Statement of Principles concerning ischaemic heart disease (Reasonable Hypothesis) (No. 27 of 2025) (Cth)

Statement of Principles concerning ISCHAEMIC HEART DISEASE (Reasonable Hypothesis) (No. 27 of 2025) The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 18 February 2025.

Professor Terence Campbell AM Chairperson by and on behalf of The Repatriation Medical Authority

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 ischaemic heart disease (Reasonable Hypothesis) (No. 27 of 2025). 1. Commencement This instrument commences on 25 March 2025. 1. Authority This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986. 1. Repeal The Statement of Principles concerning ischaemic heart disease No. 1 of 2016 (Federal Register of Legislation No. F2016L00001) made under subsections 196B(2) and (8) of the VEA is repealed. 1. 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. 1. Definitions The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument. 1. Kind of injury, disease or death to which this Statement of Principles relates 1. This Statement of Principles is about ischaemic heart disease and death from ischaemic heart disease. Meaning of ischaemic heart disease 1. For the purposes of this Statement of Principles, ischaemic heart disease: 1. means a cardiac disease in which inadequate coronary blood supply to part of the heart leads to infarction or periodic ischaemia; 2. includes: 1. myocardial infarction (ST elevation myocardial infarction (STEMI), and non-ST elevation myocardial infarction NSTEMI)); 2. angina pectoris (including unstable angina and Prinzmetal angina); 3. ischaemic cardiomyopathy; and 4. acute coronary syndrome (including STEMI, NSTEMI, and unstable angina); and 3. excludes: 1. coronary artery disease without ischaemia; 2. myocardial infarction due to generalised hypoxia, vascular shock, or cardiac arrest; Note: The inadequate coronary blood supply can be associated with coronary thrombosis, atherosclerosis, coronary vasospasm, or coronary vascular disease. 1. While ischaemic heart disease attracts ICD‑10‑AM codes I20, I21, I22, I23, I24 and I25, in applying this Statement of Principles the meaning of ischaemic heart disease is that given in subsection (2). 2. 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 ischaemic heart disease 1. For the purposes of this Statement of Principles, 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. Note: terminal event is defined in the Schedule 1 – Dictionary. 1. Basis for determining the factors 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 MRCA. Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary. 1. 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 ischaemic heart disease or death from ischaemic heart disease with the circumstances of a person's relevant service: 1. having hypertension before clinical onset or clinical worsening; 2. having diabetes mellitus before clinical onset or clinical worsening; 3. being obese or overweight for at least the 5 years before clinical onset or clinical worsening; Note: being obese or overweight is defined in the Schedule 1 – Dictionary. 1. having persistently abnormal blood lipid levels before clinical onset or clinical worsening, as indicated by any of the following: 1. a serum high density lipoprotein cholesterol level less than 1.0 mmol/L; 2. a serum low density lipoprotein cholesterol level greater than 4.0 mmol/L; 3. a total serum cholesterol level greater than 5.5 mmol/L; 4. the regular administration of drug therapy to normalise previously elevated blood lipid levels. 2. where smoking has not ceased before clinical onset or clinical worsening: 1. smoking an average of at least 1 cigarette per day, or the equivalent thereof in other tobacco products, for at least the 1 year before clinical onset or clinical worsening; or 2. smoking at least one half of one pack-year before clinical onset or clinical worsening; Note: one pack-year is defined in the Schedule 1 - Dictionary. 1. where smoking has ceased before clinical onset or clinical worsening: 1. having smoked at least one half of one pack-year but less than 5 pack-years, before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of smoking cessation; or 2. having smoked at least 5 pack-years but less than 20 pack-years, before clinical onset or clinical worsening, and the clinical onset or clinical worsening occurred within 20 years of smoking cessation; or 3. having smoked at least 20 pack-years before clinical onset or clinical worsening; Note: one pack-year is defined in the Schedule 1 - Dictionary. 1. where exposure to second-hand tobacco smoke has not ceased, being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 1,000 hours before clinical onset or clinical worsening; 2. where exposure to second-hand tobacco smoke has ceased: 1. being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 1,000 hours but less than 5,000 hours before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of the last exposure to second-hand tobacco smoke; or 2. being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 5,000 hours before clinical onset or clinical worsening; 3. where the use of smokeless tobacco has not ceased, using smokeless tobacco on more days than not for at least 1 year before clinical onset or clinical worsening; Note: smokeless tobacco is defined in the Schedule 1 – Dictionary. 1. where the use of smokeless tobacco has ceased: 1. using smokeless tobacco on more days than not for at least 1 year but less than 5 years before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of ceasing to use smokeless tobacco; or 2. using smokeless tobacco on more days than not for at least 5 years before clinical onset or clinical worsening; Note: smokeless tobacco is defined in the Schedule 1 – Dictionary. 1. an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening; Note: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening. 1. being sedentary for a cumulative total of at least 10 hours per day on more days than not for at least the 5 years before clinical onset or clinical worsening; Note: being sedentary is defined in the Schedule 1 - Dictionary. 1. an inability to consume an average of at least 100 grams per day of vegetables or fruits, for at least the 5 years before clinical onset or clinical worsening; 2. having chronic kidney disease before clinical onset or clinical worsening as indicated by one of the following: 1. a glomerular filtration rate of less than 60 mL/min/1.73 m2 for at least 3 months; 2. albuminuria with an albumin to creatinine ratio of at least 3 milligrams/millimole for at least 3 months; 3. kidney damage, as evidenced by renal biopsy, imaging studies, urinary sediment abnormalities or other markers of abnormal renal function; 4. having had a kidney transplant; 3. having hypothyroidism for at least 2 years within the 10 years before clinical onset or clinical worsening; Note: Hashimoto thyroiditis can cause hypothyroidism. 1. having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening; 2. having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the heart at least 1 year before clinical onset or clinical worsening; Note: cumulative equivalent dose is defined in the Schedule 1 - Dictionary. 1. having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening; 2. inhaling, ingesting or having cutaneous contact with 1,2 propylene glycol dinitrate (Otto fuel II): 1. for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and 2. where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or worsening occurred within 25 years of cessation; 1. undergoing a procedure involving catheterisation of the affected coronary artery within the 30 days before clinical onset or clinical worsening of myocardial infarction or unstable angina; 2. having infective endocarditis at the time of the clinical onset of myocardial infarction; 3. having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening; 4. having one of the following vasculitides at the time of clinical onset or clinical worsening: 1. antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis; 2. Behcet disease; 3. eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome); 4. giant cell (temporal) arteritis; 5. granulomatosis with polyangiitis (Wegener granulomatosis); 6. IgA vasculitis (Henoch-Schönlein purpura); 7. microscopic polyangiitis; 8. mucocutaneous lymph node syndrome (Kawasaki disease); 9. non-specific autoimmune vasculitis; 10. polyarteritis nodosa; 11. Takayasu arteritis; 5. having thromboangiitis obliterans (Buerger disease) before the clinical onset of myocardial infarction; 6. having one of the following systemic inflammatory rheumatological diseases at the time of clinical onset or clinical worsening: 1. ankylosing spondylitis; 2. dermatomyositis; 3. inflammatory bowel disease; 4. polymyositis; 5. psoriasis; 6. psoriatic arthritis; 7. rheumatoid arthritis; 8. Sjögren syndrome; 9. systemic lupus erythematosus; 10. systemic sclerosis; 7. having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening; Note: Some examples of hypercoagulable state include acquired antithrombin III deficiency, disseminated intravascular coagulation, secondary thrombocytosis and acute myeloid leukaemia. 1. having one of following clinically significant disorders of mental health for at least the 5 years before clinical onset or clinical worsening; 1. adjustment disorder; 2. agoraphobia; 3. anxiety disorder; 4. depressive disorder; 5. panic disorder; 6. posttraumatic stress disorder; 7. schizophrenia; or 8. social anxiety disorder. Note: clinically significant disorder of mental health is defined in the Schedule 1 – Dictionary. 1. taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina; 2. taking any of the following medications, within the 24 hours before clinical onset or clinical worsening: 1. alemtuzumab; 2. aromatase inhibitors; 3. bevacizumab; 4. capecitabine; 5. dextroamphetamine; 6. docetaxel; 7. ephedrine; 8. ergotamine; 9. fluorouracil; 10. methylphenidate; 11. paclitaxel; 12. phentermine; 13. pseudoephedrine; 14. the kinase inhibitors, axitinib, cabozantinib, dasatinib, erlotinib, lenvatinib, midostaurin, nilotinib, nintedanib, pazopanib, ponatinib, regorafenib, sorafenib; or 15. triptans, including sumatriptan. 3. being treated with antipsychotic agents or macrolide antibiotics within the 24 hours before the clinical onset or clinical worsening of myocardial infarction; 4. taking a non-topical, non-steroidal, anti-inflammatory drug, excluding aspirin and paracetamol, for a continuous period of at least 3 days before clinical onset or clinical worsening, where the last dose of the drug was taken within the 7 days before clinical onset or clinical worsening; Note: non-steroidal, anti-inflammatory drug is defined in the Schedule 1 - Dictionary. 1. having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening 2. taking one of the following anti-androgen medications for at least the 7 days before clinical onset or clinical worsening: 1. abiraterone; 2. androgen receptor blockers, including apalutamide, bicalutamide, darolutamide, enzalutamide, and cyproterone acetate; or 3. gonadotrophin releasing hormone agonists, including goserelin and leuprorelin; 3. 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): 1. for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and 2. where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or worsening occurred within 25 years of cessation; 1. inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): 1. for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and 2. where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or 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 1. inhaling chronically polluted air for at least 1,000 hours, within the 5 years before clinical onset or clinical worsening; Note: chronically polluted air is defined in the Schedule 1 – Dictionary. 1. consuming an average daily intake of at least 12 grams (200 millimoles) per day of salt (sodium chloride) for at least the 5 years before clinical onset or clinical worsening; 2. having periodic, heavy alcohol consumption for the 1 year before clinical onset or clinical worsening; Note: periodic, heavy alcohol consumption is defined in the Schedule 1 - Dictionary. 1. having sleep apnoea for at least the 1 year before clinical onset or clinical worsening; 2. an inability to sleep for an average of at least 5 hours daily for at least the 1 year before clinical onset or clinical worsening; 3. undertaking night shift work on at least 120 nights per year, for at least the 10 years before clinical onset or clinical worsening; Note: night shift work is defined in the Schedule 1 - Dictionary. 1. having infection with human immunodeficiency virus for at least the 5 years before clinical onset or clinical worsening; 2. having periodontitis for at least the 5 years before clinical onset or clinical worsening; 3. having gout or hyperuricaemia for at least the 5 years before clinical onset or clinical worsening; Note: hyperuricaemia is defined in the Schedule 1 - Dictionary. 1. undertaking physical activity of 5 METS or more within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: MET (metabolic equivalent) is a unit of measure of the level of physical capability of the cardiorespiratory system. For example, 1 MET = cardiorespiratory effort associated with a person sitting, 3-4 METs = cardiorespiratory effort associated with a person walking at average walking pace (5 km/h) or light gardening. 1. experiencing a category 1A stressor within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: category 1A stressor is defined in the Schedule 1 - Dictionary. 1. experiencing a category 1B stressor within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: category 1B stressor is defined in the Schedule 1 - Dictionary. 1. experiencing an acute severe stressful event that causes a sudden, intense emotional or psychological response within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 2. experiencing the death of a family member or close friend within the 4 weeks before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 3. using one of the following illicit drugs within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease: 1. amphetamines or amphetamine derivatives, including methamphetamine, 3, 4-methylenedioxymethamphetamine (Ecstasy or MDMA); 2. cocaine; 3. D-lysergic acid diethylamide; 4. marijuana; 5. Khat and synthetic cathinones, including alpha-pyrrolidinopentiophenone, 4- methylmethcathinone (4-MMC), and 3-methylmethcathinone (3-MMC). 4. having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: acute cholinergic poisoning and organophosphorus ester are defined in the Schedule 1 - Dictionary. 1. being exposed to: 1. an ambient temperature of 38 degrees Celsius or above; or 2. an ambient temperature of zero degrees Celsius or below; for a period of at least 6 hours within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 1. inhaling polluted air, for at least 2 hours within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: polluted air is defined in the Schedule 1 – Dictionary. 1. being envenomated by a snake, scorpion, wasp, bee, hornet, spider, centipede, fish or jellyfish within the 24 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 2. having an acute hypersensitivity reaction (including anaphylaxis) involving the coronary arteries within the 24 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 3. having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the 3 months before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) and sudden death from ischaemic heart disease; Note 1: SARS-CoV-2 is the virus which causes coronavirus disease 2019 (COVID-19). 1. having influenza or a lower respiratory tract infection within the 30 days before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 2. being pregnant within the 6 weeks before the clinical onset or the clinical worsening of acute myocardial infarction or sudden death from ischaemic heart disease; 3. having a hypertensive emergency or crisis within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; Note: hypertensive emergency or crisis is defined in the Schedule 1 - Dictionary. 1. having atrial fibrillation or atrial flutter within the 30 days before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; 2. having bilateral oophorectomy before the age of 45 years, before clinical onset or clinical worsening; 3. inability to obtain appropriate clinical management for ischaemic heart disease before clinical worsening. 1. 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 clinical worsening aspects of factors set out in section 9 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 did not arise out of) the person's relevant service. 2. 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.