Statement of Principles concerning heart block (Balance of Probabilities) (No. 24 of 2022) (Cth)

Statement of Principles concerning HEART BLOCK (Balance of Probabilities) (No. 24 of 2022) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) 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 Definitions 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

1 Name This is the Statement of Principles concerning heart block (Balance of Probabilities) (No. 24 of 2022). 2 Commencement This instrument commences on 4 April 2022. 3 Authority This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986. 4 Repeal The Statement of Principles concerning heart block No. 2 of 2014 (Federal Register of Legislation No. F2014L00005) made under subsections 196B(3) and (8) of the VEA is repealed. 5 Application This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies. 6 Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 7 Kind of injury, disease or death to which this Statement of Principles relates (1) This Statement of Principles is about heart block and death from heart block. Meaning of heart block (2) For the purposes of this Statement of Principles, heart block: (a) means a cardiac disorder in which there is a delay or interruption to the conduction of electrical impulse from the atria to the ventricles through the atrioventricular node, bundle of His or the bundle branches due to an anatomical or functional impairment in the conduction system; and (b) includes atrioventricular block and bundle branch block; and (c) excludes congenital heart block, long QT syndrome and transient physiological heart block. Note 1: Heart block includes right and left bundle branch block, bifascicular and trifascicular block, and first, second and third degree atrioventricular block. Note 2: Second degree heart block includes Mobitz type I (Wenckebach) and Mobitz type II atrioventricular block. Note 3: Heart block may be asymptomatic in some cases. Symptoms of heart block typically include fatigue, shortness of breath or chest pain on exertion, dizziness and fainting (syncope). (3) While heart block attracts ICD‑10‑AM code I44, I45.0, I45.1, I45.2, I45.3, I45.4 or I45.9, in applying this Statement of Principles the meaning of heart block 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 heart block (5) For the purposes of this Statement of Principles, heart block, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's heart block. Note: terminal event is defined in the Schedule 1 - Dictionary. 8 Basis for determining the factors On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that heart block and death from heart block can be related to relevant service rendered by veterans 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 exist before it can be said that, on the balance of probabilities, heart block or death from heart block is connected with the circumstances of a person's relevant service: (1) having ischaemic heart disease at the time of the clinical onset of heart block; (2) having pulmonary thromboembolism within the 7 days before the clinical onset of heart block; (3) having infiltration of the myocardium due to amyloidosis or sarcoidosis at the time of the clinical onset of heart block; (4) having cardiomyopathy at the time of the clinical onset of heart block; (5) having a benign or malignant neoplasm involving the heart before the clinical onset of heart block; Note: A neoplasm involving the heart can be primary or metastatic. An example of a primary neoplasm involving the heart is cardiac lymphoma. (6) having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical onset of heart block; Note: Examples of lesions which can compress the atrioventricular node, bundle of His or the bundle branches of the heart include a paraoeseophageal hiatus hernia, a thoracic aortic aneurysm and a haematoma. (7) having non-infectious myocarditis at the time of the clinical onset of heart block; Note 1: Non-infectious myocarditis can be acute or chronic. Note 2: Non-infectious myocarditis can be of autoimmune, infiltrative or immunological origin. Examples of causes of non-infectious myocarditis include immune checkpoint inhibitor therapy and giant cell myocarditis. (8) having viral myocarditis at the time of the clinical onset of heart block; Note 1: Viral myocarditis can be acute or chronic. Note 2: Examples of viral causes of myocarditis include severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), human immunodeficiency virus, group B coxsackieviruses and dengue virus. (9) having a non-viral infection of the myocardium at the time of the clinical onset of heart block; Note 1: A non-viral infection of the myocardium can be caused by bacteria, protozoa, fungi or parasites. Note 2: Examples of non-viral infections of the myocardium include: (a) Borrelia burgdorferi (Lyme disease); (b) Corynebacterium diphtheriae (diphtheria); (c) Cysticercus species (cysticercosis); (d) Echinococcus species (hydatid disease); (e) Treponema pallidum (tertiary syphilis); (f) Trypanosoma cruzi (Chagas disease); and (g) Toxoplasma gondii (toxoplasmosis). (10) having infective endocarditis at the time of the clinical onset of heart block; (11) having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical onset of heart block; Note: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 - Dictionary. (12) taking a drug from the specified list of drugs within the 3 weeks before the clinical onset of heart block; Note: specified list of drugs is defined in the Schedule 1 - Dictionary. (13) taking chloroquine or hydroxychloroquine for at least 1 year before the clinical onset of heart block; (14) having ingested a plant containing cardiac glycosides within the 7 days before the clinical onset of heart block; Note: Examples of plants containing cardiac glycosides include the pong-pong tree (Cerbera odollam) and foxglove (Digitalis purpurea). (15) experiencing penetrating trauma to the heart within the 1 year before the clinical onset of heart block; (16) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical onset of heart block; Note 1: Examples of thoracic surgical procedures include vascular, mediastinal, pulmonary and chest wall surgery. Note 2: Examples of invasive cardiac procedures include: (a) alcohol septal ablation; (b) catheter ablation of arrhythmias; (c) open heart surgery; and (d) transcatheter aortic valve implantation. (17) experiencing a blunt chest injury within the 60 days before the clinical onset of heart block; Note: blunt chest injury is defined in the Schedule 1 - Dictionary. (18) having a heart transplant before the clinical onset of heart block; (19) having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical onset of heart block; (20) having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical onset of heart block; (21) undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical onset of heart block; (22) undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical onset of heart block; Note: MET is defined in the Schedule 1 - Dictionary. (23) having diabetes mellitus at the time of the clinical onset of heart block; (24) having hypertension with left ventricular hypertrophy before the clinical onset of heart block; (25) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of heart block; Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary. (26) having acute rheumatic fever at the time of the clinical onset of heart block; (27) having rheumatic heart disease at the time of the clinical onset of heart block; (28) having ischaemic heart disease at the time of the clinical worsening of heart block; (29) having pulmonary thromboembolism within the 7 days before the clinical worsening of heart block; (30) having infiltration of the myocardium due to amyloidosis or sarcoidosis at the time of the clinical worsening of heart block; (31) having cardiomyopathy at the time of the clinical worsening of heart block; (32) having a benign or malignant neoplasm involving the heart before the clinical worsening of heart block; Note: A neoplasm involving the heart can be primary or metastatic. An example of a primary neoplasm involving the heart is cardiac lymphoma. (33) having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical worsening of heart block; Note: Examples of lesions which can compress the atrioventricular node, bundle of His or the bundle branches of the heart include a paraoeseophageal hiatus hernia, a thoracic aortic aneurysm and a haematoma. (34) having non-infectious myocarditis at the time of the clinical worsening of heart block; Note 1: Non-infectious myocarditis can be acute or chronic. Note 2: Non-infectious myocarditis can be of autoimmune, infiltrative or immunological origin. Examples of causes of non-infectious myocarditis include immune checkpoint inhibitor therapy and giant cell myocarditis. (35) having viral myocarditis at the time of the clinical worsening of heart block; Note 1: Viral myocarditis can be acute or chronic. Note 2: Examples of viral causes of myocarditis include severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), human immunodeficiency virus, group B coxsackieviruses and dengue virus. (36) having a non-viral infection of the myocardium at the time of the clinical worsening of heart block; Note 1: A non-viral infection of the myocardium can be caused by bacteria, protozoa, fungi or parasites. Note 2: Examples of non-viral infections of the myocardium include: (a) Borrelia burgdorferi (Lyme disease); (b) Corynebacterium diphtheriae (diphtheria); (c) Cysticercus species (cysticercosis); (d) Echinococcus species (hydatid disease); (e) Treponema pallidum (tertiary syphilis); (f) Trypanosoma cruzi (Chagas disease); and (g) Toxoplasma gondii (toxoplasmosis). (37) having infective endocarditis at the time of the clinical worsening of heart block; (38) having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical worsening of heart block; Note: Note: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 - Dictionary. (39) taking a drug from the specified list of drugs within the 3 weeks before the clinical worsening of heart block; Note: specified list of drugs is defined in the Schedule 1 - Dictionary. (40) taking chloroquine or hydroxychloroquine for at least 1 year before the clinical worsening of heart block; (41) having ingested a plant containing cardiac glycosides within the 7 days before the clinical worsening of heart block; Note: Examples of plants containing cardiac glycosides include the pong-pong tree (Cerbera odollam) and foxglove (Digitalis purpurea). (42) experiencing penetrating trauma to the heart within the 1 year before the clinical worsening of heart block; (43) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical worsening of heart block; Note 1: Examples of thoracic surgical procedures include vascular, mediastinal, pulmonary and chest wall surgery. Note 2: Examples of invasive cardiac procedures include: (a) alcohol septal ablation; (b) catheter ablation of arrhythmias; (c) open heart surgery; and (d) transcatheter aortic valve implantation. (44) experiencing a blunt chest injury within the 60 days before the clinical worsening of heart block; Note: blunt chest injury is defined in the Schedule 1 - Dictionary. (45) having a heart transplant before the clinical worsening of heart block; (46) having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical worsening of heart block; (47) having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical worsening of heart block; (48) undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical worsening of heart block; (49) undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical worsening of heart block; Note: MET is defined in the Schedule 1 - Dictionary. (50) having diabetes mellitus at the time of the clinical worsening of heart block; (51) having hypertension with left ventricular hypertrophy before the clinical worsening of heart block; (52) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of heart block; Note: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary. (53) having acute rheumatic fever at the time of the clinical worsening of heart block; (54) having rheumatic heart disease at the time of the clinical worsening of heart block; (55) inability to obtain appropriate clinical management for heart block. 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(28) to 9(55) apply only to material contribution to, or aggravation of, heart block where the person's heart block 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(3) 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.