{"id":"F2022L00919","name":"Statement of Principles concerning sick sinus syndrome (Reasonable Hypothesis) (No. 66 of 2022)","slug":"statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":441449,"registerId":"F2022L00919-fast-fetch-1775956738383","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning sick sinus syndrome (Reasonable Hypothesis) (No. 66 of 2022)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 22.10.0\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nSICK SINUS SYNDROME (Reasonable Hypothesis)\n\n(No. 66 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 24 June 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 sick sinus syndrome (Reasonable Hypothesis) (No. 66 of 2022).\n\n2 Commencement\n\n This instrument commences on 25 July 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 sick sinus syndrome No. 15 of 2014 (Federal Register of Legislation No. F2014L00020) made under subsection 196B(2) of the VEA is repealed.\n\n5 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act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 sick sinus syndrome and death from sick sinus syndrome.\n\nMeaning of sick sinus syndrome\n\n(2) For the purposes of this Statement of Principles, sick sinus syndrome:\n\n(a) means a group of cardiac arrhythmias caused by dysfunction of the sinus node, in which persistent or intermittent abnormalities of cardiac impulse formation and propagation cause an atrial rate inappropriate for physiological requirements, resulting in clinical symptoms; and\n\n(b) excludes congenital sick sinus syndrome.\n\nNote 1: Sick sinus syndrome can manifest as persistent or intermittent sinus bradycardia, sinus pause or sinus arrest, bradycardia-tachycardia syndrome, and other arrhythmias.\n\nNote 2: Symptoms of sick sinus syndrome typically include fatigue, lightheadedness, palpitations, presyncope, syncope, dyspnoea on exertion, and chest discomfort. Documented sinus node dysfunction correlates with symptoms. Symptoms are frequently intermittent with gradual progression in frequency and severity.\n\n(3) While sick sinus syndrome attracts ICD‑10‑AM code I49.5, in applying this Statement of Principles the meaning of sick sinus syndrome 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 sick sinus syndrome\n\n(5) For the purposes of this Statement of Principles, sick sinus syndrome, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's sick sinus syndrome.\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 sick sinus syndrome and death from sick sinus syndrome 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 sick sinus syndrome or death from sick sinus syndrome with the circumstances of a person's relevant service:\n\n(1) having atrial fibrillation or atrial flutter at the time of the clinical onset of sick sinus syndrome;\n\n(2) having hypertension at the time of the clinical onset of sick sinus syndrome;\n\n(3) having ischaemic heart disease at the time of the clinical onset of sick sinus syndrome;\n\n(4) having heart failure at the time of the clinical onset of sick sinus syndrome;\n\n(5) having rheumatic fever at the time of the clinical onset of sick sinus syndrome;\n\n(6) having pericarditis at the time of the clinical onset of sick sinus syndrome;\n\n(7) having cardiomyopathy at the time of the clinical onset of sick sinus syndrome;\n\n(8) having non-infectious myocarditis at the time of the clinical onset of sick sinus syndrome;\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(9) having viral myocarditis at the time of the clinical onset of sick sinus syndrome;\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(10) having a non-viral infection of the myocardium at the time of the clinical onset of sick sinus syndrome;\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) Cysticercus species (cysticercosis);\n\n(c) Echinococcus species (hydatid disease);\n\n(d) Toxoplasma gondii (toxoplasmosis); and\n\n(e) Trypanosoma cruzi (Chagas disease).\n\n(11) 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 sick sinus syndrome;\n\nNote: specified list of infiltrative diseases is defined in the Schedule 1 - Dictionary.\n\n(12) having a benign or malignant neoplasm involving the sinoatrial node before the clinical onset of sick sinus syndrome;\n\nNote: A neoplasm involving the sinoatrial node can be primary or metastatic. An example of a primary neoplasm involving the sinoatrial node is cardiac lymphoma.\n\n(13) having a non-neoplastic lesion which compresses the sinoatrial node at the time of the clinical onset of sick sinus syndrome;\n\nNote: Examples of non-neoplastic lesions which compress the sinoatrial node include cardiac tamponade and coronary artery aneurysm.\n\n(14) having a thyroid condition from the specified list of thyroid conditions at the time of the clinical onset of sick sinus syndrome;\n\nNote: specified list of thyroid conditions is defined in the Schedule 1 – Dictionary.\n\n(15) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of sick sinus syndrome;\n\nNote: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.\n\n(16) having obstructive sleep apnoea at the time of the clinical onset of sick sinus syndrome;\n\nNote: obstructive sleep apnoea is defined in the Schedule 1 - Dictionary.\n\n(17) having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical onset of sick sinus syndrome;\n\nNote: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 – Dictionary.\n\n(18) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical onset of sick sinus syndrome;\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) catheter ablation of arrhythmias;\n\n(b) open heart surgery; and\n\n(c) transcatheter aortic valve implantation.\n\n(19) having a heart transplant before the clinical onset of sick sinus syndrome;\n\n(20) having a surgical procedure involving general or regional anaesthesia within the 30 days before the clinical onset of sick sinus syndrome;\n\n(21) having cardiac stereotactic ablative radiotherapy or cryotherapy within the 6 months before the clinical onset of sick sinus syndrome;\n\n(22) experiencing penetrating trauma to the heart within the 3 months before the clinical onset of sick sinus syndrome;\n\n(23) taking a drug from the specified list of drugs within the 30 days before the clinical onset of sick sinus syndrome;\n\nNote: specified list of drugs is defined in the Schedule 1 - Dictionary.\n\n(24) undertaking strenuous physical activity greater than 6 METs:\n\n(a) for an average of at least 20 hours per week; and\n\n(b) for a continuous period of at least 5 years before the clinical onset of sick sinus syndrome; and\n\nif that strenuous physical activity has ceased before the clinical onset of sick sinus syndrome, then that onset occurred within 5 years of cessation;\n\nNote: MET is defined in the Schedule 1 – Dictionary.\n\n(25) being envenomated by a snake belonging to the family Viperidae within the 48 hours before the clinical onset of sick sinus syndrome;\n\n(26) having atrial fibrillation or atrial flutter at the time of the clinical worsening of sick sinus syndrome;\n\n(27) having hypertension at the time of the clinical worsening of sick sinus syndrome;\n\n(28) having ischaemic heart disease at the time of the clinical worsening of sick sinus syndrome;\n\n(29) having heart failure at the time of the clinical worsening of sick sinus syndrome;\n\n(30) having rheumatic fever at the time of the clinical worsening of sick sinus syndrome;\n\n(31) having pericarditis at the time of the clinical worsening of sick sinus syndrome;\n\n(32) having cardiomyopathy at the time of the clinical worsening of sick sinus syndrome;\n\n(33) having non-infectious myocarditis at the time of the clinical worsening of sick sinus syndrome;\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(34) having viral myocarditis at the time of the clinical worsening of sick sinus syndrome;\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(35) having a non-viral infection of the myocardium at the time of the clinical worsening of sick sinus syndrome;\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) Cysticercus species (cysticercosis);\n\n(c) Echinococcus species (hydatid disease);\n\n(d) Toxoplasma gondii (toxoplasmosis); and\n\n(e) Trypanosoma cruzi (Chagas disease).\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 sick sinus syndrome;\n\nNote: specified list of infiltrative diseases is defined in the Schedule 1 - Dictionary.\n\n(37) having a benign or malignant neoplasm involving the sinoatrial node before the clinical worsening of sick sinus syndrome;\n\nNote: A neoplasm involving the sinoatrial node can be primary or metastatic. An example of a primary neoplasm involving the sinoatrial node is cardiac lymphoma.\n\n(38) having a non-neoplastic lesion which compresses the sinoatrial node at the time of the clinical worsening of sick sinus syndrome;\n\nNote: Examples of non-neoplastic lesions which compress the sinoatrial node include cardiac tamponade and coronary artery aneurysm.\n\n(39) having a thyroid condition from the specified list of thyroid conditions at the time of the clinical worsening of sick sinus syndrome;\n\nNote: specified list of thyroid conditions is defined in the Schedule 1 – Dictionary.\n\n(40) having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of sick sinus syndrome;\n\nNote: specified list of autoimmune diseases is defined in the Schedule 1 - Dictionary.\n\n(41) having obstructive sleep apnoea at the time of the clinical worsening of sick sinus syndrome;\n\nNote: obstructive sleep apnoea is defined in the Schedule 1 - Dictionary.\n\n(42) having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical worsening of sick sinus syndrome;\n\nNote: specified list of mineral or electrolyte abnormalities is defined in the Schedule 1 – Dictionary.\n\n(43) having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical worsening of sick sinus syndrome;\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) catheter ablation of arrhythmias;\n\n(b) open heart surgery; and\n\n(c) transcatheter aortic valve implantation.\n\n(44) having a heart transplant before the clinical worsening of sick sinus syndrome;\n\n(45) having a surgical procedure involving general or regional anaesthesia within the 30 days before the clinical worsening of sick sinus syndrome;\n\n(46) having cardiac stereotactic ablative radiotherapy or cryotherapy within the 6 months before the clinical worsening of sick sinus syndrome;\n\n(47) experiencing penetrating trauma to the heart within the 3 months before the clinical worsening of sick sinus syndrome;\n\n(48) taking a drug from the specified list of drugs within the 30 days before the clinical worsening of sick sinus syndrome;\n\nNote: specified list of drugs is defined in the Schedule 1 - Dictionary.\n\n(49) being envenomated by a snake belonging to the family Viperidae within the 48 hours before the clinical worsening of sick sinus syndrome;\n\n(50) inability to obtain appropriate clinical management for sick sinus syndrome.\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(26) to 9(50) apply only to material contribution to, or aggravation of, sick sinus syndrome where the person's sick sinus syndrome 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\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\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 obstructive sleep apnoea means a type of sleep apnoea characterised on sleep study by repetitive cessation or decrease of airflow during sleep, despite respiratory effort.\n\nNote: Obstructive sleep apnoea includes upper airway resistance syndrome, which involves prolonged, partial obstruction of the upper airway during sleep.\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 sick sinus syndrome—see subsection 7(2).\n\n specified list of autoimmune diseases means:\n\n(a) rheumatoid arthritis; \n\n(b) systemic lupus erythematosus; or\n\n(c) systemic sclerosis (scleroderma).\n\n specified list of drugs means:\n\n(a) a general or regional anaesthetic;\n\n(b) acetylcholinesterase inhibitors including donepezil, galantamine, neostigmine and rivastigmine;\n\n(c) antidepressants including amitriptyline;\n\n(d) antihypertensives including clonidine and methyldopa;\n\n(e) antipsychotic phenothiazines;\n\n(f) beta blockers;\n\n(g) cardiac glycosides including digoxin;\n\n(h) class 1A, class 1C or class III anti-arrhythmic agents;\n\n(i) daclatasvir;\n\n(j) ergonovine;\n\n(k) lacosamide;\n\n(l) lidocaine;\n\n(m) lithium;\n\n(n) non-dihydropyridine calcium channel blockers including diltiazem and verapamil;\n\n(o) propoxyphene (dextropropoxyphene);\n\n(p) sofosbuvir;\n\n(q) ticagrelor;\n\n(r) tigecyclin; or\n\n(s) tyrosine kinase inhibitors.\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) hyperkalaemia;\n\n(b) hypocalcaemia; or\n\n(c) hypokalaemia.\n\n specified list of thyroid conditions means:\n\n(a) hyperthyroidism, including goitre and 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\n \n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"kimi_summary":{"content_quality":"ok","complexity_score":4,"scope_assessment":{"changed":false,"description":"This is a standard replacement Statement of Principles that maintains the established scope of the Repatriation Medical Authority's determinations. It updates the 2014 version with current medical knowledge (including additions like SARS-CoV-2 and immune checkpoint inhibitors) but does not expand beyond the original purpose of establishing medical connection factors for sick sinus syndrome in the veterans' compensation scheme."},"complexity_factors":["50 distinct factors listed in section 9, many with sub-conditions and time limits (e.g., 'within 30 days', 'within 5 years of cessation')","7 defined terms in Schedule 1 that reference other defined lists (e.g., 'specified list of drugs' contains 19 specific medications)","Cross-referencing structure: factors in section 9 point to definitions in Schedule 1, and section 11 creates dynamic links to other Statements of Principles","Dual application structure: factors 1-25 for clinical onset, factors 26-50 for clinical worsening, with different rules in section 10(2) for pre-existing conditions","Medical terminology throughout requiring specialist knowledge (e.g., 'METs', 'sinoatrial node', 'infiltrative diseases')","Conditional logic in factor 24 (strenuous physical activity) with three cumulative requirements plus a conditional fifth element"],"plain_english_summary":"This Statement of Principles (replacing the 2014 version) sets the medical rules for deciding whether Australian Defence Force members, veterans, and claimants under the Veterans' Entitlements Act and Military Rehabilitation and Compensation Act can get compensation for sick sinus syndrome. \n\nIt lists medical factors which, if at least one exists and can be plausibly linked to service, create a “reasonable hypothesis” that the condition is service-related — affecting access to pensions, treatment and other benefits."},"flash_summary":{"complexity_score":6,"scope_assessment":{"changed":true,"description":"This instrument replaces the 2014 Statement of Principles (see section 4) and, in doing so, expands and clarifies the set of factors that will raise a reasonable hypothesis linking sick sinus syndrome to relevant service. Compared with an earlier, single Statement, this version: (a) explicitly includes death from SSS where SSS contributed to a terminal event (section 7(5)); (b) enumerates a larger, more detailed set of factors and timing windows for both clinical onset and clinical worsening (section 9); (c) adds or updates examples of infectious and drug causes (Schedule 1 notes list SARS‑CoV‑2 and newer therapies such as immune checkpoint inhibitor therapy and tyrosine kinase inhibitors); (d) introduces a specific strenuous‑activity metric (MET) and a precise multi‑year threshold (item 24 and Schedule 1); and (e) recognises inability to obtain appropriate clinical management as a factor for worsening (item 50). Those additions broaden the clinical pathways by which service connection can be hypothesised and therefore materially change the practical scope compared with the prior instrument."},"complexity_factors":["50 discrete numbered factors in section 9 (items 1–50), split between onset (1–25) and worsening (26–50)","Multiple timing windows and conditional time limits (e.g. 30 days, 48 hours, 1 year, 6 months, 3 months, 5 years) creating many temporal conditions","Several specified lists in Schedule 1 (drugs ~19 entries, infiltrative diseases, thyroid conditions, autoimmune diseases, mineral/electrolyte abnormalities)","Cross‑references to other Statements of Principles where a factor refers to another disease (section 11)","Definitions and medical examples (e.g. viral and non‑viral myocarditis, obstructive sleep apnoea, MET) requiring clinical interpretation","Different legal tests for initial causation (reasonable hypothesis for onset) versus material contribution/aggravation for pre‑existing disease (section 10(2))","Repeal and replacement of an earlier Statement (administrative change that may shift interpretation and precedent)","Footnotes and notes that import examples (e.g. lists of infectious agents) which are not exhaustive but guide application"],"plain_english_summary":"**What this instrument does (mechanically)\n\n- Replaces the earlier Statement of Principles (No. 15 of 2014) and establishes a new Statement of Principles (No. 66 of 2022) about sick sinus syndrome (SSS) made by the Repatriation Medical Authority under subsection 196B(2) of the Veterans' Entitlements Act 1986 (see sections 3 and 4). \n- Applies to claims that are assessed under section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 (see section 5). \n- Defines the medical meaning of \"sick sinus syndrome\" for the purposes of veteran/military compensation claims, and includes death that was contributed to by SSS (see section 7). \n- Lists specific clinical and non‑clinical factors which, if present, are sufficient as a minimum to raise a \"reasonable hypothesis\" that the person's SSS (or death from SSS) is connected to their relevant service (see section 9). \n- States that any listed factor must be related to the person's relevant service (see section 10). \n- Provides a dictionary (Schedule 1) with technical definitions and several \"specified lists\" (for example, specified drugs, infiltrative diseases, thyroid conditions, autoimmune diseases, mineral/electrolyte abnormalities).\n\nOfficial purpose claim and the instrument's mechanics\n\n- The Repatriation Medical Authority states it made the Statement of Principles because it regards there as \"sound medical‑scientific evidence\" that SSS and death from SSS can be related to relevant service (see section 8). That is an express justification; the instrument then implements that judgment by setting out the legal test (the list of factors that will, if shown, raise a reasonable hypothesis linking SSS to service).\n\nWho this affects and why it matters\n\n- Who is affected: veterans and former or current members of the Australian Defence Force (and certain Peacekeeping Force members) who make claims under the VEA or MRCA asserting that sick sinus syndrome or death from sick sinus syndrome is connected to their service (section 5 and Schedule 1 definitions of \"relevant service\"). \n- Why it matters: this Statement of Principles is the medical/legal benchmark used when deciding whether there is a plausible, service‑related link between SSS and a person's service. If a claimant can establish at least one listed factor (and satisfy the timing/service relationship rules), decision‑makers may proceed on the basis that a \"reasonable hypothesis\" exists for a service connection. That affects entitlement outcomes under the VEA/MRCA.\n\nKey substantive features (how it works in practice)\n\n- Definition: SSS is defined as dysfunction of the sinus node producing clinically significant arrhythmias; congenital SSS is excluded (section 7(2)). Death is included if the SSS contributed to a terminal event (section 7(5) and Schedule 1). \n- Minimum evidence rule: the instrument does not require proof of a causal chain beyond a \"reasonable hypothesis\" — it specifies a list of factors (50 numbered items) and at least one must be present to meet that threshold (section 9). \n- Two categories of factors: (a) factors present at the clinical onset of SSS (items 1–25); and (b) factors present at clinical worsening of pre‑existing SSS (items 26–50). Items in the second category apply only where the SSS pre‑existed service or was suffered/contracted before or during (but did not arise out of) service — i.e. they operate as material contribution or aggravation tests (section 10(2)). \n- Specified lists: the Schedule identifies particular conditions, drugs and abnormalities (for example, a list of drugs at Schedule 1; a list of infiltrative diseases such as amyloidosis; viral myocarditis examples including SARS‑CoV‑2). These narrow or make explicit the clinical triggers listed in section 9. \n- Cross‑linking with other Statements of Principles: if a factor refers to another injury/disease that already has a Statement of Principles, that other Statement applies according to its own terms (section 11).\n\nPractical consequences, costs and incentives (mechanisms, not judgments)\n\n- Who decides: the Repatriation Medical Authority sets the Statement of Principles; claims decisions are made by the administering agency (using the Statement as the medical/legal standard). The instrument thus shifts the factual/legal threshold for claim assessment by specifying which clinical findings or exposures will suffice to raise a reasonable hypothesis (see sections 3, 5 and 9). \n- Evidence burden and claimant costs: claimants must produce clinical evidence showing a listed factor was present at the required time (onset or worsening) and that the factor is related to relevant service. That may require medical records, specialist reports, or tests. Where the factor refers to another disease, claimants may need evidence sufficient to engage the other Statement of Principles (section 11). \n- Administrative/compliance burden: decision‑makers must check timing, link to service, and possibly cross‑reference other Statements. The presence of many specific items (drugs, specific infections, procedures, timing windows) increases record‑checking and medical interpretation tasks. \n- Concentrated benefits and diffuse costs: the list creates a set of discrete pathways by which some claimants can more easily establish a reasonable hypothesis (concentrated benefit for those with listed factors); claimants whose plausible causes fall outside the list will face a higher hurdle (diffuse cost across those claimants). \n- Implementation risk and updating: clinical knowledge and practice evolve (new drugs, new infectious agents), and the instrument relies on specified lists and examples. Keeping the instrument aligned with current medical science requires periodic review by the Authority. \n- Behavioural incentives: the instrument may incentivise claimants and treating clinicians to document listed factors and timing precisely (for example, record exposure to specified drugs or procedures within the prescribed windows). It also makes explicit that lack of timely or appropriate clinical management can itself be a factor (item 50), which may affect how care records are compiled and presented.\n\nConcrete trade‑offs and opportunity costs\n\n- The Statement trades broader, clinician‑based causal assessment for a more administrable list: it lowers the threshold to a reasonable hypothesis when a listed factor is present, but that also concentrates decision‑weight on the presence or absence of specific items rather than broader clinical judgement alone (see section 9 and Schedule 1). \n- The specified timing windows (for example, 30 days after a drug, 1 year after thoracic surgery, 48 hours after Viperidae envenomation) impose clear cut‑offs that aid administrative certainty but can exclude borderline cases where causal linkage is medically plausible but outside the time limits (see items 18, 20, 23, 25, 43 and related notes). \n\nSelected notable items in the list (examples and where they appear)\n\n- Viral myocarditis including SARS‑CoV‑2 is explicitly mentioned as an example (items 9 and 34, Schedule 1 notes). \n- A long period of strenuous physical activity is listed with a specific threshold (greater than 6 METs, 20 hours per week on average, for at least 5 continuous years, with a 5‑year post‑cessation window) (item 24 and Schedule 1 definition of MET). \n- A broad \"specified list of drugs\" (Schedule 1) includes many commonly used cardiac‑ and CNS‑active agents (for example, beta blockers, digoxin, certain anti‑arrhythmics, some antivirals and tyrosine kinase inhibitors) and anaesthetics (item 23 and Schedule 1). \n- The instrument includes inability to obtain appropriate clinical management as a possible factor for clinical worsening (item 50). \n\nBottom line (mechanics and likely operational impact)\n\n- Mechanically, the Statement provides a concrete, list‑based test that claimants and decision‑makers use to determine whether a reasonable hypothesis exists linking sick sinus syndrome (or death from it) to relevant military service. It narrows and specifies the medical findings and timing that will satisfy that threshold, which should increase consistency of assessments but requires up‑to‑date medical documentation and administrative cross‑checking (see sections 7, 9, 10 and Schedule 1)."}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022","history":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022/history","analysis":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022/analysis","conflicts":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022/important-cases","documents":"/api/acts/statement-of-principles-concerning-sick-sinus-syndrome-reasonable-hypothesis-no-66-of-2022/documents"}}