cannot determine METs attributable to an SC cardiovascular disability due to the effects of NSC conditions states that LVEF testing renders a more accurate finding regarding cardiovascular manifestations alone evaluate based on LVEF shown on examination. cannot determine METs attributable to an SC cardiovascular disability due to the effects of NSC conditions does not state that LVEF testing renders a more accurate finding regarding cardiovascular manifestations resolve reasonable doubt in the Veteran’s favor and evaluate based on the evidence that is most advantageous to the Veteran. n. Granting SC for Arteriosclerotic Manifestations Due to Hypertension If additional arteriosclerotic manifestations are subsequently diagnosed in a Veteran with SC hypertension, SC on a secondary basis through the relationship to hypertension for any of the following cerebral arteriosclerosis or thrombosis with hemiplegia nephrosclerosis of the kidneys with impairment of renal function, or myocardial damage or coronary occlusion of the heart. Important: A claim for benefits is required to adjudicate a secondary SC claim for any of the arteriosclerotic manifestations. Notes: Do not address SC for the above-listed cardiovascular conditions through the relationship to the hypertension when a sympathetic reading of the claims does not show a claim for SC for a heart condition. 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/indicate prior hypertension. References: For more information on secondary SC, see M21-1, Part IV, Subpart ii, 2.B.5 intent to file and informal claims, see M21-1, Part III, Subpart ii, 2.C.1 reopened claims, see M21-1, Part III, Subpart ii, 2.D, and claims for increase, see M21-1, Part III, Subpart ii, 2. E. o. Effective Dates of Arteriosclerotic Manifestations Granted Secondary to Hypertension The effective date of any grant of SC for arteriosclerotic manifestations secondary to hypertension is the date of claim or date entitlement arose, whichever is later. Important: Arteriosclerotic manifestations are not considered a worsening of hypertension. Therefore do not apply
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. Notes: The cause of hypertension is unknown in the vast majority of cases. Do not establish SC for hypertension if the evidence does not contain blood pressure readings as specified in , Note 1. Reference: For more information on hypertension and nephritis, see . r. Effects of Rheumatic Heart Disease Chronic rheumatic heart disease results from single or repeated attacks of rheumatic fever that produce valvular disease, manifested by rigidity and deformity of the cusps 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 ECG study, since these reveal the earliest stages of specific chamber enlargement. Note: SC for an aortic valve insufficiency that manifests without other cause after an in-service case of rheumatic fever. s. Evaluating Rheumatic Heart Disease Coexisting With Hypertensive or Arteriosclerotic Heart Disease Accepted medical principles do not concede an etiological relationship between rheumatic heart disease and either hypertensive or arteriosclerotic heart disease. Therefore, do not extend secondary SC to systemic manifestations or arteriosclerosis in areas remote from the heart if the Veteran is SC for rheumatic heart disease. If a Veteran who is SC for rheumatic heart disease develops hypertensive or arteriosclerotic heart disease after the applicable presumptive period following military discharge, request a medical opinion to determine which condition is causing the current signs and symptoms. Note: If the examiner is unable to separate the effects of one type of heart disease from another, the effects must be rated together. t. Considering Cardiovascular Conditions Grant SC on a secondary basis for the following conditions that develop subsequent to the SC amputation of one lower extremity at or above the knee, or SC amputations of both lower extremities at or above the ankles: