V

### **VALVULAR OR CONGENITAL DISORDERS**

##### [Aortic Insufficiency or Regurgitation]{.underline}

Aortic insufficiency occurs when the aortic valve fails to close
properly, allowing blood in the aorta to flow back into the left
ventricle during diastole. This tends to overfill the left ventricles
causing a large heart on chest x-ray and an increased left ventricular
internal diameter (LVID) on echocardiogram. An aortic diastolic murmur,
which may radiate down the left sternal border, is usually present.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------- -----------------------------
  Age 15-49                                 225

  Age 50 and over                           150

  Age 35 and up, normal heart size by x-ray Allow up to 1/3 credit
  and/or echocardiogram                     

  Diastolic blood pressure less than 65,    Add 100
  pulse pressure more than 70               

  Enlarged heart by x-ray or                Add 100-R
  echocardiogram, or LVH on ECG             
  ----------------------------------------- -----------------------------

##### [Aortic Stenosis]{.underline}

The aortic valve may fail to open completely and cause obstruction to
outflow of blood from the left ventricle. A common cause of aortic valve
stenosis is congenital fusion of valve leaflets (bicuspid aortic valve).

The murmur of aortic stenosis is systolic, harsh and best heard at the
upper right sternum often radiating into the neck.

#### **Underwriting Requirements**

An APS (VA Form 299-8158) is required.

  ----------------------------------------- -----------------------------
  Ages 15-49                                200

  Ages 50 and up                            125

  Age 35 and up, normal heart size by x-ray Allow up to 1/3 credit
  and/or echocardiogram                     

  Shortness of breath with exertion         Add 100

  Enlarged heart by x-ray or echocardiogram Add 100-R
  or LVH on ECG                             

  Syncope, angina or history of CHF         R
  ----------------------------------------- -----------------------------

If aortic insufficiency and stenosis are both present, rate as aortic
insufficiency.

Aortosclerosis refers to age related degeneration of the aortic valve
and may or may not mean that the valve is actually stenotic. Individual
consideration.

##### [Mitral Insufficiency]{.underline}

If the mitral valve fails to close during systole and allows blood to
flow back into the left atrium, mitral insufficiency is present. A
systolic, apical murmur radiating into the axilla is expected.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------- -----------------------------
  Ages 15-49                                200

  Ages 50 and up                            125

  Age 35 and up, normal heart size by x-ray All up to 1/3 credit
  and/or echocardiogram                     

  Enlarged heart by x-ray or                Add 100-R
  echocardiogram, or LVH on ECG             

  Associated with mitral stenosis           Rate as Mitral Stenosis
  ----------------------------------------- -----------------------------

##### [Mitral Stenosis]{.underline}

Failure of the mitral valve to open completely impedes blood flow into
the left ventricle. Most cases are due to rheumatic fever. Dyspnea and
atrial fibrillation may occur. An opening snap and a diastolic or
presystolic apical murmur may be heard.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------- -----------------------------
  Mitral stenosis, with or without          
  commissurotomy                            

  Ages 15-49                                250

  Age 50 and over                           175

  With atrial fibrillation, even if         R
  controlled                                

  Age 35 and up, normal heart size by x-ray All up to 1/3 credit
  and/or echocardiogram                     

  Enlarged heart by x-ray or                Add 100-R
  echocardiogram, or LVH on ECG             
  ----------------------------------------- -----------------------------

##### [Mitral Valve Prolapse (MVP), Barlow's Syndrome, Click-Murmur Syndrome]{.underline}

These are names for a generally benign condition in which the mitral
leaflets become weakened and fail to close properly, often producing a
soft systolic murmur and a click, atypical chest pain, dyspnea and
fatigue. In advanced cases significant mitral insufficiency may develop.
Typically the condition is found by echocardiogram.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------- -------------------------
  MVP, Barlow's Syndrome, Click-Murmur Syndrome 0

  With LVH or cardiomegaly                      Rate as Mitral
                                                Insufficiency
  --------------------------------------------- -------------------------

##### [Murmurs]{.underline}

A heart murmur is a sound produced by blood flow through the heart.
Sometimes a murmur is an indication of heart disease but murmurs
commonly occur in completely normal hearts. Murmurs are physical
findings -- they are not a form of heart disease. Every effort should be
made to underwrite a specific heart condition rather than the murmur
itself. However, when no further information is available, debits are
assigned for unexplained heart murmurs.

A murmur caused by a structural abnormality of the heart is called an
organic murmur. A murmur resulting from turbulent blood flow in an
entirely normal heart is called a functional murmur.

**Timing** -- murmurs occur while the heart is contracting (systolic) or
while the heart is relaxing (diastolic or pre-systolic).

**Loudness** -- the intensity of a murmur is described on a scale of I
through VI. This is a subjective finding and the difference of one grade
does not indicate a significant change.

**Quality** -- the character of a murmur may be described in a variety
of ways such as harsh, blowing, musical or rough.

**Location** -- a murmur may be loudest in any of four common areas: the
apex (tip of the heart), the left sternal border (LSB), upper right
sternal border (aortic area), or upper left sternal border (pulmonic
area).

**Radiation** -- radiation of a murmur is diagrammed with an arrow.

Functional (innocent, ejection, benign) heart murmurs tend to occur
along the left sternal border or the apex, are rarely louder than grade
II/VI and do not radiate. They are very common in younger people and
less likely to occur in the elderly.

Functional murmurs and the murmur associated with mitral valve prolapse
and IHSS tend to be present only intermittently. As a rule, murmurs
caused by valvular or congenital heart disease change only gradually
over the years.

Organic murmurs may radiate to the neck or axilla and may be associated
with thrills (vibrations felt with the hand) or gallop rhythms (S3 and
S4 sounds). Diastolic or presystolic murmurs always represent organic
disease.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

**Use of the Murmur Table**

Where a murmur is described in the examination and there is no other
information, such as physician records or diagnostic tests, enter the
table where indicated. If a definite diagnosis is made on the basis of
examination or studies such as echocardiogram or catheterization, the
murmur should be rated under that condition, e.g., aortic stenosis.

**Discrepant records** -- in general, murmurs are poorly described, and
even where well described, the interpretations may vary among reasonable
observers. Where there is conflicting information, judgment must be used
in giving appropriate weight to objective tests and to the experience
and training of the physicians. A diagnosis from a cardiologist can
usually be accepted as definitive.

**Complications** -- in any murmur in which there is a history of
congestive heart failure, unusual dyspnea, angina, a finding of enlarged
heart on exam or x-ray, abnormal findings on ECG, echo or
catheterization, or significant arrhythmia such as atrial fibrillation,
significant additional debits or rejection may be called for.
Conversely, where there is a normal heart size and electrocardiogram in
the presence of an organic murmur, up to 1/3 credits may be allowed.

**Murmur Table**

+-------------------------+-----+--------+--------+--------+---------+
| **Systolic murmurs**    |     | Age    | Age    | Age    | Age     |
|                         |     |        |        |        |         |
| **Basic Debits**        |     | 15-29  | 30-39  | 40-49  | 50 and  |
|                         |     |        |        |        | Up      |
+-------------------------+-----+--------+--------+--------+---------+
| Grade or intensity at   | I   | 20     | 20     | 30     | 40      |
| rest, loudest systolic  |     |        |        |        |         |
| (if also a diastolic    | II  | 80     | 60     | 60     | 60      |
| murmur, see double      |     |        |        |        |         |
| murmur)                 | III | 175    | 150    | 125    | 95      |
|                         |     |        |        |        |         |
|                         | IV  | 225    | 200    | 175    | 125     |
|                         |     |        |        |        |         |
|                         | V   | 300    | 250    | 225    | 175     |
|                         | -VI |        |        |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| **Modifications of      |     | -125   | -100   | -75    | -30     |
| table**                 |     |        |        |        |         |
|                         |     |        |        |        |         |
| Confined to pulmonic    |     |        |        |        |         |
| area and called         |     |        |        |        |         |
| functional by E.P.      |     |        |        |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| Called functional,      |     |        | Reduce |        |         |
| probably functional,    |     |        | to the |        |         |
| diagrammed as localized |     |        | top    |        |         |
| by E.P.                 |     |        | debit  |        |         |
|                         |     |        | for    |        |         |
|                         |     |        | the    |        |         |
|                         |     |        | next   |        |         |
|                         |     |        | lower  |        |         |
|                         |     |        | rating |        |         |
|                         |     |        | class  |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| Report of reasonably    |     |        | Up to  |        |         |
| current normal chest    |     |        | ¼      |        |         |
| x-ray or echocardiogram |     |        | credit |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| Heard in aortic area or |     |        | Rate   |        |         |
| radiating into neck     |     |        | as     |        |         |
|                         |     |        | aortic |        |         |
|                         |     |        | st     |        |         |
|                         |     |        | enosis |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| **Diastolic murmurs**   |     |        | Rate   |        |         |
|                         |     |        | as     |        |         |
| Heard at the apex       |     |        | mitral |        |         |
|                         |     |        | st     |        |         |
|                         |     |        | enosis |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| Heard at the base or    |     |        | Rate   |        |         |
| left sternal border     |     |        | as     |        |         |
|                         |     |        | aortic |        |         |
|                         |     |        | i      |        |         |
|                         |     |        | nsuffi |        |         |
|                         |     |        | ciency |        |         |
+-------------------------+-----+--------+--------+--------+---------+
| **Double murmurs**      |     |        | R-350  |        |         |
|                         |     |        |        |        |         |
|                         |     |        | Co     |        |         |
|                         |     |        | nsider |        |         |
|                         |     |        | 1/3    |        |         |
|                         |     |        | credit |        |         |
|                         |     |        | for    |        |         |
|                         |     |        | normal |        |         |
|                         |     |        |        |        |         |
|                         |     |        | x-ray  |        |         |
+-------------------------+-----+--------+--------+--------+---------+

##### [Prosthetic Valves, Valve Replacement]{.underline}

Artificial heart valves are surgically implanted when the symptoms of
valvular heart disease become intolerable or if evidence of pulmonary
hypertension or congestive heart failure has emerged.

Metal or plastic heart valves and sometimes porcine (organic) valves
require anticoagulant therapy for a lifetime. Valves may wear out and
need replacement.

A murmur is common with artificial valves and is usually ignored if the
valve functions well.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ------------------------------------------------------------ ----------
  One valve replaced, returned to normal activity, heart size  
  not over 10% enlarged                                        

  Ages 15 and over                                             200

  More than one valve replaced                                 200

  With atrial fibrillation                                     R

  Valvular surgery without replacement                         

  Commissurotomy, valvuloplasty, balloon valvuloplasty         200
  ------------------------------------------------------------ ----------

##### [Valvular Heart Disease]{.underline}

The most common causes of valve dysfunction are rheumatic fever,
congenital malformations, endocarditis and myocardial infarction.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------- -----------------------------
  Valvular heart disease                    RFC

  ----------------------------------------- -----------------------------

VARICOCELE

# A varicocele is a dilated condition of the veins of the scrotum. When very large it may cause pain or a "dragging" sensation in the scrotum.

## 

+------------------------------------------------+---------------------+
| Varicocele                                     | #####               |
|                                                | Generally disregard |
+------------------------------------------------+---------------------+

### 

### **VASCULAR DISEASE**

##### [Aneurysm]{.underline}

An aneurysm is a widening and bulging of a blood vessel due to weakness
in its wall. Rupture and hemorrhage are complications. Ratings depend on
location and complication.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

**Coronary artery or ventricular** -- These may be congenital, traumatic
or secondary to atherosclerosis and vasculitis. Complications include
myocardial infarction.

  --------------------------------------------- -------------------------
  Single coronary artery aneurysm               125

  Others                                        R
  --------------------------------------------- -------------------------

**Aortic, abdominal or thoracic** -- Atherosclerosis is the most common
cause of aneurysms of the descending aorta. Ascending aortic aneurysms
are most commonly secondary to arteritis or connective tissue disease
(Marfan syndrome). Dissecting aortic aneurysms which involve a tear in
the inner wall of the aorta may result from trauma or hypertension.

  --------------------------------------------- -------------------------
  Present                                       

  Over 4 cm., or stable for less than 2 years   R

  4 cm. or less, stable for 2 years, well       300
  followed                                      

  Operated, with recovery                       100
  --------------------------------------------- -------------------------

**Renal artery** -- these are usually secondary to atherosclerosis.

  --------------------------------------------- -------------------------
  Present                                       R-300

  Operated, with recovery                       100
  --------------------------------------------- -------------------------

**Peripheral artery** -- trauma and atherosclerosis are common causes.

  --------------------------------------------- -------------------------
  Present                                       

  Below knee                                    55-0

  Others                                        R-80

  Operated, no circulatory impairment           0
  --------------------------------------------- -------------------------

##### [Buerger's Disease, Thromboangiitis Obliterans]{.underline}

Buerger's disease is an obstructive arterial disorder caused by
inflammation and thickening of the vessel wall. It is most common in men
and is especially aggravated by smoking. Raynaud's phenomenon, ulcers of
fingers and toes, gangrene, stroke and myocardial infarction can occur
depending on the specific arteries involved.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ----------------------------------------------------------- -----------
  Within 5 years of diagnosis                                 175

  6^th^ to 10^th^ year                                        80

  After 10 years                                              55

  If still smoking, or if complicated (ulcers or gangrene of  R
  fingers, toes, etc.) or if there is any evidence of         
  involvement of the arteries of the G.I. tract, heart brain, 
  etc.                                                        
  ----------------------------------------------------------- -----------

##### [Arteriosclerosis Obliterans, Intermittent Claudication]{.underline}

Atherosclerosis (arteriosclerosis) may involve the abdominal aorta and
the large arteries that branch from the aorta into the legs (iliac,
femoral, popliteal and tibial arteries). The arteries to the kidneys
(renal arteries) may also be involved. A bruit may be heard near
obstructions, and pulses in the feet may be reduced or absent. Ischemic
leg muscle pain, provoked by walking and relieved by rest, is called
intermittent claudication. Gangrene and impotence may occur. Surgical
intervention may include bypass operations or replacement of sections of
arteries with grafts. Ratings are necessary because of the higher
probability of associated coronary disease.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------- -------------------------
  With or without symptoms, with or without     100
  surgical intervention (i.e. formal bypass),   
  no coronary or cerebrovascular disease        

  Abdominal or femoral bruit, no other symptoms 

  Diminished or absent pulses                   75

  Normal pulses in feet                         0
  --------------------------------------------- -------------------------

**[Raynaud's Disease, Raynaud's Syndrome (Phenomenon)]{.underline}**

Raynaud's disease is characterized by pallor and cyanosis of the hands
and feet induced by spasm of the arteries to the extremities. It is most
common in women and is accentuated by exposure to cold, stress and other
illnesses. Complications, including gangrene, are rare. It disappears
spontaneously in about 50% of cases.

Raynaud's syndrome differs because it is secondary to a number of
underlying diseases such as Beurger's disease, connective tissue
disorders, neurologic disorders, atherosclerosis and others.

#### 

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------- -------------------------
  Cause known                                   RFC

  Cause unknown                                 

  Within 1 year of onset                        200

  2^nd^ year                                    100

  After 2 years                                 0
  --------------------------------------------- -------------------------

##### [Thrombophlebitis]{.underline}

Blood may clot in veins causing pain and swelling in the area involved,
commonly the legs. Causes include trauma, surgery, stasis as seen with
varicose veins, prolonged bed rest, pregnancy, congestive heart failure
and hypercoagulable states as seen with polycythemia vera, oral
contraceptives, lupus and malignancies.

Complications include emboli which may lodge in the lungs or within the
heart and chronic swelling of the affected extremity.

#### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  --------------------------------------------- -------------------------
  Single episode, resolved                      0

  Recurrent, after recovery from last attack    

  Within 1 year of last attack                  55

  2^nd^ -- 3^rd^ year                           30

  After 3 years                                 0
  --------------------------------------------- -------------------------

##### [Varicose Veins, Venous Insufficiency]{.underline}

A varicosity is an enlarged tortuous vein. Those occurring in the legs
are of little underwriting significance. Varices on the abdominal wall
or in the esophagus or stomach are indicative of cirrhosis of the liver,
portal hypertension or obstruction of the vena cava.

  --------------------------------------------- -------------------------
  Legs                                          

  Asymptomatic or cured with surgery or         0
  injection                                     

  Others                                        0

  Abdominal wall, esophagus, stomach            RFC
  --------------------------------------------- -------------------------

**VASCULITIS**

Vasculitis is a general term for the disease characterized by
inflammation and necrosis of blood vessels.

**[Giant Cell Arteritis]{.underline}**

Giant cell arteritis, which includes temporal or cranial arteritis,
involves the medium and large arteries. It characteristically involves
the temporal artery or one or more branches of the carotid artery.
However, it may also involve arteries in other locations and is closely
associated with polymyalgia rheumatica. The typical clinical
presentation is fever, anemia, headaches and an elevated erythrocyte
sedimentation rate in an elderly patient. Most patients achieve
permanent remission after treatment with steroids.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------------- --------------
  Present                                                  R

  In remission, therapy continuing, or less than 1 year of 75
  therapy                                                  

  Complete recovery and cessation of drug therapy at least 0
  1 year                                                   
  -------------------------------------------------------- --------------

**[Henoch-Schonlein Purpura]{.underline}**

Henoch-Schonlein purpura, also known as anaphylactoid purpura, usually
occurs in children but may occur at any age. It may recur over weeks or
months but usually resolves and most resolve completely. However, in
some cases, renal disease persists and is progressive. It is
characterized by a purpuric rash, arthritis, renal and gastrointestinal
symptoms.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Recovered, no residual renal disease               

  Within 1^st^ year                                  200

  2^nd^ year                                         100

  After 2 years                                      0

  Present or residual renal disease                  200
  -------------------------------------------------- --------------------

**[Polyarteritis]{.underline}**

Polyarteritis is a disease of small- and medium-sized blood vessels. The
kidney, heart, liver and gastrointestinal tract are most commonly
involved; the disease may also involve the muscles, peripheral nerves,
skin, central nervous system and testes. The clinical course is variable
and may be rapidly progressive or characterized by intermittent
exacerbations.

**Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  -------------------------------------------------- --------------------
  Present                                            R

  Within 1^st^ year of remission                     300

  2^nd^-3^rd^ year of remission, therapy continuing  200

  Thereafter, therapy continuing                     100

  Remission maintained after cessation of therapy    0
  for more than 1 year                               
  -------------------------------------------------- --------------------

# 

# **[Wegner's Granulomatosis]{.underline}**

This is a vasculitis involving the respiratory tract accompanied by
glomerulonephritis. It may be associated with vasculitis of other small
arteries and veins. With appropriate cytotoxic and steroid therapy a
large percentage of patients achieve long-term remission. Patients with
renal failure may be candidates for transplantation.

### **Underwriting Requirements**

An APS (VA Form 29-8158) is required.

  ---------------------------------------------------- ------------------
  With renal disease                                   Usually R

  Treatment continuing, or remission less than 5 years R-300

  No treatment, in remission at least 5 years          150-55
  ---------------------------------------------------- ------------------

**VAS DEFERENS**

The vas deferens is the excretory duct of the testicle. Tying off
(ligation) or removal (vasectomy) of these ducts produce sterility in
the male.

**Underwriting Requirements**

APS (VA Form 29-8158) is required within 1 year.

+----------------------------------------------------+-----------------+
| For sterilization -- ligation or vasectomy         | 0               |
+----------------------------------------------------+-----------------+
| For other causes                                   | ####### RFC     |
+----------------------------------------------------+-----------------+

### **VINCENT'S ANGINA**

Vincent's Angina or commonly called "trench mouth" is an infectious
disease of the mouth, characterized by painful bleeding gums,
ulceration, and retraction of gums.

###### Underwriting Requirements

Generally disregard, unless causing other ratable symptoms.

### **VISCEROPTOSIS**

Visceroptosis and gastroptosis are terms applied to a downward or
sagging displacement of the stomach (fallen stomach) or abdominal
organs. The condition frequently causes digestive symptoms and
constipation. It is much more prominent in women than men.

**Underwriting Requirements**

An APS (VA Form 29-8158) may be required if not adequately explained.

  ------------------------------------------------------ ----------------
  Present -- No symptoms                                 0

  With digestive symptoms of constipation requiring      30
  medical treatment                                      

  History -- after recovery                              0
  ------------------------------------------------------ ----------------