GARP Chapter 2: Hypertension and Vascular Conditions — Why Your Blood Pressure Is Only Worth 2 Points

Hypertension is one of the most commonly accepted conditions in the veteran population, and one of the most commonly misunderstood at assessment. Veterans routinely expect it to be worth more than it is, and are surprised when well-controlled blood pressure on a single tablet comes back at 2 impairment points.

That is not an error. It is exactly what Chapter 2 says. The value in a hypertension claim is almost never in the hypertension itself — it is in what the hypertension has damaged, and in the long list of conditions that accepted hypertension now unlocks.

This is part of our series working through the GARP. Start with what the GARP is, the chapter map, and Chapter 1.

What Chapter 2 covers

Three parts:

Part 2.1 — Hypertension
Part 2.2 — Vascular conditions of the lower limbs
Part 2.3 — Other non-cardiac vascular conditions

Anything affecting the heart itself goes to Chapter 1. The Guide gives the reason for the split in one line: hypertension, of itself, does not affect effort tolerance. Since Chapter 1 rates on exercise tolerance, uncomplicated hypertension would rate at nothing there, so it gets its own method.

Part 2.1: hypertension

Four steps: establish whether there is target organ damage; if so, rate it; rate the hypertension itself from Table 2.1.1; then take the higher of the two.

Step 1 — target organ damage, defined narrowly

"Target organ damage" has a closed definition in this chapter. It means only:

hypertensive retinopathy, grade III or IV;
hypertensive cardiac disease, with ECG or X-ray evidence of left ventricular hypertrophy;
hypertensive nephropathy demonstrated at biopsy, or by proteinuria or elevated serum creatinine; or
hypertensive cerebral haemorrhage.

And there is an express exclusion that catches a lot of people out. Conditions which merely have hypertension as a contributing factor in their aetiology — the Guide names ischaemic heart disease and peripheral vascular disease — are not target organ damage for this purpose. They are separate conditions, separately claimed and separately rated.

Step 2 — rating the damage, in other chapters

Target organ damage is not rated here. Each element goes to its own chapter: retinopathy to Chapter 8, hypertensive cardiac disease to Chapter 1, nephropathy to Chapter 9, and cerebral haemorrhage according to its specific effects. Where other conditions affect the same system, Chapter 19 or Chapter 20 is applied. The resulting ratings are combined via Chapter 18.

Then comes the rule that decides whether any of this is worth anything:

"Target organ damage that is not an accepted condition cannot be assessed under this Guide. Target organ damage can be assessed under this Guide only after it has been claimed and has become an accepted condition."

Your hypertensive nephropathy is worth nothing at assessment until it is claimed and accepted in its own right. This is the general sequelae rule, and it bites hardest here, because hypertension is precisely the condition whose value lies downstream.

Step 3 — Table 2.1.1, and why the numbers are small

The hypertension rating itself comes from a four-row table:

NIL — adequately controlled by diet and weight loss, without long-term medication.
TWO — requiring long-term medication, but without side effects and with no evidence of target organ damage.
FIVE — diastolic pressure consistently at or above 90 mm Hg despite treatment; or controlled but with frequent minor medication side effects causing no loss of function.
TEN — diastolic consistently above 100 mm Hg; or hypertension of such a degree that target organ damage is present; or controlled but with medication side effects causing a significant and persistent loss of function.

Only one rating may be selected, and no age adjustment is permitted. Ten points is the ceiling for hypertension as a condition in its own right.

Two things in that table are worth reading twice.

Medication side effects are rated. Two of the seven criteria turn on them. Frequent minor side effects with no loss of function is a 5. Side effects causing a significant and persistent loss of function is a 10 — the same as uncontrolled hypertension. Veterans very rarely mention side effects at assessment, because nobody asks and because they have adjusted to them. Fatigue, dizziness on standing, cough, erectile dysfunction, exercise intolerance, cold extremities: if your blood pressure medication does that to you, say so.

The 10-point target organ damage criterion works differently from Step 2. The Guide is explicit that this criterion "is not an assessment of the target organ damage itself but is a measure of the severity of the hypertension" — and that for this purpose, target organ damage may be either an accepted or a non-accepted condition. So damage that is not accepted, and therefore cannot be rated at Step 2, can still push the hypertension rating from 2 to 10 at Step 3.

Step 4 — higher wins, and the loser is discarded entirely

The total for accepted target organ damage is compared with the Table 2.1.1 rating and the higher is taken. The Guide then spells out what happens to the other one, and it is unusually harsh:

If Table 2.1.1 is higher, the target organ damage rating is discarded and its components are not used in any further calculations.
If the target organ damage rating is higher, the Table 2.1.1 rating is discarded, and each component of the target organ damage rating goes into the final combining.

The asymmetry matters. Under the second branch the components combine individually through Chapter 18 rather than entering as a single lumped figure — which generally produces more. The Guide also states that the total target organ damage rating is not combined with the Table 2.1.1 rating; it is strictly one or the other.

One exception is noted: ratings from Table 2.1.1 are not routinely compared with Chapter 1 functional loss tables except where hypertensive cardiomyopathy is present.

Part 2.2: vascular conditions of the lower limbs

Three categories — arterial peripheral vascular disease, varicose veins and vascular leg ulcers, and oedema — assessed over a ten-step process that is really one idea repeated: rate the condition by its functional effects, rate it again by the Other Impairment tables, and take whichever line produces more.

Functional effects. Lower limb function is assessed under Chapter 3, Part 3.2 — peripheral vascular disease typically reduces walking distance through intermittent claudication. Skin effects (discolouration, pruritus, excoriations from varicose veins) are assessed under Chapter 11. The Guide is clear these are symptoms or manifestations of the vascular condition and are assessed as part of it, not as separate conditions.

The Other Impairment tables. Three of them, and a condition may be rated under more than one, but only one rating may be taken from each table regardless of how many conditions contribute:

Table 2.2.1 — peripheral vascular disease. NIL none; TWO minor or successfully treated; FIVE moderate but little restriction of activities; TEN severe disease whose expected effects are masked by a non-accepted condition — for example, where walking is already restricted by a musculoskeletal disorder. That last criterion is unusual and useful: it exists precisely so a veteran whose bad knees hide the severity of their vascular disease is not penalised for it.
Table 2.2.2 — varicose veins. NIL for veins that are not greatly disfiguring with only trivial symptoms, or superficial, small or transient ulceration; TWO for veins that are unsightly or even gross but impose no significant restriction; FIVE where symptoms are constant or almost constant, not easily tolerated, and require medication or therapy; TEN for very severe veins or ulceration that is difficult to control and requires periodic confinement or hospital admission.
Table 2.2.3 — oedema. NIL mild or transient; FIVE moderate and persistent; TEN marked and only partly controlled by treatment.

All three are one rating whether one leg or both are affected, and none permits age adjustment.

Then the comparison: combine the functional ratings (Steps 3 and 4), combine the Other Impairment ratings (Step 5), and compare. Whichever side is higher supplies the final ratings — and importantly, the individual ratings on the winning side go into the final combining separately rather than as the combined figure used for the comparison.

One further note: amputations arising from peripheral vascular disease cannot be assessed unless separately accepted, after which they are rated under Chapter 3. The same sequelae rule again.

Part 2.3: other non-cardiac vascular conditions

A single table, 2.3.1, for aneurysms and intra-vascular conditions:

TWO — aortic aneurysm under 6 cm; renal artery stenosis; iliac, femoral or carotid aneurysms.
FIVE — embolus requiring anticoagulant medication; non-valvular vascular conditions requiring anticoagulant medication; aortic aneurysm of 6 cm or more; aortic aneurysm surgically corrected.
TEN — other vascular conditions difficult to control, such as severe deep venous thrombosis.

One rating per condition, highest applicable criterion, no age adjustment. Note that a surgically corrected aortic aneurysm still rates 5 — successful treatment does not reduce it to nothing.

Finally, the chapter directs that impairment from atherosclerosis is rated through Chapter 1, Part 2.2 and Chapter 5 according to the losses of function it causes, and that cerebral aneurysms and cerebrovascular disease are rated under Chapter 5 and any other applicable chapter according to their effects.

What this means in practice

Hypertension alone is worth 2 to 10 points, and usually 2. If that is the whole claim, expect a small number. Nothing about the assessment will change that — the table has four rows and a ceiling of ten.

The value is downstream, and it has to be claimed. Hypertensive retinopathy, hypertensive cardiac disease and hypertensive nephropathy are each worth more than the hypertension, and each is worth nothing until separately accepted. Under presumptive liability, accepted hypertension now also makes atrial fibrillation or flutter, sick sinus syndrome, subarachnoid haemorrhage, aortic aneurysm, aortic stenosis, carotid artery disease, ischaemic heart disease, peripheral artery disease and retinal vascular occlusion attributable to service without proving the link. If your hypertension is accepted and those claims have not been made, that is the single largest gap in your file.

Tell the doctor about your medication side effects. They are worth up to 10 points on their own, and they are the most under-reported item in this chapter.

Bring the readings. Two of the criteria turn on diastolic pressure "consistently" at or above a threshold despite treatment. One reading in a clinic does not establish that. A series does.

If another condition masks your vascular disease, say so explicitly. Table 2.2.1 has a 10-point criterion written for exactly that situation, but only if someone records that the masking is happening.

Frequently asked questions

Why is my hypertension only worth 2 points?

Because Table 2.1.1 rates long-term medication without side effects and without target organ damage at 2. The table's maximum is 10. Hypertension is a low-value condition in its own right; its significance is in what it causes and what it now unlocks.

Does high blood pressure get assessed on exercise tolerance like heart conditions?

No. The Guide says hypertension of itself does not affect effort tolerance, which is why uncomplicated hypertension is expressly kept out of Chapter 1.

Is my ischaemic heart disease "target organ damage" from my hypertension?

Not for the purposes of Part 2.1. The Guide expressly excludes conditions that merely have hypertension as a contributing factor, and names ischaemic heart disease and peripheral vascular disease. IHD is a separate claim — and one that presumptive liability may now assist with where hypertension is accepted before its onset.

Do medication side effects really count?

Yes. Frequent minor side effects causing no loss of function rate 5. Side effects causing significant and persistent loss of function rate 10 — the same as uncontrolled hypertension.

Can I get points for both the hypertension and the organ damage?

No. Step 4 takes the higher of the two and discards the other. The Guide states the target organ damage total is not to be combined with the Table 2.1.1 rating.

My varicose veins look terrible but do not stop me doing anything — what is that worth?

Table 2.2.2 rates veins that are "unsightly or even gross" but impose no significant restriction at 2 points. If symptoms are constant and require medication or therapy, 5.

Does a repaired aortic aneurysm still count?

Yes. "Aortic aneurysm surgically corrected" is one of the 5-point criteria in Table 2.3.1.

Next in this series

Chapter 3: impairment of spine and limbs — the biggest chapter in the Guide, and the one most veterans are assessed under.

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.