## Section E. Cardiovascular System Conditions

#### Overview

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| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  20           Heart Conditions                               4-E-2

  21           Residuals of Cold Injuries                     4-E-7
  ------------ ---------------------------------------------- ------------

#### 20. Heart Conditions

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| ##### In   | > This topic contains information about heart           |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   definition of the term ***congenital heart          |
|            |     defect***                                           |
|            |                                                         |
|            | -   definition of the term ***arteriosclerotic heart    |
|            |     disease***                                          |
|            |                                                         |
|            | -   granting service connection for arteriosclerotic    |
|            |     heart disease                                       |
|            |                                                         |
|            | -   rating hypertensive vascular disease                |
|            |                                                         |
|            | -   considering the long term effects of hypertension   |
|            |                                                         |
|            | -   granting service connection arteriosclerotic        |
|            |     manifestations due to hypertension                  |
|            |                                                         |
|            | -   effects of rheumatic heart disease                  |
|            |                                                         |
|            | -   rheumatic heart disease coexisting with             |
|            |     hypertensive or arteriosclerotic heart disease, and |
|            |                                                         |
|            | -   considering conditions subsequent to amputation.    |
+------------+---------------------------------------------------------+

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| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > ***Congenital heart defects*** include common heart   |
| # a. Defin | > conditions due to prenatal influences, such as        |
| ition: Con |                                                         |
| genital He | -   patent foramen ovale                                |
| art Defect |                                                         |
|            | -   patent ductus arteriosus                            |
|            |                                                         |
|            | -   coarctation of the aorta, and                       |
|            |                                                         |
|            | -   intraventricular septal defect.                     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > ***Arteriosclerotic heart disease***, also diagnosed  |
| #### b. De | > as ischemic heart disease and coronary heart disease, |
| finition:  | > is a disease of the heart caused by the diminution of |
| Arterioscl | > blood supply to the heart muscle due to narrowing of  |
| erotic Hea | > the cavity of one or both coronary arteries due to    |
| rt Disease | > the accumulation of fatty material on the inner       |
|            | > lining of the arterial wall.                          |
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Continued on next page

20\. Heart Conditions, Continued

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| #          | > Grant service connection for any sudden development   |
| #### c. Gr | > during service of coronary occlusion or thrombosis.   |
| anting Ser | >                                                       |
| vice Conne | > ***Notes***:                                          |
| ction for  |                                                         |
| Arterioscl | -   The mere identification of coronary heart disease   |
| erotic Hea |     upon routine examination early in service is *not*  |
| rt Disease |     a basis for service connection.                     |
|            |                                                         |
|            | -   Under [38 CFR                                       |
|            |     3.6(a)](http:/                                      |
|            | /www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_6.DOC), |
|            |     inactive duty for training qualifies as active      |
|            |     service if an individual becomes disabled or dies   |
|            |     from an acute myocardial infarction, a cardiac      |
|            |     arrest, or a cerebrovascular accident occurring     |
|            |     during such training.                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Evaluate hypertension separately from hypertensive    |
|  d. Rating | > heart disease and other types of heart disease.       |
|  Hypertens | >                                                       |
| ive Vascul | > Evaluate hypertension due to aortic insufficiency or  |
| ar Disease | > hyperthyroidism, which is usually the isolated        |
|            | > systolic type, or the elevation of systolic or        |
|            | > diastolic blood pressure due to nephritis, as part of |
|            | > the condition causing it rather than by a separate    |
|            | > evaluation.                                           |
|            | >                                                       |
|            | > However, a separate evaluation for hypertension may   |
|            | > be awarded when the sole renal disability is the      |
|            | > absence of a kidney, or the requirement of regular    |
|            | > dialysis.                                             |
|            | >                                                       |
|            | > ***Note***: The cause of hypertension is unknown in   |
|            | > the vast majority of cases.                           |
|            | >                                                       |
|            | > ***References***: For more information on             |
|            |                                                         |
|            | -   hypertension, see [38 CFR                           |
|            |     4.104](http://w                                     |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_104.DOC), |
|            |     Diagnostic Code 7101, and                           |
|            |                                                         |
|            | -   hypertension and nephritis, see [38 CFR             |
|            |     4.115](http://w                                     |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_115.DOC). |
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Continued on next page

20\. Heart Conditions, Continued

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| #####      | > Hypertension may                                      |
|  e. Consid |                                                         |
| ering Long | -   exist for years without causing symptoms            |
|  Term Effe |                                                         |
| cts of Hyp | -   so increase the cardiac load as to result in        |
| ertension  |     hypertrophy of the cardiac muscle or cardiac        |
|            |     dilation and decompensation, if sufficiently        |
|            |     severe, and                                         |
|            |                                                         |
|            | -   cause arteriosclerosis of uneven distribution that  |
|            |     often involves the vessels of one organ to a        |
|            |     greater degree than those of the rest of the body,  |
|            |     in cases where hypertension is long-standing.       |
|            |                                                         |
|            | > If the hypertension is of sufficient degree to cause  |
|            | > significant impairment of circulation to the organ,   |
|            | > symptoms will manifest in accordance with the         |
|            |                                                         |
|            | -   organ involved, and                                 |
|            |                                                         |
|            | -   degree of impairment.                               |
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| ##         | > If any of the following arteriosclerotic              |
| ### f. Gra | > manifestations are diagnosed in a veteran with        |
| nting Serv | > service-connected (SC) hypertension, grant service    |
| ice Connec | > connection through the relationship to hypertension:  |
| tion for A |                                                         |
| rterioscle | -   symptoms and signs in the brain that warrant a      |
| rotic Mani |     diagnosis of cerebral arteriosclerosis or           |
| festations |     thrombosis with hemiplegia                          |
|  Due to Hy |                                                         |
| pertension | -   nephrosclerosis of the kidneys with impairment of   |
|            |     renal function, or                                  |
|            |                                                         |
|            | -   myocardial damage or coronary occlusion of the      |
|            |     heart.                                              |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   Arteriosclerosis occurs with advancing age without  |
|            |     preexisting hypertension, and may occur in some     |
|            |     younger individuals who are predisposed to arterial |
|            |     changes.                                            |
|            |                                                         |
|            | -   The existence of arteriosclerosis does not imply or |
|            |     indicate previous hypertension.                     |
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Continued on next page

20\. Heart Conditions, Continued

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| ###        | > Chronic rheumatic heart disease results from single   |
| ## g. Effe | > or repeated attacks of rheumatic fever which produce  |
| cts of Rhe |                                                         |
| umatic Hea | -   rigidity and deformity of the cusps                 |
| rt Disease |                                                         |
|            | -   fusion of the commissures, or                       |
|            |                                                         |
|            | -   shortening and fusion of the chordae tendineae.     |
|            |                                                         |
|            | > The earliest evidence of                              |
|            |                                                         |
|            | -   organic valvular disease is a significant murmur,   |
|            |     and                                                 |
|            |                                                         |
|            | -   hemodynamically significant valvular lesions found  |
|            |     on x-ray, fluoroscopy, and electrocardiogram (ECG)  |
|            |     study, since these reveal the earliest stages of    |
|            |     specific chamber enlargement.                       |
|            |                                                         |
|            | > Grant service connection for an aortic valve          |
|            | > insufficiency that manifests without other cause      |
|            | > after an in-service case of rheumatic fever.          |
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| #####      | > Accepted medical principles do not concede an         |
|  h. Rheuma | > etiological relationship between rheumatic heart      |
| tic Heart  | > disease and either hypertensive or arteriosclerotic   |
| Disease Co | > heart disease.                                        |
| existing W | >                                                       |
| ith Hypert | > If a veteran who is SC for rheumatic heart disease    |
| ensive or  | > develops hypertensive or arteriosclerotic heart       |
| Arterioscl | > disease after the applicable presumptive period       |
| erotic Hea | > following military discharge, request a medical       |
| rt Disease | > opinion to determine which condition is causing the   |
|            | > current signs and symptoms.                           |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   If the examiner is unable to separate the effects   |
|            |     of one type of heart disease from another, the      |
|            |     effects must be rated together.                     |
|            |                                                         |
|            | -   Do not extend service connection to systemic        |
|            |     manifestations or arteriosclerosis in areas remote  |
|            |     from the heart, since medically there is no         |
|            |     recognized etiological relationship between         |
|            |     rheumatic heart disease and later developing        |
|            |     hypertensive or arteriosclerotic changes.           |
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20\. Heart Conditions, Continued

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| #####      | > Grant service connection on a secondary basis for the |
| i. Conside | > following conditions that develop subsequent to the   |
| ring Condi | > SC amputation of one lower extremity at or above the  |
| tions Subs | > knee, or SC amputations of both lower extremities at  |
| equent to  | > or above the ankles:                                  |
| Amputation |                                                         |
|            | -   ischemic heart disease, or                          |
|            |                                                         |
|            | -   other cardiovascular disease, including             |
|            |     hypertension.                                       |
|            |                                                         |
|            | > ***Reference***: For more information on proximate    |
|            | > results or secondary conditions, see [38 CFR          |
|            | > 3.310(b)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_310.DOC). |
+------------+---------------------------------------------------------+

#### 21. Residuals of Cold Injuries

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about residuals of    |
| troduction | > cold injury, including                                |
|            |                                                         |
|            | -   the general effects of injury due to cold           |
|            |                                                         |
|            | -   long-term effects of exposure to cold               |
|            |                                                         |
|            | -   the chronic effects of exposure to cold             |
|            |                                                         |
|            | -   granting service connection for residuals of cold   |
|            |     injuries                                            |
|            |                                                         |
|            | -   considering cold injuries incurred during the       |
|            |     Chosin Reservoir Campaign, and                      |
|            |                                                         |
|            | -   granting service connection for cold injuries       |
|            |     incurred during the Chosin Reservoir Campaign.      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Injury due to exposure to extremely cold temperatures |
| a. General | > causes structural and functional disturbances of      |
|  Effects o |                                                         |
| f Injury D | -   small blood vessels                                 |
| ue to Cold |                                                         |
|            | -   cells                                               |
|            |                                                         |
|            | -   nerves                                              |
|            |                                                         |
|            | -   skin, and                                           |
|            |                                                         |
|            | -   bone.                                               |
|            |                                                         |
|            | > The physical effects of exposure may be acute or      |
|            | > chronic, with immediate or latent manifestations.     |
|            | >                                                       |
|            | > ***Examples***: Exposure to                           |
|            |                                                         |
|            | -   damp cold temperatures (around freezing) cause      |
|            |     frostnip and immersion or trench foot.              |
|            |                                                         |
|            | -   dry cold, or temperatures well below freezing,      |
|            |     cause frostbite with, in severe cases, loss of body |
|            |     parts, such as fingers, toes, earlobes, or the tip  |
|            |     of the nose.                                        |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > The fact that the immediate effects of cold injury    |
| b. Long-Te | > may have been characterized as "*acute"* or           |
| rm Effects | > "*healed"* does not preclude development of           |
|  of Exposu | > disability at the original site of injury many years  |
| re to Cold | > later.                                                |
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21\. Residuals of Cold Injuries, Continued

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| ####       | > Veterans with a history of cold injury may experience |
| # c. Chron | > the following signs and symptoms at the site of the   |
| ic Effects | > original injury:                                      |
|  of Exposu |                                                         |
| re to Cold | -   chronic fungal infection of the feet                |
|            |                                                         |
|            | -   disturbances of nail growth                         |
|            |                                                         |
|            | -   hyperhidrosis                                       |
|            |                                                         |
|            | -   chronic pain of the causalgia type                  |
|            |                                                         |
|            | -   abnormal skin color or thickness                    |
|            |                                                         |
|            | -   cold sensitization                                  |
|            |                                                         |
|            | -   joint pain or stiffness                             |
|            |                                                         |
|            | -   Raynaud's phenomenon                                |
|            |                                                         |
|            | -   weakness of hands or feet                           |
|            |                                                         |
|            | -   night pain                                          |
|            |                                                         |
|            | -   weak or fallen arches                               |
|            |                                                         |
|            | -   edema                                               |
|            |                                                         |
|            | -   numbness                                            |
|            |                                                         |
|            | -   paresthesias                                        |
|            |                                                         |
|            | -   breakdown or ulceration of cold injury scars        |
|            |                                                         |
|            | -   vascular insufficiency, indicated by edema, shiny,  |
|            |     atrophic skin, or hair loss, and                    |
|            |                                                         |
|            | -   increased risk of developing conditions, such as    |
|            |                                                         |
|            | ```{=html}                                              |
|            | <!-- -->                                                |
|            | ```                                                     |
|            | -   peripheral neuropathy                               |
|            |                                                         |
|            | -   squamous cell carcinoma of the skin, at the site of |
|            |     the scar from a cold injury, or                     |
|            |                                                         |
|            | -   arthritis or other bone abnormalities, such as      |
|            |     osteoporosis, or subarticular punched-out lesions.  |
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21\. Residuals of Cold Injuries, Continued

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| ##### d    | > Grant service connection for the residuals of cold    |
| . Granting | > injury if                                             |
|  Service C |                                                         |
| onnection  | -   the cold injury was incurred during military        |
| for Residu |     service, and                                        |
| als of Col |                                                         |
| d Injuries | -   an intercurrent nonservice-connected (NSC) cause    |
|            |     cannot be determined.                               |
|            |                                                         |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   The fact that an NSC systemic disease that could    |
|            |     produce similar findings is present, or that other  |
|            |     areas of the body not affected by cold injury have  |
|            |     similar findings, does not necessarily preclude     |
|            |     service connection for residual conditions in the   |
|            |     cold-injured areas.                                 |
|            |                                                         |
|            | -   When considering the possibility of intercurrent    |
|            |     cause, always resolve reasonable doubt in the       |
|            |     veteran's favor.                                    |
|            |                                                         |
|            | > ***Reference***: For more information on reasonable   |
|            | > doubt, see [38 CFR                                    |
|            | > 3.102](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_102.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > The Chosin Reservoir Campaign was conducted during    |
| #### e. Co | > the Korean War, October 1950 through December 1950,   |
| nsidering  | > in temperatures of --20ºF or lower. Many participants |
| Cold Injur | > in this campaign suffered from frostbite for which    |
| ies Incurr | > they received no treatment and, as a result, there    |
| ed During  | > may be no service treatment records (STRs) to         |
| the Chosin | > directly support their claims for frostbite.          |
|  Reservoir | >                                                       |
|  Campaign  | > If the veteran's participation in the Chosin          |
|            | > Reservoir Campaign is confirmed, concede exposure to  |
|            | > extreme cold under the provisions of [38 U.S.C.       |
|            | > 1154(a)](http://straylight.law.cornell.edu/           |
|            | uscode/html/uscode38/usc_sec_38_00001154----000-.html). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Grant service connection under the provisions of [38  |
| #### f. Gr | > CFR                                                   |
| anting Ser | > 3.303(a)](http://                                     |
| vice Conne | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC) |
| ction for  | > and [38 CFR                                           |
| Cold Injur | > 3.304(d)](http://                                     |
| ies Incurr | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_304.DOC) |
| ed During  | > if                                                    |
| the Chosin |                                                         |
|  Reservoir | -   the veteran has a disability which is diagnosed as  |
|  Campaign  |     a residual of cold injury, and                      |
|            |                                                         |
|            | -   there are no other circumstances to which this      |
|            |     disability may be attributed.                       |
+------------+---------------------------------------------------------+