M21-1 Manual  /  Part V, Subpart iii, Chapter 5

Cardiovascular System Conditions

M21-1, Part V, Subpart iii, Chapter 5

Overview

In This Chapter

This chapter contains the following topics:
TopicTopic Name
1 Rating Principles for Heart Conditions
2Evaluating Diseases of the Heart
3Rating Principles for Hypertension
4Residuals of Cold Injuries
5Other Cardiovascular Disabilities

1. Rating Principles for Heart Conditions


Introduction

This topic contains miscellaneous cardiovascular concepts and principles, including
  • definition of arteriosclerotic heart disease
  • documentation required to support a diagnosis of arteriosclerotic heart disease
  • manifestations of advanced arteriosclerotic disease in service
  • documentation of myocardial infarction (MI)
  • effective dates and liberalizing changes affecting service connection (SC) for ischemic heart disease (IHD)
  • considering cardiovascular conditions subsequent to amputation
  • effects of rheumatic heart disease, and
  • definition of congenital heart defects.

Change Date

February 5, 2024

V.iii.5.1.a. Definition: Arteriosclerotic Heart Disease

Arteriosclerotic heart disease, also diagnosed as ischemic heart disease (IHD) and coronary artery disease (CAD), is a disease of the heart caused by the diminution of blood supply to the heart muscle due to narrowing of the cavity of one or both coronary arteries due to the accumulation of fatty material on the inner lining of the arterial wall.Note: IHD refers only to heart disease, and therefore, does not include hypertension or peripheral manifestations of arteriosclerosis such as peripheral vascular disease or stroke. Consider presumptive service connection (SC) for IHD under 38 CFR 3.309(e).Reference: For more information on the definition of IHD, see

V.iii.5.1.b. Documentation Required to Support a Diagnosis of Arteriosclerotic Heart Disease

For rating purposes, a diagnosis of arteriosclerotic heart disease must be documented by objective testing. Objective tests include, but are not limited to
  • electrocardiogram (ECG or EKG) findings
  • treadmill exercise testing (with or without a thallium scan),or
  • cardiac catheterization and angiography.
Note: The actual test results do not need to be of record if the evidence indicates that the diagnosis was rendered by a competent medical professional and based on the results of an objective test. Important: Symptoms of chest pain alone are not sufficient to support a clinical diagnosis of arteriosclerotic heart disease for rating purposes. As chest pain is a symptom of multiple disabilities, the diagnosis of arteriosclerotic heart disease must be supported with objective documentation.

V.iii.5.1.c. Manifestations of Advanced Arteriosclerotic Disease in Service

When SC for a cardiovascular condition is claimed, the mere identification of arteriosclerotic disease upon routine examination early in service is not a basis for SC. Manifestation of lesions or symptoms of chronic disease will establish pre-service existence under 38 CFR 3.303(c) if objective evidence shows manifestation
  • from date of enlistment, or
  • so close to enlistment that chronic disease could not have originated during service.
Important:
  • An analysis of the presumption of soundness under 38 CFR 3.304 and the provisions on aggravation under 38 CFR 3.306 may be required.
  • Grant SC for any sudden development during service of coronary occlusion or thrombosis whether or not these are manifestations of advanced long-standing arteriosclerotic disease.
Note: Under 38 CFR 3.6(a), inactive duty for training qualifies as active service if an individual becomes disabled or dies from an acute myocardial infarction (MI), a cardiac arrest, or a cerebrovascular accident occurring during such training.

V.iii.5.1.d. Documentation of MI

38 CFR 4.104, diagnostic code (DC) 7006 requires documentation of an MI by laboratory tests. Health providers may rely on a variety of diagnostic tests to document MI.
  • Testing may include, but is not limited to,
    • EKG
    • cardiac enzymes (Troponin, CKMB), and
    • radionuclide imaging.
  • The Heart Conditions Disability Benefits Questionnaire (DBQ) elicits information about testing conducted in support of cardiac workup.
If an assessment of an MI appears to have been made without diagnostic testing or if there is a question about whether the assessment was supported by appropriate testing, obtain clarification from the Department of Veterans Affairs (VA) examiner or other provider. Reference: For more information on evaluating medical evidence, see M21-1, Part V, Subpart ii, 1.A.3.

V.iii.5.1.e. Effective Dates and Liberalizing Changes Affecting SC for IHD

IHD became a condition presumptively associated with herbicide exposure effective August 31, 2010. This was a liberalizing change of law. Therefore, unless an earlier effective date is available under the provisions of 38 CFR 3.816, consider the application of 38 CFR 3.114(a) when granting presumptive SC for IHD related to herbicide exposure under the provisions of 38 CFR 3.307(a)(6) and 38 CFR 3.309(e). References: For more information on

V.iii.5.1.f. Considering Cardiovascular Conditions Subsequent to Amputation

Grant SC on a secondary basis for the following conditions that develop subsequent to the service-connected (SC) amputation of one lower extremity at or above the knee, or SC amputations of both lower extremities at or above the ankles:
  • IHD, or
  • other cardiovascular disease, including hypertension.
References: For more information on

V.iii.5.1.g. 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: Grant SC for an aortic valve insufficiency that manifests without other cause after an in-service case of rheumatic fever.

V.iii.5.1.h. Definition: Congenital Heart Defects

Congenital heart defects include common heart conditions due to prenatal influences, such as
  • patent foramen ovale
  • patent ductus arteriosus
  • coarctation of the aorta, and
  • intraventricular septal defect.

2. Evaluating Diseases of the Heart

Introduction

This topic contains information about applying the evaluation criteria for diseases of the heart, including
  • evaluating heart disease using metabolic equivalents (METs)
  • impact of non-service-connected (NSC) conditions on the evaluation of METs
  • aspirin as continuous medication
  • evaluation of nephritis and cardiovascular disabilities
  • evaluating arrhythmias, and
  • considering co-existing heart conditions and arrhythmia.

Change Date

November 15, 2021

V.iii.5.2.a. Evaluating Heart Disease Using METs

The General Rating Formula (GRF) for Diseases of the Heart relies on the measured or estimated workload capacity of the heart using metabolic equivalents (METs) at which symptoms of heart failure occur for the assignment of disability evaluations.When METs cannot be obtained through exercise testing for medical reasons, the examiner may provide an estimation of the METs. Important: The examiner must state that the estimated METs are due solely to an SC cardiovascular disability.References: For more information on
  • the definition of MET, see Note 2 of the GRF for Diseases of the Heart at 38 CFR 4.104
  • symptoms of heart failure, see Note 3 of the GRF for Diseases of the Heart at 38 CFR 4.104
  • provisions for the application of the general rating formula for diseases of the heart, see 38 CFR 4.100, and
  • the historical use of congestive heart failure and ejection fraction when evaluating diseases of the heart, see
    • historical 38 CFR 4.104 in effect prior to November 14, 2021, and
    • the attachment Historical_M21-1V_iii_5_9-15-21.

V.iii.5.2.b. Impact of NSC Conditions on the Evaluation of METs

Non-service-connected (NSC) disabilities, such as a chronic respiratory condition or morbid obesity, may have an impact on METs results. When an examiner cannot determine METs attributable to an SC cardiovascular disability due to the effects of NSC conditions and provides a sufficient rationale detailing why the determination cannot be provided, follow the guidance in M21-1, Part V, Subpart ii, 3.D.2.c.

V.iii.5.2.c. Aspirin as Continuous Medication

Aspirin is a medication that may be medically recommended for control of a cardiovascular disability such as an ischemic stroke, angina, or coronary artery bypass graft. When considering a compensable evaluation based on need for continuous medication as provided in 38 CFR 4.100(a) and the GRF for evaluating diseases of the heart as provided in 38 CFR 4.104 for the 10-percent evaluation, aspirin treatment must be medically required for care of the SC cardiovascular disorder.
  • A medical professional must have advised the claimant to use aspirin to reduce disability from the SC cardiovascular disorder or to prevent additional disability from that disorder.
  • A formal prescription to obtain the medication from a pharmacy is not required given that aspirin is an over-the-counter medication.
  • Self-directed or voluntary use of aspirin by a claimant who is a layperson will not be accepted as competently proving that aspirin treatment is medically necessary for treatment of the SC cardiovascular disorder.
To satisfy the requirement of “continuous” medication the evidence must show an ongoing regimen – not periodic, irregular use. Take care not to incorrectly conclude that an aspirin treatment regimen is necessary simply because aspirin appears on a current medication list. A medication list may not contain enough information to conclude:
  • whether aspirin was medically recommended or self-prescribed
  • whether aspirin is being used for the SC cardiovascular condition or another disability, and/or
  • how frequently aspirin is being taken.

V.iii.5.2.d. Evaluation of Nephritis and Cardiovascular Disabilities

38 CFR 4.115 states that separate ratings cannot be assigned for disability from disease of the heart and any form of nephritis. Reference: For more information on the limits on separate evaluation of nephritis and cardiovascular conditions, see M21-1, Part V, Subpart iii, 7.2.g.

V.iii.5.2.e. Evaluating Arrhythmias

The impairment and disability resulting from one or more types of arrhythmia, evaluated under 38 CFR 4.104, DCs 7009-7011 and 7015, are essentially indistinguishable. Consequently, assignment of multiple evaluations under any of these DCs would be in violation of 38 CFR 4.14. Assign a single evaluation under the DC which reflects the predominant disability picture for the arrhythmia(s) in question.

V.iii.5.2.f. Considering Co-Existing Heart Conditions andArrhythmia

When questions arise as to whether a single or separate evaluations may be assigned for co-existing cardiovascular disabilities, such as arrhythmias and other cardiovascular diseases, consider whether the criteria for evaluating the disability and/or the symptoms of the disability are separate and distinct and apply 38 CFR 4.14 and any other condition-specific guidance. When the evaluation criteria are separate and distinct, the symptoms do not overlap, and no specific prohibition applies, separate evaluations are warranted.

3. Rating Principles for Hypertension

Introduction

This topic contains information on concepts and principles relating to hypertension, including
  • definitions of hypertension and isolated systolic hypertension
  • blood pressure readings required for SC of hypertension
  • confirmation with multiple blood pressure readings
  • pre-hypertension
  • predominant blood pressure in evaluations of hypertension
  • long term effects of hypertension
  • granting SC for arteriosclerotic manifestations due to hypertension
  • effective dates of arteriosclerotic manifestations granted secondary to hypertension
  • separately evaluating hypertension and heart disease
  • prohibition on separate evaluation of hypertension and renal dysfunction from nephritis, and
  • evaluating rheumatic heart disease coexisting with hypertensive or arteriosclerotic heart disease.

Change Date

February 5, 2024

V.iii.5.3.a. Definitions: Hypertension and Isolated Systolic Hypertension

Two types of hypertensive vascular disease are defined in 38 CFR 4.104, DC 7101, Note 1. Hypertension means elevated diastolic blood pressure is predominantly 90mm or greater. Isolated systolic hypertension means that systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Note: Use of the term “hypertension” in reports or in VA guidance will most often be used as a synonym for any type of hypertensive vascular disease.

V.iii.5.3.b. Blood Pressure Readings Required for SC of Hypertension

Subject to the exception below, SC for hypertensive vascular disease requires current blood pressure readings (obtained during the claim period) which meet the regulatory definition of either
  • hypertension, or
  • isolated systolic hypertension.
Exception: Current readings meeting the regulatory standards for the definitions above are not required if
  • the competent evidence shows a diagnosis of hypertension or isolated systolic hypertension, currently controlled by (or asymptomatic with) medication, and
  • a past competent diagnosis was made
    • in service
    • based on manifestation of blood pressure readings to a compensable degree within the presumptive period as provided in 38 CFR 3.307 and 38 CFR 3.309(a), or
    • secondary to an SC disability.
Notes:
  • When SC is established based on the exception above (where current readings do not meet the regulatory definitions), the disability percentage will be either 0 percent or 10 percent, depending on whether or not the predominant diastolic pressure was 100 or more before symptoms were controlled with medication as provided in 38 CFR 4.104, DC 7101.
  • A disability first clearly diagnosed after service can be SC under 38 CFR 3.303(d) when all the evidence, including that pertinent to service, establishes that the disease was incurred in service
Reference: For more information on

V.iii.5.3.c. Confirmation With Multiple Blood Pressure Readings

In addition to the definitional requirements for a diagnosis of hypertension or isolated systolic hypertension 38 CFR 4.104, DC 7101 provides a second criterion that must be met for a diagnosis to be acceptable. Subject to the exceptions below, a diagnosis of hypertension (or isolated systolic hypertension) must be confirmed by blood pressure readings taken two or more times on at least three different days. The rulemaking for the regulation stated that the purpose of this requirement, was to “assure that the existence of hypertension is not conceded based solely on readings taken on a single, perhaps unrepresentative, day.” Exceptions: Important: The decision maker must critically evaluate the evidence to ensure the in-service diagnosis was based on blood pressure readings in accordance with 38 CFR 4.104, DC 7101 and M21-1, Part V, Subpart iii, 5.3.b in claims for SC for hypertension where
  • hypertension is currently diagnosed, and
  • controlled with medication.
If the evidence is unclear, medical clarification and/or a medical opinion may be warranted. References: For more information on

V.iii.5.3.d. Pre-Hypertension

Pre-hypertension is generally defined as systolic pressure between 120mm and 139mm and diastolic pressure from 80mm to 89mm. Pre-hypertension is not a disability for VA purposes. If the VA examination (or evidence used in lieu of a VA examination) contains only a diagnosis of pre-hypertension based on readings that do not meet the definition of hypertension or isolated systolic hypertension, do not
  • seek clarification, or
  • grant SC for hypertension based on the diagnosis.
Exception: Clarification may be required if a current diagnosis of “pre-hypertension” is made where readings exist in the record that meet the regulatory definition of hypertension. This may indicate
  • conflicting evidence, and/or
  • equivocation by the medical professional on diagnosis or chronicity (particularly if, for example, the facts show a predominance of readings not meeting the regulatory definition of hypertension).
References: For more information on

V.iii.5.3.e. Predominant Blood Pressure in Evaluations of Hypertension

Every level of evaluation specified under 38 CFR 4.104, DC 7101 requires consideration of the predominant (most common or prevailing) blood pressure. Blood pressure may fluctuate depending on a number of variables and disability evaluations must be based on valid evidence demonstrating representative disability. Generally the regulation requires analysis of predominant current readings— readings from the period during which an effective date can be assigned. When current predominant blood pressure readings are non-compensable, a 10-percent evaluation may be assigned if
  • continuous medication is required for blood pressure control, and
  • past diastolic pressure (before medication was prescribed) was predominantly 100 or greater.
Important: Do not assign a 10-percent evaluation based upon a showing of one of the two conjunctive criteria above by invoking the benefit of the doubt rule (38 CFR 3.102 and 38 CFR 4.3 or 38 CFR 4.7). When either criterion is simply not shown (for example, the claimant is using prescribed anti-hypertensive medication but diastolic pressure has never been predominantly 100 or greater) the evidence is not in relative equipoise on whether a 10-percent evaluation is appropriate and the disability picture does not more nearly approximate the 10-percent criteria. However, 38 CFR 3.102, 38 CFR 4.3, and 38 CFR 4.7 may be applicable to whether the evidence supports each criterion, namely
  • whether diastolic readings before were predominantly 100 or higher or
  • whether continuous medication is required for control of blood pressure.
Use the table below to assist in analyzing predominant blood pressure.
When ...Then ...
determining which diastolic or systolic pressure range is predominant
  • make note of the competent and credible evidence of diastolic and systolic readings (see M21-1, Part V, Subpart ii, 1.A)
  • determine which readings correspond with the various levels of evaluation specified in the diagnostic criteria (for example diastolic readings “100 or more” or “110 or more”), and
  • subject to the notes below, conclude that the range with the most qualifying readings is the predominant blood pressure.
Notes:

Example: If there are six diastolic measurements from one doctor in the 100 to 109 range (108, 106, 108, 104, 106, 100) in June, and six diastolic readings from another doctor in the 110 to 119 range (110, 110, 114, 110, 112, 110) the same month, give the benefit of the doubt and assign the higher 20-percent evaluation.

  • If during the evaluation period more than one blood pressure range is supported for at least a month stage the evaluation in accordance with the facts.

Example: Use the readings above but assume second doctor’s readings were taken in November. Assign a 10-percent evaluation based on the June results from the date of claim or date entitlement arose, whichever is the later; stage to 20 percent as of the date of the first readings from November.

considering predominant blood pressure before control with medicationstart with the more current of
  • the readings taken as part of the diagnostic workup period leading to the diagnosis of hypertension if medication was prescribed at that time, or
  • the readings taken as part of a subsequent diagnostic workup period leading to the prescription of medication.
Explanation: These are the readings pertinent to whether hypertensive readings were predominantly in the compensable range before hypertension was brought under control with medication. Do not consider
  • normal blood pressure readings taken long before the diagnosis of hypertensive vascular disease was made, or
  • minimally hypertensive readings prior to active medical surveillance or observation leading to the prescription of medication.
Explanation: These are not pertinent and will impermissibly skew the analysis of the predominant blood pressure.
considering a history of predominant blood pressure for the purposes of a 10 percent evaluation under 38 CFR 4.104, DC 7101
  • only consider blood pressure readings obtained when the Veteran was undergoing a diagnostic evaluation for hypertension, and
  • do not consider other clinical records documenting treatment prior to the diagnostic evaluation for hypertension.

V.iii.5.3.f. Long Term Effects of Hypertension

Hypertension may
  • exist for years without causing symptoms
  • so increase the cardiac load as to result in 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.

V.iii.5.3.g. Granting SC for Arteriosclerotic Manifestations Due to Hypertension

If additional arteriosclerotic manifestations are subsequently diagnosed in a Veteran with SC hypertension, grant 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:
  • Address SC for the above-listed cardiovascular conditions through the relationship to the hypertension when a sympathetic reading of the Veteran’s claim reasonably implies a claim for SC for those conditions.
  • 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

V.iii.5.3.h. 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 hypertensive vascular disease (hypertension and isolated systolic hypertension) rated under 38 CFR 4.104, DC 7101. They are separate conditions which may be secondary to hypertensive vascular disease, but which nonetheless must be evaluated under rating criteria specific to their symptomology and the functions and anatomical localities they affect. Therefore, do not apply 38 CFR 3.400(o)(2) to allow an effective date prior to the date of claim, as this only applies to increases.
  • If awarding SC for a disability as within scope of the hypertension claim, apply an effective date based on the date of claim for hypertension.
References: For more information on

V.iii.5.3.i. Separately
Evaluating Hypertension and Heart Disease

Evaluate hypertension separately from hypertensive heart disease and other types of heart disease. Evaluate hypertension due to aortic insufficiency, which is usually the isolated systolic type, as part of the condition causing it rather than by a separate evaluation. 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 38 CFR 4.104, DC 7101, Note 1.

V.iii.5.3.j. Prohibition on Separate Evaluation of Hypertension and Renal Dysfunction from Nephritis

38 CFR 4.115 prohibits assignment of separate evaluations for renal dysfunction from nephritis and for hypertensionexcept where
  • the sole renal disability is absence of a kidney (even if that was due to nephritis), or
  • nephritis has progressed to the point where regular dialysis is required.
References: For more information on

V.iii.5.3.k. 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, follow the guidance in M21-1, Part V, Subpart ii, 3.D.2.c.

4. Residuals of Cold Injuries

Introduction

This topic contains information about residuals of cold injury, including
  • general effects of injury due to cold
  • long-term effects of exposure to cold
  • granting SC for residuals of cold injuries
  • x-ray findings in cold injury cases
  • considering
    • circumstances of service in cold injury cases, and
    • cold injuries incurred during the Chosin Reservoir Campaign, and
  • granting SC for cold injuries incurred during the Chosin Reservoir Campaign.

Change Date

November 15, 2021

V.iii.5.4.a. General Effects of Injury Due to Cold

Injury due to exposure to extremely cold temperatures causes structural and functional disturbances of
  • small blood vessels
  • 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.

V.iii.5.4.b. Long-Term Effects of Exposure to Cold

The fact that the immediate effects of cold injury may have been characterized as “acute” or “healed” does not preclude development of disability at the original site of injury many years later. There does not need to be continuity of symptoms following a cold injury. Typically symptoms may last for days up to a week or two after the cold injury. Unless there was a loss (such as part of a hand or foot), the initial injury is followed by a long symptom-free period, after which signs and symptoms may reoccur. An SC cold injury is, therefore, evaluated based on those residuals identified in 38 CFR 4.104, DC 7122.

V.iii.5.4.c. Granting SC for Residuals of Cold Injuries

Grant SC for the residuals of cold injury if
  • the cold injury was incurred during military service, and
  • an intercurrent 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 SC 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.

V.iii.5.4.d. X-Ray Findings in Cold Injury Cases

For appropriate evaluation of cold injuries under the criteria of 38 CFR 4.104, DC 7122, it is very important that there be medical evidence addressing whether or not x-ray abnormalities (specifically osteoporosis, subarticular punched out lesions, or osteoarthritis) exist. The Cold Injury ResidualsDisability Benefits Questionnaire instructs that the x-ray abnormalities (osteoporosis, subarticular punched out lesions, or osteoarthritis) must be confirmed by x-rays. Once these abnormalities have been documented no further imaging studies are indicated. This means that x-ray studies do not have to be completed on each and every subsequent examination after the specified abnormalities have been documented. The DBQ asks the examiner whether x-rays have been performed and if so to provide the date of the studies. If an examination is necessary for evaluation purposes, x-ray studies were not performed as part of the examination, and the specified x-ray abnormalities have not been previously documented, return the examination. References: For more information on

V.iii.5.4.e. Considering Circumstances of Service in Cold Injury Cases

Consider the circumstances of service as provided in 38 U.S.C. 1154(a) and 38 CFR 3.303(a), even if STRs are not positive for a claimed cold injury. Also as provided in 38 U.S.C. 1154(b) and 38 CFR 3.304(d), in cases involving cold injuries related to documented combat service, satisfactory lay evidence of service conditions will be accepted if consistent with the circumstances, conditions, or hardships of combat service even if there is no official documentation in service records. For example, the Battle of the Bulge (Ardennes/Rhineland) in the winter of 1944/1945 during World War II was known for its extreme cold. If participation in the Battle of the Bulge is confirmed by the DD Form 214, Certificate of Release or Discharge from Active Duty, or personnel records, concede exposure to extreme cold. If the Veteran engaged in combat with the enemy and the circumstances of service are consistent with claimed service in the Battle of the Bulge, concede exposure to extreme cold. Afford an examination if the circumstances are consistent with exposure to extreme cold, proving an event in service, and the criteria for a necessary examination are otherwise met. Reference: For more information on determining whether an examination is necessary, see

V.iii.5.4.f. Considering Cold Injuries Incurred During the Chosin Reservoir Campaign

The Chosin Reservoir Campaign was conducted during the Korean War, October 1950 through December 1950, in temperatures of –20ºF or lower. Many participants in this campaign suffered from frostbite for which they received no treatment and, as a result, there may be no STRs to directly support their claims for frostbite. 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).

V.iii.5.4.g. Granting SC for Cold Injuries Incurred During the Chosin Reservoir Campaign

Grant SC under the provisions of 38 CFR 3.303(a) and 38 CFR 3.304(d) if
  • the Veteran has a disability which is diagnosed as a residual of cold injury, and
  • there are no other circumstances to which this disability may be attributed.

5. Other Cardiovascular Disabilities

Introduction

This topic contains information about other cardiovascular disabilities, including
  • evaluating Raynaud’s syndrome and Raynaud’s disease
  • testing requirements for peripheral arterial disease, and
  • changes in the rating schedule for the cardiovascular system.

Change Date

February 5, 2024

V.iii.5.5.a. Evaluating Raynaud’s Syndrome and Raynaud’s Disease

Raynaud’s syndrome and Raynaud’s disease are unrelated in etiology and severity. Raynaud’s disease is more common and tends to be less severe than Raynaud’s syndrome.
  • Raynaud’s syndrome (also known as secondary Raynaud’s phenomenon) is typically caused by autoimmune diseases such as scleroderma, lupus, rheumatoid arthritis, atherosclerosis, or polycythemia. This condition is rated under 38 CFR 4.104, DC 7117.
  • Raynaud’s disease (also known as primary Raynaud’s phenomenon) is idiopathic (due to an unknown cause). This condition is rated under 38 CFR 4.104, DC 7124.
Note: A Veteran cannot receive simultaneous ratings under both 38 CFR 4.104, DC 7117 and DC 7124 because Raynaud’s disease and Raynaud’s syndrome cannot be comorbid conditions.

V.iii.5.5.b. Testing Requirements for Peripheral Arterial Disease

Under 38 CFR 4.104, DC 7114, Note 2, peripheral arterial disease may be evaluated utilizing ankle brachial index, ankle pressure, toe pressure, or transcutaneous oxygen tension values. The ankle/brachial index is the most common type of testing for evaluating peripheral arterial disease. In some situations, ankle/brachial index measurement is not appropriate for a given disability. In those cases, ankle pressure, toe pressure, or transcutaneous oxygen tension values are more appropriate tests.
  • If the ankle pressure, toe pressure, and/or transcutaneous oxygen tension measurements are not of record, evaluate based on the ankle/brachial index unless the examiner indicates that one of the other tests is necessary.
  • If more than one test result is available, evaluate using the test result that results in the highest evaluation.

V.iii.5.5.c. Changes in the Rating Schedule for the Cardiovascular System

The rating criteria for cardiovascular conditions have undergone historical changes. Recent full-scale historical revisions were effective on the following dates:
  • November 14, 2021, and
  • January 12, 1998.
Notes:
  • These changes in the rating criteria
    • are not considered liberalizing, and
    • should not be the basis for a reduction in disability rating unless medical evidence establishes that the disability has actually improved.
  • A regulatory change to 38 CFR 4.104, DC 7122 effective August 13, 1998, further revised, but did not substantively change, the evaluation criteria of long-term effects of cold injury residuals.
References: For more information on

Source: VA M21-1 Adjudication Procedures Manual, M21-1, Part V, Subpart iii, Chapter 5 (U.S. government work, reproduced for reference). Browse all sections →