organ, stem cell or bone marrow transplant before the clinical worsening of hypertension; (31) having diabetes mellitus for at least the 5 years before the clinical worsening of hypertension; (32) having chronic kidney disease at the time of the clinical worsening of hypertension; Note: chronic kidney disease is defined in the Schedule 1 - Dictionary. (33) having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical worsening of hypertension; Note: specified list of endocrine disorders is defined in the Schedule 1 - Dictionary. (34) having sleep apnoea at the time of the clinical worsening of hypertension; (35) having extrinsic compression of the renal parenchyma from a haematoma or mass at the time of the clinical worsening of hypertension; (36) having: (a) an aneurysm of the renal artery; or (b) an arteriovenous fistula involving the blood supply of the kidney; or (c) an arteriovenous malformation involving the blood supply of the kidney; before the clinical worsening of hypertension; (37) having a clinically significant disorder of mental health as specified at the time of the clinical worsening of hypertension; Note: clinically significant disorder of mental health as specified is defined in the Schedule 1 – Dictionary. (38) having gout or hyperuricaemia at the time of the clinical worsening of hypertension; Note: hyperuricaemia is defined in the Schedule 1 – Dictionary. (39) taking a drug specified in the Schedule 2 - Drugs of this Instrument, where that drug cannot be ceased or substituted, for a continuous period of at least the 28 days before the clinical worsening of hypertension; (40) taking a drug from the Specified List 1 of drugs at the time of the clinical worsening of hypertension; Note: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary. (41) having glucocorticoid therapy as specified before the clinical worsening of hypertension, and if the glucocorticoid therapy as specified has ceased or decreased before the clinical worsening of hypertension, then that worsening occurred within 30 days of cessation or reduction of therapy; Note: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary. (42) taking medroxyprogesterone acetate or megestrol acetate for a malignant disease or human immunodeficiency virus infection: (a) for at least 28 days before the clinical worsening of hypertension; and (b) if treatment has ceased before the clinical worsening of hypertension, then that worsening occurred within 30 days of cessation; (43) inability to undertake any physical activity greater than 3 METs for at least the 1 year before the clinical worsening of hypertension; Note: MET is defined in the Schedule 1 - Dictionary. (44) being exposed to arsenic as specified before the clinical worsening of hypertension; Note: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary. (45) undergoing a course of therapeutic radiation for cancer, where the whole body was in the field of radiation, at least 1 year before the clinical worsening of hypertension; (46) having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the whole body at least 1 year before the clinical worsening of hypertension; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. (47) inhaling, ingesting or having cutaneous contact with the phenoxy acid herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) or 2,4,5-trichlorophenoxyacetic acid (2,4,5-T): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and if that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation; (48) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and if that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation; Note: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary. (49) inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl: (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and (b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and if that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation; Note: inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl is defined in the Schedule 1 – Dictionary. (50) inhaling ambient, chronically polluted air as specified for at least 1 year, within the 2 years before the clinical worsening of hypertension; Note: ambient, chronically polluted air as specified is defined in the Schedule 1 – Dictionary. (51) inability to obtain appropriate clinical management for hypertension. 10 Relationship to service (1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person. (2) The factors set out in subsections 9(26) to 9(51) apply only to material contribution to, or aggravation of, hypertension where the person's hypertension was suffered or contracted before or during (but did not arise out of) the person's relevant service. 11 Factors referring to an injury or disease covered by another Statement of Principles In this Statement of Principles: (1) if a factor referred to in section 9 applies in relation to a person; and (2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA; then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.