GARP Chapter 1: How DVA Rates Heart and Lung Conditions

Chapter 1 of the GARP covers the heart and the lungs. If you have accepted ischaemic heart disease, chronic obstructive pulmonary disease, asthma, chronic bronchitis, or the cardiac or respiratory consequences of something else that happened in service, this is the chapter your impairment is rated under.

It is also the chapter with the most counter-intuitive rule in the Guide: your rating is largely determined by how far you can walk before you get symptoms — not by your diagnosis, your ejection fraction, or how many stents you have.

This is part of our series working through the GARP. Start with what the GARP is and the chapter map if you have not read those.

What Chapter 1 covers

The Guide says Chapter 1 applies to most conditions of the heart and lungs, and usually also to conditions affecting the function of the thorax or diaphragm, lesions of the nerves supplying the muscles of respiration, and conditions such as anaemia.

Two things go elsewhere:

Conditions that are predominantly intermittent are better assessed under Chapter 15. Poorly controlled asthma that comes in discrete attacks may belong there rather than here.
Hypertension and non-cardiac vascular conditions — aortic aneurysm, varicose veins — go to Chapter 2.

The eight steps

The chapter runs a fixed sequence:

Establish what cardiorespiratory conditions are present.
Assess whether the available information is reliable and sufficient.
Determine an impairment rating from effort tolerance.
If respiratory disease is present, determine a rating from lung function measurements.
Combine those into a total cardiorespiratory functional impairment rating.
Consider the effects of cardiac failure.
Moderate the rating for any non-accepted conditions.
Check the Other Impairment tables.

Step 1: everything counts, accepted or not

This surprises people. For the purposes of Chapter 1, both accepted and non-accepted conditions are taken into account. The Guide is explicit that it is "not appropriate to rely simply on a list of accepted conditions" — previously rejected and entirely unclaimed cardiorespiratory conditions may be present too, and they affect how the calculation runs.

The non-accepted contribution is then stripped back out at Step 7 using Chapter 19. But it has to be identified first, and identifying it properly is what stops a delegate from simply discounting your whole rating later on.

Step 2: what evidence the assessment actually needs

The Guide sets standards for the material, and they have deadlines attached.

Medical history. An adequate history of the illness, current symptoms and current treatment. The history is reviewed to establish whether a major cardiorespiratory event — a myocardial infarction, bypass surgery — occurred within the assessment period, and to flag whether any Other Impairment ratings apply.

Effort tolerance information must always be obtained unless a condition makes it impracticable. The Guide's examples of when it is impracticable are hemiparesis after stroke, quadriplegia or hemiplegia, severe arthritis of the lower limbs, and certain mental conditions such as dementia.

Spirometry should always be obtained if any condition affecting lung function is present, with three exceptions: the person is very old or frail and cannot reasonably attend a clinic; they live remotely and cannot reasonably attend; or their impairment from other accepted conditions is already such that it would produce a combined rating of at least 68 points.

Both must be current. Effort tolerance information and spirometry must be no more than six months older than the relevant time in the assessment period. This is the single most common practical failure — a veteran arrives with lung function tests from two years ago, and they cannot be used.

There is also a useful concession: if a person has emphysema evidenced by diminished carbon monoxide diffusing capacity and diagnosed by a specialist respiratory physician, the assessment can be made on effort tolerance alone.

Step 3: METs, and the question you are actually being asked

Exercise tolerance is quantified in METs. One MET is the energy expenditure associated with consuming 3.5 mL of oxygen per kilogram of body weight per minute. Table 1.1 lists everyday activities grouped by their MET cost — lying down, sitting and drinking tea and light sweeping at 1–2 METs; dressing, washing and light household duties at 2–3; and upward from there.

Your symptomatic activity level is the MET level at which activities consistently produce symptoms of your accepted condition — angina, dyspnoea, palpitations or fatigue. That level is then converted to an impairment rating using Table 1.2 (males) or Table 1.3 (females), both of which are age adjusted.

Now the part that costs veterans points. The Guide states plainly:

"Responses of the type 'I cannot do such and such' or 'I do not do so and so' are not useful in assessing the symptomatic activity level. What must be established is that level of exercise that the person is able to do but which results in angina, breathlessness, or some other cardiorespiratory symptom."

Saying "I don't do the stairs any more" is not an answer the tables can use. Saying "I can manage one flight, and I'm short of breath at the top and have to stop" is. If you take one thing from this chapter, take that.

Three further rules shape how the level is set:

Greater reliance is placed on activities involving steady rather than sporadic energy expenditure.
Less reliance is placed on activities completed in under a few minutes, because symptoms may take longer than that to appear.
Estimates above 6–7 METs must come from exercise testing; the higher activities in Table 1.1 are listed for information only.

"Exercise tolerance" also means cardiorespiratory tolerance specifically. The Guide's own illustration: someone with osteoarthritis of both knees may barely walk but still swim a long way — their cardiorespiratory exercise tolerance is good even though total exercise ability is poor. Where other conditions genuinely limit the measurement, the Guide directs that Chapter 19 should always be considered before disregarding exercise tolerance figures.

Step 4: lung function

The measurements are FEV1, FVC and MEF 25–75 (treated as equivalent to FEF 25–75). They should be performed by an experienced operator without specific administration of a bronchodilator, and the best set of results is selected — the one indicating the greatest degree of health and therefore the lowest impairment.

Where both pre- and post-bronchodilator results exist, the pre-bronchodilator results are used.

Each measurement is expressed as a percentage of the value predicted for a person of the same age, height and gender, using the nomograms at Figures 1a and 1b or their formulas. Those percentages are converted to ratings via Table 1.4, and the highest rating obtained from any of the three measurements is the one that applies. Anything at 85% or more of predicted is rated NIL.

Step 5: combining the two, which depends on what you have

Table 1.5 decides how the effort tolerance rating and the spirometry rating come together, and the rule changes according to which systems are involved:

Cardiac disease, no respiratory disease → the rating is METs alone.
Respiratory disease, no cardiac disease → the rating is the rounded average of the METs rating and the spirometry rating.
Both present → the rating is the higher of the two.

Where one input is unobtainable the table falls back to whichever is available; where neither is obtainable, no functional impairment rating can be calculated at all.

Two constraints apply regardless: only one effort tolerance rating is given no matter how many conditions contribute, and only one lung function rating is given no matter how many conditions contribute. No age adjustment is permitted on Table 1.5 itself.

Step 6: cardiac failure

Table 1.6 rates cardiac failure: NIL for none; 10 for no symptoms but X-ray evidence of early failure, or evidence of right ventricular failure; 15 for left or biventricular failure with an ejection fraction between 40% and 60% persisting despite therapy; 20 for left or biventricular failure on X-ray or with an ejection fraction of 40% or less persisting despite therapy.

The rating from Table 1.6 is compared with the Step 5 figure and the higher is taken. The Guide notes that where effort tolerance can be measured it will usually produce the larger number — Table 1.6 matters most for someone who cannot be rated on effort tolerance because of something like hemiplegia.

Step 7: subtracting what service did not cause

Because Step 1 counted everything, Step 7 removes the part attributable to non-accepted conditions by applying Chapter 19 (Partially Contributing Impairment). The result is the total accepted cardiorespiratory functional impairment rating.

This is where a thirty-year smoking history, or non-accepted heart disease alongside accepted chronic bronchitis, gets weighed. It is also where a vague report does the most damage: if nothing in the evidence separates the accepted contribution from the rest, the split will be estimated, and it will not be estimated in your favour.

Step 8: the Other Impairment tables

Finally the functional rating is compared against four Other Impairment tables, one for each recognised category:

Table 1.7 — ischaemic heart disease
Table 1.8 — valvular heart disease
Table 1.9 — miscellaneous heart disease
Table 1.10 — lower respiratory tract conditions

Consistent with the rest of the Guide, the higher of the functional and Other Impairment ratings is the one that applies. This is why the history matters at Step 2 — a past myocardial infarction or bypass surgery, or the nature of your current respiratory treatment, can produce a rating here that exceeds what your current exercise tolerance would give you.

What this means in practice

Get the tests done, and get them done recently. Six months is the outer limit for both spirometry and effort tolerance information. Turning up without current results is the most common reason a cardiorespiratory assessment underestimates.

Answer the effort tolerance question the way the Guide asks it. Not what you avoid — what you can do, and what happens when you do it. Be specific: distances, flights of stairs, gradients, and the symptom that stops you.

Think about steady activities. Walking the dog, mowing, carrying shopping from the car. Those are more useful to the assessment than anything brief or sporadic.

Have the non-accepted contribution addressed properly. Chapter 19 is going to be applied. It is far better done on evidence than on assumption.

Long-standing respiratory disease usually spreads. The Guide expressly recognises that asthma may lead to chronic obstructive respiratory disease, and chronic bronchitis to small airways disease — and that such extensions are assessed as part and parcel of the original condition unless there is clear reason otherwise. Do not assume a broader diagnosis means a new claim is required to capture it here.

Frequently asked questions

Which conditions are assessed under Chapter 1?

Most heart and lung conditions, plus conditions affecting the thorax or diaphragm, lesions of the nerves supplying the muscles of respiration, and conditions such as anaemia. Hypertension and non-cardiac vascular conditions go to Chapter 2; predominantly intermittent conditions go to Chapter 15.

Is sleep apnoea assessed under Chapter 1?

Not usually by this route. Sleep apnoea does not typically reduce cardiorespiratory exercise tolerance, and conditions that do not decrease exercise tolerance cannot be rated by that method. Where it produces cardiac consequences that are separately accepted, those consequences are assessed here.

How old can my spirometry be?

No more than six months older than the relevant time in the assessment period. The same limit applies to effort tolerance information.

Should I use my post-bronchodilator results because they look worse?

The Guide requires the pre-bronchodilator results to be used where both are available, and requires the best set of results to be selected. The measurement protocol is fixed — it is not something to be managed.

What if I cannot exercise because of my knees or my back?

The Guide anticipates this. Exercise tolerance means cardiorespiratory tolerance, not total exercise ability, and Chapter 19 must be considered before effort tolerance figures are disregarded. Make sure the assessing doctor records why the measurement is limited and by what.

Does age affect my rating?

Yes. Ratings derived from METs (Tables 1.2 and 1.3) and from Table 1.4 are age adjusted. Tables 1.5 and 1.6 permit no age adjustment.

Next in this series

Chapter 2: hypertension and non-cardiac vascular conditions.

Talk to us

If you have a permanent impairment assessment coming up and want it done by a doctor who applies this Guide every week, call 0429 146 039 or email reception@vhc.org.au.