{"id":"F2022L00276","name":"Statement of Principles concerning heart block (Reasonable Hypothesis) (No. 23 of 2022)","slug":"statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":441259,"registerId":"F2022L00276-fast-fetch-1775956617206","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning heart block (Reasonable Hypothesis) (No. 23 of 2022)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 20.2\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nHEART BLOCK (Reasonable Hypothesis)\n\n(No. 23 of 2022)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 4 March 2022\n\n \n\n \n\n \n\n \n\n \n\n| The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:
|\n| --- |\n|
Professor Terence Campbell AM
Chairperson
|\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Repeal\n\n5 Application\n\n6 Definitions\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n8 Basis for determining the factors\n\n9 Factors that must exist\n\n10 Relationship to service\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning heart block (Reasonable Hypothesis) (No. 23 of 2022).\n\n2 Commencement\n\n This instrument commences on 4 April 2022.\n\n3 Authority\n\nThis instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n4 Repeal\n\nThe Statement of Principles concerning heart block No. 1 of 2014 (Federal Register of Legislation No. F2014L00007) made under subsections 196B(2) and (8) of the VEA is repealed.\n\n5 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n6 Definitions\n\nThe terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about heart block and death from heart block.\n\nMeaning of heart block\n\n(2) For the purposes of this Statement of Principles, heart block:\n\n(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\n\n(b) includes atrioventricular block and bundle branch block; and\n\n(c) excludes congenital heart block, long QT syndrome and transient physiological heart block.\n\nNote 1: Heart block includes right and left bundle branch block, bifascicular and trifascicular block, and first, second and third degree atrioventricular block.\n\nNote 2: Second degree heart block includes Mobitz type I (Wenckebach) and Mobitz type II atrioventricular block.\n\nNote 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).\n\n(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).\n\n(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.\n\nDeath from heart block\n\n(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.\n\nNote: terminal event is defined in the Schedule 1 - Dictionary.\n\n8 Basis for determining the factors\n\nThe Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that heart block and death from heart block 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.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.\n\n9 Factors that must exist\n\nAt least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting heart block or death from heart block with the circumstances of a person's relevant service:\n\n(1) having ischaemic heart disease at the time of the clinical onset of heart block;\n\n(2) having pulmonary thromboembolism within the 7 days before the clinical onset of heart block;\n\n(3) having infiltration of the myocardium due to an infiltrative disease from the specified list of infiltrative diseases at the time of the clinical onset of heart block;\n\nNote: specified list of infiltrative diseases is defined in the Schedule 1 - Dictionary.\n\n(4) having cardiomyopathy at the time of the clinical onset of heart block;\n\n(5) having a benign or malignant neoplasm involving the heart before the clinical onset of heart block;\n\nNote: A neoplasm involving the heart can be primary or metastatic. An example of a primary neoplasm involving the heart is cardiac lymphoma.\n\n(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;\n\nNote: 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.\n\n(7) having non-infectious myocarditis at the time of the clinical onset of heart block;\n\nNote 1: Non-infectious myocarditis can be acute or chronic.\n\nNote 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.\n\n(8) having viral myocarditis at the time of the clinical onset of heart block;\n\nNote 1: Viral myocarditis can be acute or chronic.\n\nNote 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.\n\n(9) having a non-viral infection of the myocardium at the time of the clinical onset of heart block;\n\nNote 1: A non-viral infection of the myocardium can be caused by bacteria, protozoa, fungi or parasites.\n\nNote 2: Examples of non-viral infections of the myocardium include:\n\n(a) Borrelia burgdorferi (Lyme disease);\n\n(b) Corynebacterium diphtheriae (diphtheria);\n\n(c) Cysticercus species (cysticercosis);\n\n(d) Echinococcus species (hydatid disease);\n\n(e) Treponema pallidum (tertiary syphilis);\n\n(f) Trypanosoma cruzi (Chagas disease); and\n\n(g) Toxoplasma gondii (toxoplasmosis).\n\n(10) having infective endocarditis at the time of the clinical onset of heart block;\n\n(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;\n\nNote: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 - Dictionary.\n\n(12) taking a drug from the specified list of drugs within the 3 weeks before the clinical onset of heart block;\n\nNote: specified list of drugs is defined in the Schedule 1 - Dictionary.\n\n(13) taking chloroquine or hydroxychloroquine for at least 1 year before the clinical onset of heart block;\n\n(14) having ingested a plant containing cardiac glycosides within the 7 days before the clinical onset of heart block;\n\nNote: Examples of plants containing cardiac glycosides include the pong-pong tree (Cerbera odollam) and foxglove (Digitalis purpurea).\n\n(15) having acute pyrethroid poisoning after inhaling, ingesting or having cutaneous contact with a pyrethroid insecticide within the 3 days before the clinical onset of heart block;\n\nNote: Clinical features of acute pyrethroid poisoning may include dermal, neurological, gastrointestinal and respiratory symptoms. Cardiac involvement can lead to chest pain, tachycardia, hypertension, hypotension and arrhythmia.\n\n(16) experiencing penetrating trauma to the heart within the 1 year before the clinical onset of heart block;\n\n(17) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical onset of heart block;\n\nNote 1: Examples of thoracic surgical procedures include vascular, mediastinal, pulmonary and chest wall surgery.\n\nNote 2: Examples of invasive cardiac procedures include:\n\n(a) alcohol septal ablation;\n\n(b) catheter ablation of arrhythmias;\n\n(c) open heart surgery; and\n\n(d) transcatheter aortic valve implantation.\n\n(18) experiencing a blunt chest injury within the 60 days before the clinical onset of heart block;\n\nNote: blunt chest injury is defined in the Schedule 1 - Dictionary.\n\n(19) having a heart transplant before the clinical onset of heart block;\n\n(20) having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical onset of heart block;\n\n(21) having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical onset of heart block;\n\n(22) undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical onset of heart block;\n\n(23) 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;\n\nNote: MET is defined in the Schedule 1 - Dictionary.\n\n(24) being envenomated by a scorpion or snake within the 24 hours before the clinical onset of heart block;\n\n(25) having diabetes mellitus at the time of the clinical onset of heart block;\n\n(26) having hypertension before the clinical onset of heart block;\n\n(27) having obstructive sleep apnoea at the time of the clinical onset of heart block;\n\n(28) having smoked cannabis products within the 7 days before the clinical onset of heart block;\n\n(29) binge drinking within the 2 days before the clinical onset of heart block;\n\nNote: binge drinking is defined in the Schedule 1 - Dictionary.\n\n(30) having a thyroid condition from the specified list of thyroid conditions at the time of the clinical onset of heart block;\n\nNote: specified list of thyroid conditions is defined in the Schedule 1 - Dictionary.\n\n(31) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of heart block;\n\nNote: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.\n\n(32) having acute rheumatic fever at the time of the clinical onset of heart block;\n\n(33) having rheumatic heart disease at the time of the clinical onset of heart block;\n\n(34) having ischaemic heart disease at the time of the clinical worsening of heart block;\n\n(35) having pulmonary thromboembolism within the 7 days before the clinical worsening of heart block;\n\n(36) having infiltration of the myocardium due to an infiltrative disease from the specified list of infiltrative diseases at the time of the clinical worsening of heart block;\n\nNote: specified list of infiltrative diseases is defined in the Schedule 1 - Dictionary.\n\n(37) having cardiomyopathy at the time of the clinical worsening of heart block;\n\n(38) having a benign or malignant neoplasm involving the heart before the clinical worsening of heart block;\n\nNote: A neoplasm involving the heart can be primary or metastatic. An example of a primary neoplasm involving the heart is cardiac lymphoma.\n\n(39) 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;\n\nNote: 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.\n\n(40) having non-infectious myocarditis at the time of the clinical worsening of heart block;\n\nNote 1: Non-infectious myocarditis can be acute or chronic.\n\nNote 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.\n\n(41) having viral myocarditis at the time of the clinical worsening of heart block;\n\nNote 1: Viral myocarditis can be acute or chronic.\n\nNote 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.\n\n(42) having a non-viral infection of the myocardium at the time of the clinical worsening of heart block;\n\nNote 1: A non-viral infection of the myocardium can be caused by bacteria, protozoa, fungi or parasites.\n\nNote 2: Examples of non-viral infections of the myocardium include:\n\n(a) Borrelia burgdorferi (Lyme disease);\n\n(b) Corynebacterium diphtheriae (diphtheria);\n\n(c) Cysticercus species (cysticercosis);\n\n(d) Echinococcus species (hydatid disease);\n\n(e) Treponema pallidum (tertiary syphilis);\n\n(f) Trypanosoma cruzi (Chagas disease); and\n\n(g) Toxoplasma gondii (toxoplasmosis).\n\n(43) having infective endocarditis at the time of the clinical worsening of heart block;\n\n(44) 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;\n\nNote: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 - Dictionary.\n\n(45) taking a drug from the specified list of drugs within the 3 weeks before the clinical worsening of heart block;\n\nNote: specified list of drugs is defined in the Schedule 1 - Dictionary.\n\n(46) taking chloroquine or hydroxychloroquine for at least 1 year before the clinical worsening of heart block;\n\n(47) having ingested a plant containing cardiac glycosides within the 7 days before the clinical worsening of heart block;\n\nNote: Examples of plants containing cardiac glycosides include the pong-pong tree (Cerbera odollam) and foxglove (Digitalis purpurea).\n\n(48) having acute pyrethroid poisoning after inhaling, ingesting or having cutaneous contact with a pyrethroid insecticide within the 3 days before the clinical worsening of heart block;\n\nNote: Clinical features of acute pyrethroid poisoning may include dermal, neurological, gastrointestinal and respiratory symptoms. Cardiac involvement can lead to chest pain, tachycardia, hypertension, hypotension and arrhythmia.\n\n(49) experiencing penetrating trauma to the heart within the 1 year before the clinical worsening of heart block;\n\n(50) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical worsening of heart block;\n\nNote 1: Examples of thoracic surgical procedures include vascular, mediastinal, pulmonary and chest wall surgery.\n\nNote 2: Examples of invasive cardiac procedures include:\n\n(a) alcohol septal ablation;\n\n(b) catheter ablation of arrhythmias;\n\n(c) open heart surgery; and\n\n(d) transcatheter aortic valve implantation.\n\n(51) experiencing a blunt chest injury within the 60 days before the clinical worsening of heart block;\n\nNote: blunt chest injury is defined in the Schedule 1 - Dictionary.\n\n(52) having a heart transplant before the clinical worsening of heart block;\n\n(53) having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical worsening of heart block;\n\n(54) having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical worsening of heart block;\n\n(55) undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical worsening of heart block;\n\n(56) 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;\n\nNote: MET is defined in the Schedule 1 - Dictionary.\n\n(57) being envenomated by a scorpion or snake within the 24 hours before the clinical worsening of heart block;\n\n(58) having diabetes mellitus at the time of the clinical worsening of heart block;\n\n(59) having hypertension before the clinical worsening of heart block;\n\n(60) having obstructive sleep apnoea at the time of the clinical worsening of heart block;\n\n(61) having smoked cannabis products within the 7 days before the clinical worsening of heart block;\n\n(62) binge drinking within the 2 days before the clinical worsening of heart block;\n\nNote: binge drinking is defined in the Schedule 1 - Dictionary.\n\n(63) having a thyroid condition from the specified list of thyroid conditions at the time of the clinical worsening of heart block;\n\nNote: specified list of thyroid conditions is defined in the Schedule 1 - Dictionary.\n\n(64) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of heart block;\n\nNote: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.\n\n(65) having acute rheumatic fever at the time of the clinical worsening of heart block;\n\n(66) having rheumatic heart disease at the time of the clinical worsening of heart block;\n\n(67) inability to obtain appropriate clinical management for heart block.\n\n10 Relationship to service\n\n(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.\n\n(2) The factors set out in subsections 9(34) to 9(67) 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.\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 9 applies in relation to a person; and\n\n(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;\n\nthen 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.\n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\n\n binge drinking means consumption of large amounts of alcohol in a short space of time resulting in acute alcohol intoxication.\n\nNote 1: Acute alcohol intoxication typically occurs when there is consumption of:\n\n(a) 4 or more standard alcoholic drinks by an adult female within a 2 hour time period; or\n\n(b) 5 or more standard alcoholic drinks by an adult male within a 2 hour time period; or\n\n(c) sufficient alcohol as would result in a blood alcohol concentration greater than 0.1 gram of alcohol per 100 millilitres of blood.\n\nNote 2: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.\n\n blunt chest injury means a non-penetrating blow to the chest.\n\nNote: Examples of causes of blunt chest injury include a motor vehicle accident, a direct blow to the chest wall by airbag deployment, impact in contact sports, a fall from a height, a crush injury and being struck by a projectile.\n\n heart block—see subsection 7(2).\n\n MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, or 1.0 kcal/kg of body weight per hour, or resting metabolic rate.\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n relevant service means:\n\n(a) operational service under the VEA;\n\n(b) peacekeeping service under the VEA;\n\n(c) hazardous service under the VEA;\n\n(d) British nuclear test defence service under the VEA;\n\n(e) warlike service under the MRCA; or\n\n(f) non-warlike service under the MRCA.\n\nNote: MRCA and VEA are also defined in the Schedule 1 - Dictionary.\n\n specified list of autoimmune diseases means:\n\n(a) ankylosing spondylitis;\n\n(b) Behcet disease;\n\n(c) granulomatosis with polyangiitis (Wegener granulomatosis);\n\n(d) inflammatory myopathy (polymyositis and dermatomyositis);\n\n(e) rheumatoid arthritis; \n\n(f) Sjögren syndrome;\n\n(g) spondyloarthritis;\n\n(h) systemic lupus erythematosus; or\n\n(i) systemic sclerosis (scleroderma).\n\nNote: Spondyloarthritis includes reactive arthritis, psoriatic arthritis and inflammatory bowel disease-related spondyloarthritis.\n\n specified list of drugs means:\n\n(a) acetylcholinesterase inhibitors including donepezil, galantamine, neostigmine and rivastigmine;\n\n(b) anthracycline chemotherapeutic agents including doxorubicin and daunorubicin;\n\n(c) antimony;\n\n(d) beta blockers; \n\n(e) carbamazepine;\n\n(f) cardiac glycosides including digoxin;\n\n(g) chloroquine or hydroxychloroquine;\n\n(h) class 1A, class 1C or class III anti-arrhythmic agents including procainamide, flecainide and amiodarone;\n\n(i) cough linctus containing squill;\n\n(j) dextropropoxyphene;\n\n(k) fingolimod;\n\n(l) immune checkpoint inhibitors;\n\n(m) infliximab;\n\n(n) interferons;\n\n(o) lacosamide;\n\n(p) lithium;\n\n(q) mefloquine;\n\n(r) non-dihydropyridine calcium channel blockers including diltiazem and verapamil;\n\n(s) opioids;\n\n(t) paliperidone;\n\n(u) paclitaxel;\n\n(v) quinine;\n\n(w) risperidone;\n\n(x) trastuzumab; or\n\n(y) trazodone.\n\n specified list of infiltrative diseases means:\n\n(a) amyloidosis;\n\n(b) hereditary haemochromatosis; or\n\n(c) sarcoidosis.\n\n specified list of mineral or electrolyte abnormalities means:\n\n(a) hypercalcaemia; \n\n(b) hyperkalaemia;\n\n(c) hypermagnesaemia;\n\n(d) hypokalaemia;\n\n(e) hypomagnesaemia; or\n\n(f) hyponatraemia.\n\n specified list of thyroid conditions means:\n\n(a) hyperthyroidism, including goitre or Graves disease that has resulted in hyperthyroidism;\n\n(b) hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism; or\n\n(c) thyrotoxicosis.\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n VEA means the Veterans' Entitlements Act 1986.\n\n \n\n \n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"flash_summary":{"complexity_score":5,"scope_assessment":{"changed":true,"description":"This instrument repeals the 2014 Statement of Principles for heart block (section 4) and replaces it with a more detailed list of specific medical causes, exposures, drugs, procedures and timing windows (section 9 and Schedule 1). Compared with a generic statement about heart block, this version adds granular items (for example, specific modern causes such as SARS‑CoV‑2 viral myocarditis and immune checkpoint inhibitor therapy are named in notes and the drugs/causes lists), explicit timing windows for many exposures, and a catch‑all factor for \"inability to obtain appropriate clinical management\" (section 9(67)). It also separates onset and clinical‑worsening pathways and cross‑links factor application to other SoPs (section 11). Taken together, these changes expand the operational detail and scope of medical circumstances covered by the SoP and alter how claimants and decision‑makers must marshal and evaluate evidence."},"complexity_factors":["Long list of 67 discrete factors (section 9) separated into onset and clinical worsening variants (doubling many items).","Multiple specified lists in Schedule 1: drugs list (~25 items), autoimmune diseases (9), infiltrative diseases (3), mineral/electrolyte abnormalities (6), thyroid conditions (3).","Timing and quantitative thresholds spread through factors (e.g. 7 days, 3 weeks, 1 year, 24 hours, 5 years at >6 METs).","Cross‑references to other legislation and other Statements of Principles (sections 5, 8, 11) requiring lookups and application of external tests.","Several defined but potentially subjective terms (e.g. clinical onset, clinical worsening, inability to obtain appropriate clinical management) that require interpretive judgement.","Reference to ICD‑10‑AM codes and an external classification (subsection 7(3)–(4)), creating dependence on an external document/versioning.","Replaces an earlier 2014 SoP (section 4) — historical cross‑comparison may be required when applied to older claims. "],"plain_english_summary":"**What this instrument does (mechanics)**\n\n- This is a Statement of Principles (SoP) made by the Repatriation Medical Authority (RMA) about **heart block** and **death from heart block**. (See sections 3, 7.)\n- The instrument replaces the earlier 2014 Statement of Principles for heart block (section 4) and takes effect for covered claims from 4 April 2022 (section 2).\n- It is a medical‑evidentiary tool that tells claims decision‑makers which medical and exposure factors, if present, are sufficient to raise a **reasonable hypothesis** that a veteran’s heart block is connected to their relevant service (sections 8–9, 10). The instrument itself does not pay benefits; it defines the medical relationships decision‑makers use when applying the Veterans’ Entitlements Act 1986 (VEA) or the Military Rehabilitation and Compensation Act 2004 (MRCA) to a claim (section 5).\n\n**Who it affects**\n\n- Veterans, members of Peacekeeping Forces and members of the Forces to whom the VEA or MRCA applies (Schedule 1 definitions of \"relevant service\") — i.e. people making claims for service‑related heart block or death from heart block (section 5; Schedule 1).\n- Medical practitioners and hospitals who supply clinical records and expert opinions to support or rebut claims.\n- The government claims decision‑makers who apply the SoP (the agency that processes VEA or MRCA claims).\n\n**How it works in practice (key rules)**\n\n- The RMA sets out a list of specific medical conditions, exposures, procedures, injuries and behaviours such that **at least one** listed factor must exist to raise the reasonable hypothesis that heart block is related to service (section 9).\n- The list is split into factors tied to the **clinical onset** of heart block and corresponding factors tied to **clinical worsening** of pre‑existing heart block. Many factors appear both for onset and for worsening (section 9, items 1–67).\n- Examples of factors that can raise the reasonable hypothesis include: ischaemic heart disease, myocarditis (viral and non‑viral), cardiomyopathy, infiltrative disease (amyloidosis, haemochromatosis, sarcoidosis), certain infections (e.g. Lyme, diphtheria, Chagas), specific drugs and drug classes, specific surgical or invasive cardiac procedures, radiotherapy to the heart, severe chest trauma, transplantation, graft‑versus‑host disease, some endocrine and autoimmune conditions, recent envenomation, substance use (recent cannabis, binge drinking), and prolonged strenuous physical activity (section 9 and Schedule 1 defined lists).\n- Timing windows and quantitative thresholds are embedded for many factors (for example: pulmonary thromboembolism within 7 days before clinical onset, certain drug use within 3 weeks, chloroquine/hydroxychloroquine for at least 1 year, strenuous activity >6 METs for ≥10 hours/week for ≥5 years) — these timing/threshold rules matter for causation assessment (section 9; Schedule 1 definitions for MET, binge drinking, etc.).\n- The SoP also says a listed factor that is itself covered by another SoP must be treated according to that other SoP (section 11). That creates cross‑application between disease‑specific SoPs.\n- Section 10 requires that any listed factor relied upon for a claim must be related to the person’s relevant service. For a material contribution or aggravation argument, the SoP limits the factors in items 34–67 to situations where the heart block existed before or during service (section 10).\n\n**Official rationale and how the instrument is intended to be used**\n\n- The RMA states it formed the SoP because it is of the view there is sound medical‑scientific evidence that heart block and death from heart block can be related to service (section 8). The SoP translates that medical view into a fixed list of factors and timing rules used to raise a \"reasonable hypothesis\" of service connection.\n\n**Who pays, who decides, and what changes in behaviour**\n\n- Who decides: the government claims decision‑maker for a particular claim (the decision authority that applies the VEA or the MRCA provisions for relevant claims) uses this SoP as the medical test to decide whether the claimant’s heart block can be reasonably connected to service (sections 5, 8–11).\n- Who pays: if the decision‑maker accepts the claim under the VEA or MRCA rules, the relevant government benefits or compensation program funds any entitlements. The SoP itself does not itself create or expend money; it provides the medical basis used in decisions.\n- Behavioural and practical impacts: claimants and their clinicians will need to assemble medical evidence that documents the presence/timing of any listed factor; decision‑makers will rely on the SoP’s timing windows and lists; clinicians or hospitals may need to record exposures/procedures with greater specificity; administrative systems will need to check cross‑references to other SoPs where a factor is itself a separate listed disease.\n\n**Implementation, costs and risks (concrete mechanisms)**\n\n- Administrative burden: the SoP creates discrete evidentiary tasks — proof of timing windows, confirmation of specific drug exposure or procedure, or demonstration that the heart was in a radiotherapy field. That raises record‑gathering and clinical‑opinion costs for claimants and processing costs for decision‑makers (section 9 and Schedule 1).\n- Bureaucratic discretion and interpretive risk: decision‑makers still must judge whether the available evidence meets the SoP thresholds (for example, whether a drug was taken within the specified window, or whether clinical onset/worsening timing is established). Some items are inherently judgmental (e.g. \"inability to obtain appropriate clinical management\", section 9(67)).\n- Evidentiary trade‑offs: the SoP lowers the evidentiary threshold for service connection where one of the listed factors (and timing) is present — it is a shortcut to raising a \"reasonable hypothesis\" but it does not automatically establish causation. Claimants benefit from clearer rules on what evidence matters; the state bears the cost of investigating complex medical records.\n- Implementation risk: definitions that rely on clinical judgement or incomplete records (e.g. onset dates, exact duration of drug exposure, level of physical activity measured in METs over 5 years) can lead to disputes and requests for expert opinions.\n- Effects on private parties: minimal direct effects on commercial markets. Indirect effects may include changes in how hospitals, treating clinicians and insurers document and code relevant exposures or procedures to support claims; and potential downstream effects on procurement of certain therapies if they affect long‑term liability or recordkeeping.\n\n**Concentrated benefits, diffuse costs and potential unintended consequences**\n\n- Concentrated benefits: veterans whose medical records show one of the listed factors and meet the timing rules gain a clearer path to a reasonable hypothesis of service connection.\n- Diffuse costs: administrative effort to collect, assess and possibly litigate medical evidence will be borne across many claimants and the department; clinicians may face small increases in documentation effort.\n- Potential substitution/unintended consequences: clinicians might alter record practices (more detailed the better); claimants may need to commission expert reports; borderline cases may produce more requests for clarification or review because of tight timing windows.\n\n**Key statutory cross‑links and definitions to note**\n\n- This SoP applies to claims under the VEA (section 120A) or MRCA (section 338) (section 5).\n- Many specialist lists and timing thresholds are defined in Schedule 1 (for example: drugs list, infiltrative diseases, mineral/electrolyte abnormalities, autoimmune diseases, MET definition, binge drinking) and are essential to applying section 9.\n\n**Bottom line (practical effect)**\n\n- The instrument is a rule‑set the claims system uses to decide whether a veteran’s heart block can reasonably be connected to their service. It specifies a long list of medical conditions, exposures, procedures and behaviours (with timing rules) that, if present and related to service, will raise a reasonable hypothesis of service connection. That simplifies and standardises how decision‑makers treat heart block cases, but it requires precise clinical evidence and creates administrative and interpretive work for claimants and the decision system.\n"},"kimi_summary":{"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":false,"description":"This is a standard replacement instrument maintaining the established scope of Repatriation Medical Authority Statements of Principles. It updates the 2014 version to reflect current medical knowledge (notably adding SARS-CoV-2 as an example of viral myocarditis) but does not expand beyond the original purpose of establishing service connection criteria for heart block compensation claims."},"complexity_factors":["67 distinct factors with specific temporal requirements (ranging from 24 hours to 5+ years before onset/worsening)","Extensive cross-referencing to defined terms in Schedule 1 (9 defined terms including multiple 'specified lists')","5 separate 'specified lists' containing enumerated medical conditions, drugs, and diseases (autoimmune diseases: 9 items; drugs: 25 items; infiltrative diseases: 3 items; mineral/electrolyte abnormalities: 6 items; thyroid conditions: 3 items)","Dual structure covering both 'clinical onset' (factors 1-33) and 'clinical worsening' (factors 34-66) with near-mirror provisions","Nested definitions requiring external medical knowledge (ICD-10-AM codes, MET units, specific drug classes)","Conditional logic in section 10 limiting worsening factors to pre-existing conditions not arising from service","Reference to other Statements of Principles for conditions mentioned in factors (section 11)"],"plain_english_summary":"This instrument sets when Australian Defence Force members and veterans can claim compensation for heart block (or death from it). Claimants must show at least one of 67 specified medical factors — ranging from heart disease, infections (including COVID‑19), drugs, surgeries, injuries, environmental exposures, lifestyle or other diseases — was connected to their service.\n\nIt covers both new onset during/after service, service‑aggravation of pre‑existing heart block, and inability to obtain proper treatment."}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022","history":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022/history","analysis":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022/analysis","conflicts":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022/important-cases","documents":"/api/acts/statement-of-principles-concerning-heart-block-reasonable-hypothesis-no-23-of-2022/documents"}}