Start formula, impairment rating based on FVC equals 108 –% FVC plus, start fraction, 100 over, open parentheses, % FVC minus 88.5, close parentheses, end fraction, end formula
Start formula, impairment rating based on MEF 25 to 75 equals 98 –% MEF plus, start fraction, 50 over, open parentheses, % MEF minus 90, close parentheses, end fraction, end formula
When the measured parameter is 85% or more of the predicted, then the impairment rating is defined as NIL
“%FEV1” means measured FEV1 expressed as a percentage of predicted FEV1.
“%FVC” means measured FVC expressed as a percentage of predicted FVC. “%MEF” means measured MEF 25‑75 expressed as a percentage of predicted MEF 25–75.
In each case the percentage is to be rounded to the nearest integer before the formula is applied.
If these formulas are applied the resulting impairment rating is always to be rounded to the nearest integer.
Step 5: Calculate the total accepted cardiorespiratory functional impairment rating.
At this stage there will usually be an impairment rating derived from effort tolerance information and there may also be an impairment rating derived from measurements of lung function. These must be combined into a single cardiorespiratory functional impairment rating. The method by which that is to be done is set out in Table 1.5.
For the purposes of Table 1.5, the following abbreviations have been used:
Abbreviation
Meaning
“FI”
means cardiorespiratory functional impairment rating.
“No FI”
means a cardiorespiratory functional impairment rating cannot be calculated from either effort tolerance information or measurements of lung function.
“METs”
means the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from METs alone.
“Spirometry”
means the cardiorespiratory functional impairment rating is to be taken as the impairment rating derived from measurements of respiratory function.
“average of METs and Spirometry”
means the average of the cardiorespiratory functional impairment rating derived from METs alone and the cardiorespiratory functional impairment rating derived from measurements of respiratory function alone — using the ordinary formula for averaging two quantities or by use of the nomogram in Figure 1c. In either case, the result is to be rounded to the nearest integer.
Procedural Table 1.5 Combined male and female symbol
CARDIORESPIRATORY FUNCTIONAL IMPAIRMENT
Respiratory disease present No respiratory disease
Spirometry obtainable Spirometry not obtainable
Cardiac disease present METs data obtainable FI = higher of METs and Spirometry FI = METs FI = METs
METs data not obtainable FI = Spirometry No FI No FI
No cardiac disease METs data obtainable FI = average of METs and Spirometry FI = METs
METs data not obtainable FI = Spirometry No FI
In applying this table, both accepted and non‑accepted conditions are to be taken into account.
No age adjustment permitted for this table
From Table 1.5 it will be seen that:
if cardiac conditions exist in the absence of respiratory disease, cardiorespiratory functional impairment should be measured by effort tolerance alone;
if respiratory conditions exist in the absence of cardiac disease, the cardiorespiratory functional impairment rating is the rounded average of (i) impairment as measured by effort tolerance, and (ii) impairment as measured by spirometry;
if both cardiac and respiratory conditions co‑exist, the cardiorespiratory functional impairment rating is the greater of (i) the impairment rating as measured by effort tolerance, and (ii) the impairment rating as measured by spirometry.
In applying these rules, both accepted and non‑accepted cardiac and respiratory conditions are to be taken into account.
Only one rating for effort tolerance is to be given irrespective of the number of conditions that contribute to the relevant impairment.
Only one rating is to be given for physiological measurements of lung function irrespective of the number of conditions that contribute to the relevant impairment.
This single “total cardiorespiratory functional impairment” is due to the combined effect of all cardiorespiratory conditions whether accepted or not.
FIGURE 1c ‑ LOSS OF REPIRATORY FUNCTION RESPIRATORY NOMOGRAM
Graph depicting a loss of respiratory function respiratory nomogram
This nomogram is to be used in accordance with the instructions in Step 5 and the procedural Table 1.5.
Results from this nomogram are to be rounded to the nearest five points. 2.5 is to be rounded up to 5 and 7.5 is to be rounded up to 10.
This nomogram corresponds to the formula:
Start formula, impairment rating equals, start fraction, METs impairment rating plus impairment rating of physiological measurement over 2, end fraction, end formula
Step 6: Consider the effects of cardiac failure (if any).
For the purposes of assessment under this Guide, cardiac failure is considered to be a surrogate measure of cardiorespiratory impairment. When cardiac failure is present, the impairment rating calculated using effort tolerance will usually exceed any possible impairment rating from Table 1.6. Table 1.6 is of particular importance in assessing a veteran who is unable to be rated using effort tolerance because of significant conditions such as hemiplegia.
Functional Loss Table 1.6 Combined male and female symbol
CARDIAC FAILURE
Impairment Ratings Criteria
NIL No cardiac failure; that is, neither symptoms nor X‑ray evidence of cardiac failure.
TEN No symptoms, but X‑ray evidence of early cardiac failure. Evidence of right ventricular failure.
FIFTEEN Left or biventricular cardiac failure demonstrated by ejection fraction of between 40% and 60% and persisting despite therapy.
TWENTY Left or biventricular cardiac failure demonstrated on X‑ray or by ejection fraction of less than or equal to 40% and persisting despite therapy.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment allowed for this table
A rating from Table 1.6 is to be compared with the total cardiorespiratory functional impairment rating (obtained in Step 5) and the higher of the two is to be chosen.
Step 7: Moderate the total cardiorespiratory functional impairment rating to allow for effects of any non‑accepted conditions.
Partially contributing impairment
If non‑accepted conditions contribute to the impairment, Chapter 19 (Partially Contributing Impairment) is to be applied to determine impairment from the accepted conditions.
If cardiac conditions exist in the absence of respiratory disease: if there is more than one cardiac condition present (for example ischaemic heart disease and a valvular heart disease) and some are accepted and some are not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition.
If a respiratory condition exists in the absence of cardiac disease, the symptomatic activity level will generally be the exercise level (in METs) at which dyspnoea occurs. If there is more than one respiratory condition present and at least one is accepted and at least one is not accepted, then the total cardiorespiratory functional impairment rating must be moderated by applying Chapter 19 to determine the impairment due to the accepted condition or conditions.
If cardiac and respiratory conditions co‑exist, and at least one is accepted and at least one is not accepted, it is necessary to determine the total cardiorespiratory functional impairment rating (as set out in the previous steps), and then to moderate that rating by applying Chapter 19 to determine the impairment due to the accepted condition.
The result that is then derived is the “total accepted cardiorespiratory functional impairment rating”.
Step 8: Determine whether any ratings from the cardiorespiratory Other Impairment tables apply.
Cardiorespiratory Other Impairment tables
Once the total accepted cardiorespiratory functional impairment rating has been determined, it must be compared with the relevant cardiorespiratory Other Impairment tables. For assessment purposes, four categories of cardiorespiratory condition are recognised. These categories are:
ischaemic heart disease;
valvular heart disease;
miscellaneous heart disease; and
lower respiratory tract conditions.
There are four cardiorespiratory Other Impairment tables — corresponding to each of the above categories. These tables are:
Only one rating is to be selected from each of these cardiorespiratory Other Impairment tables (Tables 1.7, 1.8, 1.9, and 1.10) for any condition or combination of conditions.
If accepted conditions belonging to more than one of the four categories of cardiorespiratory disease above are present, then the relative contribution of their effect on the total accepted cardiorespiratory functional impairment must be estimated by applying Chapter 20 (Apportionment). The rating for each condition will be the higher of the cardiorespiratory functional impairment rating attributed to it and its cardiorespiratory Other Impairment rating.
The cardiorespiratory worksheet (at page 29) should also be consulted.
Other Impairment Table 1.7 Combined male and female symbol
NIL No history of symptoms but evidence of transient ischaemia on exercise ECG testing.
TEN Coronary artery disease, characterised by typical history of angina pectoris. Coronary artery disease, characterised by history of uncomplicated myocardial infarct, with no subsequent evidence of cardiac failure and infrequent or no angina. Coronary artery disease, with single vessel disease (other than left main coronary) demonstrated on angiogram. Coronary artery disease with successful coronary artery surgery, followed by no angina or only infrequent angina but no further infarcts or cardiac failure.
FIFTEEN Coronary artery disease with multi‑vessel disease (not successfully corrected) demonstrated on angiogram.
TWENTY Coronary artery disease characterised by a history of myocardial infarct followed, immediately or after a lapse of time, by continuing angina or further infarcts. Coronary artery disease characterised by left main coronary artery disease (not successfully corrected) demonstrated on angiogram. Coronary artery disease with successful coronary artery surgery, followed, after a lapse of time, by frequent angina or further infarcts or cardiac failure.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
Other Impairment Table 1.8 Combined male and female symbol
NIL Mitral valve prolapse with no or minimal symptoms. Aortic sclerosis with no or minimal symptoms.
FIVE Diagnosed valvular heart disease (other than mitral valve prolapse or aortic sclerosis) with no symptoms and no X‑ray evidence of cardiac failure.
TEN Valvular heart disease with successful valve replacement, not requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.
FIFTEEN Valvular heart disease with successful valve replacement, requiring anticoagulant medication, with no subsequent symptoms or evidence of cardiac failure.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
Other Impairment Table 1.9 Combined male and female symbol
CARDIORESPIRATORY IMPAIRMENT: MISCELLANEOUS
Impairment Ratings Criteria
NIL Flow murmurs.
TWO Chronic asymptomatic arrhythmia, eg. atrial fibrillation, atrial or ventricular ectopic beats.
FIVE Need for a permanent pacemaker.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
Arrhythmias are usually to be rated by applying Chapter 15 (Intermittent Impairment) unless they cause a permanent restriction of exercise tolerance, in which case they are to be assessed by their effect on effort tolerance.
Other Impairment Table 1.10 Combined male and female symbol
TWO Recurrent lower respiratory infections (at least 6 per year) Intermittent use of bronchodilator medication.
FIVE Daily use of inhaled steroids required. Regular, daily use of bronchodilator medication. Chronic cough, with production of at least 50mL sputum/day.
TEN Regular, daily use of bronchodilator medication required in addition to daily inhaled steroids. Chronic cough, with production of at least 100 mL sputum/day.
TWENTY Repeated courses (at least several courses per year) or permanent use of oral steroids required.
Only one rating is to be selected from this table for any condition or combination of conditions. If more than one criterion applies, that which gives the higher or highest rating is to be chosen.
No age adjustment permitted for this table
Peripheral Vascular Conditions
Tables 1.2 and 1.3 are to be applied to assess those conditions that affect exercise tolerance from a cardiorespiratory point of view. Peripheral vascular conditions typically cause loss of function of the lower limbs only and therefore are to be assessed under lower limb impairment (using Chapter 3).
Atherosclerosis frequently causes both a cardiorespiratory condition and a peripheral vascular condition. In such cases, if both types of conditions are accepted conditions, then both conditions are to be rated using the appropriate assessment procedure.
The rating of asthma depends on the clinical circumstances. If asthma has caused chronic airways obstruction the method of assessment described in this chapter is to be applied. If there is little fixed obstruction and a large reversible component, the rating is to be based on the occurrence of attacks using the method of intermittent impairment (Chapter 15). Asthma can also be rated, if there is minimal loss of function, from Table 1.10.
A cardiorespiratory worksheet to note various assessment details
CHAPTER 2
HYPERTENSION AND NON‑CARDIAC VASCULAR CONDITIONS
This Chapter contains three parts:
Part 2.1 — Hypertension
Part 2.2 — Vascular Conditions of the Lower Limbs
Part 2.3 — Other Non‑Cardiac Vascular Conditions
INTRODUCTION
This chapter is to be applied in determining impairment ratings for hypertension and non‑cardiac vascular conditions. For conditions affecting the heart itself refer to Chapter 1 (Cardiorespiratory Impairment).
PART 2.1: HYPERTENSION
Hypertension, of itself, does not affect effort tolerance. Therefore, uncomplicated hypertension is not to be assessed under Chapter 1 (Cardiorespiratory Impairment) but in the manner set out below.
Calculation of the impairment rating for hypertension
Follow the steps below to calculate the impairment rating for hypertension.
STEP 1
Establish whether any target organ damage is present.
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STEP 2
(Omit this step if there is no target organ damage.)<br>Calculate the total functional impairment for any accepted target organ damage
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STEP 3
Calculate the Other Impairment rating for the accepted hypertension by applying Table 2.1.1.
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STEP 4
(Omit this step if there is no target organ damage.)<br>Compare the rating obtained in Step 2 with the rating obtained in Step 3. Take the higher of these two ratings
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Step 1: Establish whether any target organ damage is present.
For the purposes of this chapter, “target organ damage” means any of the following:
hypertensive retinopathy, grade III or IV;
hypertensive cardiac disease, with ECG or X‑ray evidence of left ventricular hypertrophy;
hypertensive nephropathy demonstrated at biopsy, or by presence of proteinuria or elevated serum creatinine level; or
hypertensive cerebral haemorrhage.
Certain other conditions have hypertension as a contributing factor in their aetiology (for example: ischaemic heart disease and peripheral vascular disease). Such conditions are not to be regarded as being target organ damage when applying Part 2.1.
Step 2: Calculate the total functional impairment due to any accepted target organ damage.
Accepted hypertensive retinopathy is to be assessed by applying Chapter 8.
If other ophthalmic conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.
Accepted hypertensive cardiac disease is to be assessed by applying Chapter 1.
If other cardiorespiratory conditions are present, they must be allowed for by applying Chapter 20 (Apportionment) or Chapter 19 (Partially Contributing Impairment) as appropriate.
Accepted hypertensive nephropathy is to be assessed by applying Chapter 9.