Diagnostic Assessment — Heart Block
Example 1 of 1 · fictitious patient (Veteran BZ)
Diagnostic Assessment
Heart Block
BOP Code: 24 of 2022 (Heart Block)
RH Code: 23 of 2022 (Heart Block)
ADF History
Veteran BZ, date of birth 08 October 1974, Australian Army, Physical Training Instructor (formerly Rifleman), enlisted 15 January 1993, medically discharged 28 February 2018. Operational service: East Timor, 20 September 1999 to 18 February 2000 (warlike); Afghanistan, 12 March 2008 to 30 October 2008 (warlike); Middle East Area of Operations, 05 January 2013 to 20 July 2013 (warlike).
Occupational History
As a rifleman and later a physical training instructor the veteran carried out sustained high-intensity physical activity, including running, loaded marches with 30 to 40 kilograms, circuit and obstacle training and combatives, leading and joining sessions for many hours each week in garrison and on deployment.
On deployment he was exposed to tropical infections, including streptococcal disease in East Timor, and to fine dust, burn-pit smoke and diesel exhaust in Afghanistan and the Middle East. Deployed members were issued permethrin-treated clothing and bed nets and took antimalarial prophylaxis, and the service culture of the period normalised heavy episodic drinking at unit functions and memorials.
History
Veteran BZ, a physical training instructor in the Australian Army, developed acute rheumatic fever after service in East Timor and cardiac sarcoidosis after service in Afghanistan, which led to a heart transplant in 2014, a lymphoma of the transplanted heart and an allogeneic stem cell transplant. He developed first-degree atrioventricular block with right bundle branch block at 01:00 on 15 March 2017, which progressed to complete heart block later that morning and required a permanent pacemaker.
Timeline
- 14 Jan 2000 — During warlike service in East Timor the veteran developed streptococcal pharyngitis, followed by fever, migratory polyarthritis and a new mitral regurgitant murmur. A physician diagnosed acute rheumatic fever with carditis on aeromedical evacuation to Darwin, and echocardiography showed mild rheumatic mitral regurgitation. Monthly benzathine penicillin was given for ten years. "acute rheumatic fever, carditis"
- 11 Apr 2011 — Transbronchial biopsy confirmed sarcoidosis, after progressive breathlessness that began following dust and burn-pit smoke exposure in Afghanistan in 2008. A rheumatologist also diagnosed seropositive rheumatoid arthritis and started hydroxychloroquine 400 mg daily. Echocardiography the following year, on 02 July 2012, showed left ventricular hypertrophy, and hypertension was diagnosed on 19 June 2012. "sarcoidosis, RA, hydroxychloroquine started"
- 18 Jun 2014 — After deterioration from cardiac sarcoidosis, with ventricular tachycardia and an ejection fraction of 20 per cent from December 2013, the veteran received an orthotopic heart transplant. The donor was Toxoplasma seropositive and the veteran seronegative. He began immunosuppression with tacrolimus, mycophenolate and prednisolone, and developed post-transplant diabetes in August 2015. "orthotopic heart transplant"
- 04 Feb 2016 — A post-transplant lymphoproliferative disorder, diffuse large B-cell lymphoma, was diagnosed as a 42 mm right atrial mass extending into the atrioventricular groove. He received six cycles of R-CHOP chemotherapy, including doxorubicin, then radiotherapy with the heart in the field from July to August 2016. An endomyocardial biopsy on 10 October 2016 perforated the right ventricle and required a pericardial window. "PTLD right atrium, R-CHOP"
- 05 Dec 2016 — After lymphoma relapse the veteran received an allogeneic stem cell transplant. He developed grade III acute graft versus host disease in January 2017 and Graves hyperthyroidism, and echocardiography on 17 January 2017 showed anthracycline cardiomyopathy with an ejection fraction of 38 per cent. He fell and struck his chest on 25 January 2017. "allogeneic SCT, GVHD grade III"
- 08 Mar 2017 — At a hospital-in-the-home review the ECG showed sinus rhythm with a PR interval of 180 ms and normal QRS duration. In the preceding three weeks he had developed Staphylococcus aureus tricuspid endocarditis, a recurrence of acute rheumatic fever, and acute rejection with cytomegalovirus and Toxoplasma myocarditis on biopsy. Pulmonary emboli were confirmed the next day. "ECG sinus, PR 180 ms"
- 15 Mar 2017 — After a stem cell boost at 13:00 and a brown snake bite at 19:00 the previous day, the veteran was being monitored in a regional hospital. At 01:00 the ECG showed new first-degree atrioventricular block with a PR interval of 280 ms and right bundle branch block. At 11:30 it progressed to Mobitz type II and then complete heart block with a ventricular escape rhythm of 34 beats per minute and syncope, and transcutaneous pacing was started. "complete heart block, escape 34"
- 22 Mar 2017 — At the transplant centre a cardiac electrophysiologist confirmed infra-Hisian complete atrioventricular block that did not recover after correction of electrolytes and withdrawal of rate-slowing drugs, and implanted a permanent dual-chamber pacemaker. The veteran remained pacemaker-dependent at follow-up. "dual-chamber pacemaker, pacing dependent"
Symptoms
At onset the veteran had fatigue, light-headedness and breathlessness, which he initially attributed to his other illnesses. When the block progressed later that morning he had a syncopal episode, severe breathlessness and confusion from a heart rate of 34 beats per minute.
Since the pacemaker was implanted he reports reduced exercise tolerance, fatigue and anxiety about device failure, and he is pacemaker-dependent. He can no longer undertake strenuous physical activity.
Imaging
- 02 Jul 2012 — Transthoracic echocardiogram: "Concentric left ventricular hypertrophy, septal thickness 14 mm, with preserved systolic function. Mild rheumatic mitral regurgitation."
- 04 Feb 2016 — Cardiac MRI and CT chest: "42 mm enhancing mass in the right atrial wall extending into the atrioventricular groove, consistent with lymphoma."
- 22 Nov 2016 — Coronary angiography: "Cardiac allograft vasculopathy with 70 per cent proximal left anterior descending stenosis and diffuse distal vessel pruning."
- 20 Feb 2017 — Cardiac FDG-PET: "Focal FDG uptake in the basal interventricular septum of the allograft, consistent with active cardiac sarcoidosis."
- 01 Mar 2017 — Transoesophageal echocardiogram: "9 mm vegetation on the tricuspid valve. Thickened, restricted allograft mitral leaflets with moderate regurgitation. Left ventricular ejection fraction 38 per cent."
- 02 Mar 2017 — Cardiac MRI: "Residual 18 mm soft tissue mass in the posterior atrioventricular groove adjacent to the atrioventricular node, and an organised pericardial haematoma along the inferior septum."
- 09 Mar 2017 — CT pulmonary angiogram: "Bilateral segmental pulmonary emboli with right ventricular dilatation."
Onset Date
The most likely date of onset of this condition is 15 Mar 2017.
At that date the veteran was serving full time on long-term medical restriction, awaiting medical discharge, and was being treated at home under the hospital-in-the-home program. He had received a stem cell boost at 13:00 on 14 March 2017 and was bitten by a brown snake at 19:00, and he was being monitored in a regional hospital when the ECG changed at 01:00.
This date is appropriate because the ECG on 08 March 2017 showed sinus rhythm with a PR interval of 180 ms and a normal QRS, and the ECG at 01:00 on 15 March 2017 showed new first-degree atrioventricular block with right bundle branch block. It falls within continuous full-time service.
For the 24-hour factors, the 24 hours before onset run from 01:00 on 14 Mar 2017 to 01:00 on 15 Mar 2017, covering the stem cell boost at 13:00 and the snake bite at 19:00 on 14 Mar 2017. The 2 days before onset run from 13 Mar 2017, covering the binge drinking that evening, and the 3 days run from 12 Mar 2017, covering the permethrin exposure. The 7 days before onset run from 08 Mar 2017 to 15 Mar 2017, covering the pulmonary emboli, the foxglove tonic and daily cannabis. The 3 weeks run from 22 Feb 2017, during which he took metoprolol, and the 60 days run from 14 Jan 2017, covering the chest injury of 25 Jan 2017. The 1 year runs from 15 Mar 2016, covering the ventricular perforation, pericardial window and biopsies. The 5 years run from 15 Mar 2012 to 15 Mar 2017, during which his strenuous activity averaged about 10.4 hours a week, and hydroxychloroquine was taken from 11 Apr 2011. Each of the conditions required to be present at onset was documented before 15 Mar 2017.
For the worsening factors, the documented worsening is the progression to complete heart block at 11:30 on 15 Mar 2017. The stem cell boost was 22 hours and 30 minutes, and the snake bite 16 hours and 30 minutes, before the worsening, both within 24 hours. The binge drinking, permethrin exposure, pulmonary emboli, foxglove tonic, cannabis, metoprolol and digoxin, chest injury and cardiac procedures each fall within the corresponding windows before the worsening, and every condition present at onset persisted at 11:30.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Heart Block (ICD-10-AM I44.2), first-degree atrioventricular block with right bundle branch block that progressed to complete (third-degree) atrioventricular block, under the Statements of Principles concerning heart block, Balance of Probabilities No. 24 of 2022 and Reasonable Hypothesis No. 23 of 2022.
Heart block is a delay or interruption in the conduction of the electrical impulse from the atria to the ventricles through the atrioventricular node, bundle of His or bundle branches. First-degree block prolongs the PR interval; second-degree block drops some beats; in complete heart block no atrial impulses reach the ventricles, which beat slowly from an escape rhythm. It causes fatigue, breathlessness, dizziness and syncope and can cause sudden death. Causes include ischaemia, infiltration, inflammation and infection of the myocardium, cardiac surgery and procedures, drugs and electrolyte disturbance.
The condition began at 01:00 on 15 March 2017 in the transplanted heart, progressed to complete heart block at 11:30 that day and was treated with a permanent pacemaker on 22 March 2017.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 March 2017.
When did the veteran first present to a health / medical provider for this condition?
15 March 2017.
When was the condition confirmed / formally diagnosed?
15 March 2017.
When did the veteran first present to you (or your practice) for this condition?
27 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed on 12-lead ECG at 01:00 on 15 March 2017, which showed a PR interval of 280 ms with right bundle branch block, and on continuous monitoring at 11:30, which showed Mobitz type II block progressing to complete atrioventricular dissociation with a ventricular escape rhythm of 34 beats per minute. This meets the Statement of Principles definition of heart block, which includes atrioventricular block and bundle branch block. It is not congenital, is not long QT syndrome and was not a transient physiological block.
A cardiac electrophysiologist confirmed infra-Hisian complete heart block on 22 March 2017 that persisted after correction of electrolytes and withdrawal of drugs, and implanted a permanent pacemaker.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 15 March 2017, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 1999 to 2000, where acute rheumatic fever began, in Afghanistan in 2008, where the exposures that led to sarcoidosis, the heart transplant and its complications occurred, and in the Middle East in 2013.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Heart Block, No. 24 of 2022
Causative factors
Factor 9(1): having ischaemic heart disease at the time of the clinical onset of heart block; — MET
- Coronary angiography on 22 November 2016 showed cardiac allograft vasculopathy with a 70 per cent stenosis of the proximal left anterior descending artery and diffuse distal pruning, and a cardiologist diagnosed ischaemic heart disease of the transplanted heart. It was present at the onset at 01:00 on 15 March 2017. Ischaemia of the septum, which carries the bundle branches, impairs conduction.
Factor 9(2): having pulmonary thromboembolism within the 7 days before the clinical onset of heart block; — MET
- CT pulmonary angiography on 09 March 2017 showed bilateral segmental pulmonary emboli with right ventricular strain, associated with his tunnelled central venous catheter. This was 5 days and 15 hours before onset, within the 7 days from 08 March 2017 to 15 March 2017. Acute right ventricular strain causes right bundle branch block and atrioventricular block.
Factor 9(3): having infiltration of the myocardium due to amyloidosis or sarcoidosis at the time of the clinical onset of heart block; — MET
- Sarcoidosis was diagnosed on transbronchial biopsy on 11 April 2011, with cardiac involvement leading to heart transplantation in 2014. Cardiac FDG-PET on 20 February 2017 showed focal uptake in the basal septum of the allograft, and granulomas were present on endomyocardial biopsy on 06 March 2017, confirming sarcoid infiltration of the myocardium at the onset.
Factor 9(4): having cardiomyopathy at the time of the clinical onset of heart block; — MET
- Echocardiography on 17 January 2017 showed global left ventricular dysfunction with an ejection fraction of 38 per cent, diagnosed by the transplant cardiologist as anthracycline cardiomyopathy after doxorubicin-containing chemotherapy in 2016. It was present at the onset on 15 March 2017.
Factor 9(5): having a benign or malignant neoplasm involving the heart before the clinical onset of heart block; — MET
- A post-transplant lymphoproliferative disorder, diffuse large B-cell lymphoma, was diagnosed on 04 February 2016 as a 42 mm mass in the right atrial wall extending into the atrioventricular groove, confirmed on biopsy. This neoplasm involving the heart preceded the onset of heart block by more than a year.
Factor 9(6): having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical onset of heart block; — MET
- Cardiac MRI on 02 March 2017 showed a residual 18 mm lymphoma mass in the posterior atrioventricular groove adjacent to the atrioventricular node, and an organised pericardial haematoma from the biopsy perforation of October 2016 lying against the inferior septum. Both were present at the onset and compress the region of the atrioventricular node and bundle of His.
Factor 9(7): having non-infectious myocarditis at the time of the clinical onset of heart block; — MET
- Surveillance endomyocardial biopsy on 06 March 2017 showed acute cellular rejection, ISHLT grade 2R, an immune-mediated myocarditis of the transplanted heart. Augmented immunosuppression was started but the rejection was still present at the onset on 15 March 2017.
Factor 9(8): having viral myocarditis at the time of the clinical onset of heart block; — MET
- The endomyocardial biopsy of 06 March 2017 showed cytomegalovirus inclusions in myocytes with a positive tissue PCR, and the blood CMV viral load was 52,000 IU/mL on 13 March 2017. A transplant cardiologist diagnosed cytomegalovirus myocarditis, present at the onset.
Factor 9(9): having a non-viral infection of the myocardium at the time of the clinical onset of heart block; — MET
- The same biopsy showed Toxoplasma gondii tissue cysts with surrounding myocarditis. The donor heart was Toxoplasma seropositive and the veteran seronegative, and prophylaxis had been stopped during chemotherapy. Toxoplasma myocarditis was being treated with pyrimethamine and sulfadiazine and was present at the onset.
Factor 9(10): having infective endocarditis at the time of the clinical onset of heart block; — MET
- Blood cultures on 26 February 2017 grew Staphylococcus aureus from his tunnelled catheter, and transoesophageal echocardiography on 01 March 2017 showed a 9 mm tricuspid valve vegetation. Infective endocarditis was diagnosed and he was receiving intravenous cefazolin through hospital in the home at the onset.
Factor 9(11): having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical onset of heart block; — MET
- Bloods at 22:00 on 14 March 2017 showed hyperkalaemia, with a potassium of 6.3 mmol/L from tacrolimus and impaired renal function, and hypercalcaemia, with a corrected calcium of 2.94 mmol/L from active sarcoidosis. Both abnormalities were present at the onset three hours later.
Factor 9(12): taking a drug from the specified list of drugs within the 3 weeks before the clinical onset of heart block; — MET
- Metoprolol 50 mg twice daily, a beta blocker, was started on 14 February 2017 for paroxysmal atrial fibrillation and was taken every day up to the onset, within the 3 weeks from 22 February 2017 to 15 March 2017. Digoxin 125 micrograms daily, a cardiac glycoside, was added on 01 March 2017.
Factor 9(13): taking chloroquine or hydroxychloroquine for at least 1 year before the clinical onset of heart block; — MET
- Hydroxychloroquine 400 mg daily was prescribed by a rheumatologist on 11 April 2011 for rheumatoid arthritis and sarcoidosis and was taken continuously to the onset, a period of almost 6 years, well beyond the 1 year required.
Factor 9(14): having ingested a plant containing cardiac glycosides within the 7 days before the clinical onset of heart block; — MET
- From 10 March 2017 the veteran took a herbal tonic supplied by an alternative practitioner, later found to contain foxglove (Digitalis purpurea) leaf. He took it daily up to 14 March 2017, within the 7 days before onset from 08 March 2017 to 15 March 2017, and his serum digoxin level at 22:00 on 14 March 2017 was 3.1 nmol/L, well above the level expected from his prescribed dose.
Factor 9(15): experiencing penetrating trauma to the heart within the 1 year before the clinical onset of heart block; — MET
- During a surveillance endomyocardial biopsy on 10 October 2016 the bioptome perforated the right ventricular free wall, causing haemopericardium and tamponade. This penetrating trauma to the heart occurred 5 months and 5 days before onset, within the 1 year from 15 March 2016 to 15 March 2017.
Factor 9(16): having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical onset of heart block; — MET
- The veteran underwent an emergency subxiphoid pericardial window and repair of the right ventricular perforation on 10 October 2016, and further surveillance endomyocardial biopsies, invasive cardiac procedures, on 12 December 2016 and 06 March 2017. All were within the 1 year before onset, from 15 March 2016 to 15 March 2017.
Factor 9(17): experiencing a blunt chest injury within the 60 days before the clinical onset of heart block; — MET
- On 25 January 2017 the veteran fell on his stairs during a hypotensive episode and struck the front of his chest on the edge of a step, with sternal bruising recorded by the hospital-in-the-home nurse and a normal chest radiograph. This non-penetrating blow to the chest was 49 days before onset, within the 60 days from 14 January 2017 to 15 March 2017.
Factor 9(18): having a heart transplant before the clinical onset of heart block; — MET
- The veteran received an orthotopic heart transplant on 18 June 2014 for end-stage cardiac sarcoidosis, nearly 3 years before the onset of heart block. Transplanted hearts are denervated and the donor conduction system is vulnerable to ischaemia, rejection and surgical injury.
Factor 9(19): having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical onset of heart block; — MET
- The veteran received an allogeneic stem cell transplant on 05 December 2016 for relapsed lymphoma and, because of poor graft function, a CD34-selected stem cell boost from the same donor as a day infusion at 13:00 on 14 March 2017. The onset at 01:00 on 15 March 2017 was 12 hours later, within 24 hours. The cryopreservative dimethyl sulfoxide in stem cell products is a recognised cause of bradycardia and atrioventricular block.
Factor 9(20): having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical onset of heart block; — MET
- Acute graft versus host disease of the skin and gut, grade III, was diagnosed by the haematologist on 09 January 2017 after the allogeneic stem cell transplant and was present at the onset, still requiring prednisolone 1 mg/kg daily.
Factor 9(21): undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical onset of heart block; — MET
- From 18 July 2016 to 19 August 2016 the veteran received 36 Gy in 20 fractions of radiotherapy to the right atrial and atrioventricular groove lymphoma, with the heart in the radiation field, before the onset on 15 March 2017.
Factor 9(22): undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical onset of heart block; — MET
- As a physical training instructor the veteran led and took part in physical training at 8 to 12 METs, including running, circuit training and loaded marches, for about 22 hours a week until November 2013, including on deployment in 2013. After his transplant he trained at 7 to 9 METs for about 12 hours a week from October 2014 to January 2016 for the transplant games. His training logs give an average of about 10.4 hours a week over the 5 years before onset, from 15 March 2012 to 15 March 2017.
Factor 9(23): having diabetes mellitus at the time of the clinical onset of heart block; — MET
- Post-transplant diabetes mellitus was diagnosed on 03 August 2015, with an HbA1c of 7.9 per cent, from tacrolimus and prednisolone. It was present at onset, with an HbA1c of 8.6 per cent in February 2017.
Factor 9(24): having hypertension with left ventricular hypertrophy before the clinical onset of heart block; — MET
- Hypertension was diagnosed at his periodic health examination on 19 June 2012, with readings of 162/98 mmHg, and echocardiography on 02 July 2012 showed left ventricular hypertrophy with a septal thickness of 14 mm and an increased left ventricular mass index out of proportion to athletic training. Hypertension with left ventricular hypertrophy was therefore established before the onset.
Factor 9(25): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of heart block; — MET
- Rheumatoid arthritis was diagnosed by a rheumatologist on 11 April 2011, with symmetrical small-joint synovitis, positive anti-CCP antibodies and erosions on hand radiographs. It was present at the onset, treated with hydroxychloroquine.
Factor 9(26): having acute rheumatic fever at the time of the clinical onset of heart block; — MET
- On 17 February 2017 the veteran developed streptococcal pharyngitis, followed by migratory polyarthritis, fever and a rising antistreptolysin O titre of 800 IU/mL. On 01 March 2017 an infectious diseases physician diagnosed a recurrence of acute rheumatic fever under the Jones criteria, his first episode having followed service in East Timor in 2000. It was active at the onset, with a C-reactive protein of 96 mg/L on 14 March 2017.
Factor 9(27): having rheumatic heart disease at the time of the clinical onset of heart block; — MET
- Rheumatic heart disease was diagnosed after his first episode of acute rheumatic fever in 2000. After the recurrence in 2017, transoesophageal echocardiography on 01 March 2017 showed rheumatic thickening of the allograft mitral valve leaflets with restricted motion and moderate regurgitation, meeting World Heart Federation criteria, and it was present at the onset.
Worsening factors
Factor 9(28): having ischaemic heart disease at the time of the clinical worsening of heart block; — MET
- Cardiac allograft vasculopathy with ischaemic heart disease persisted and was present when the heart block progressed to complete atrioventricular block at 11:30 on 15 March 2017.
Factor 9(29): having pulmonary thromboembolism within the 7 days before the clinical worsening of heart block; — MET
- The pulmonary emboli of 09 March 2017 were 6 days and 1 hour before the worsening at 11:30 on 15 March 2017, within 7 days, with persisting right ventricular strain on echocardiography that morning.
Factor 9(30): having infiltration of the myocardium due to amyloidosis or sarcoidosis at the time of the clinical worsening of heart block; — MET
- Sarcoid infiltration of the allograft septum was present at the worsening and was confirmed again on the explanted biopsy specimens reviewed in April 2017.
Factor 9(31): having cardiomyopathy at the time of the clinical worsening of heart block; — MET
- Anthracycline cardiomyopathy, with an ejection fraction of 35 per cent on echocardiography at 09:00 on 15 March 2017, was present at the worsening.
Factor 9(32): having a benign or malignant neoplasm involving the heart before the clinical worsening of heart block; — MET
- The lymphoma involving the right atrium and atrioventricular groove was diagnosed on 04 February 2016, before the worsening.
Factor 9(33): having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical worsening of heart block; — MET
- The residual lymphoma mass and organised haematoma in the atrioventricular groove were present at the worsening.
Factor 9(34): having non-infectious myocarditis at the time of the clinical worsening of heart block; — MET
- Acute cellular rejection, grade 2R, persisted at the worsening; repeat biopsy on 17 March 2017 still showed grade 2R.
Factor 9(35): having viral myocarditis at the time of the clinical worsening of heart block; — MET
- Cytomegalovirus myocarditis was present at the worsening, with a blood viral load of 61,000 IU/mL on 15 March 2017.
Factor 9(36): having a non-viral infection of the myocardium at the time of the clinical worsening of heart block; — MET
- Toxoplasma myocarditis was under treatment and present at the worsening.
Factor 9(37): having infective endocarditis at the time of the clinical worsening of heart block; — MET
- Staphylococcus aureus tricuspid endocarditis was present at the worsening, still on intravenous cefazolin.
Factor 9(38): having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical worsening of heart block; — MET
- Bloods at 10:00 on 15 March 2017 showed persisting hyperkalaemia, potassium 6.5 mmol/L, and hypercalcaemia, corrected calcium 2.97 mmol/L, at the worsening.
Factor 9(39): taking a drug from the specified list of drugs within the 3 weeks before the clinical worsening of heart block; — MET
- Metoprolol and digoxin were taken every day up to the morning of 15 March 2017, within the 3 weeks before the worsening, and were not withheld until 09:00 that day.
Factor 9(40): taking chloroquine or hydroxychloroquine for at least 1 year before the clinical worsening of heart block; — MET
- Hydroxychloroquine 400 mg daily had been taken continuously from 11 April 2011 to the worsening, almost 6 years.
Factor 9(41): having ingested a plant containing cardiac glycosides within the 7 days before the clinical worsening of heart block; — MET
- The foxglove-containing herbal tonic was last taken on 14 March 2017, the day before the worsening and within 7 days of it.
Factor 9(42): experiencing penetrating trauma to the heart within the 1 year before the clinical worsening of heart block; — MET
- The right ventricular perforation of 10 October 2016 was 5 months and 5 days before the worsening, within 1 year.
Factor 9(43): having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical worsening of heart block; — MET
- The pericardial window of 10 October 2016 and the endomyocardial biopsies of 12 December 2016 and 06 March 2017 were within the 1 year before the worsening.
Factor 9(44): experiencing a blunt chest injury within the 60 days before the clinical worsening of heart block; — MET
- The blunt chest injury of 25 January 2017 was 49 days before the worsening, within 60 days.
Factor 9(45): having a heart transplant before the clinical worsening of heart block; — MET
- The heart transplant of 18 June 2014 preceded the worsening.
Factor 9(46): having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical worsening of heart block; — MET
- The CD34-selected stem cell boost at 13:00 on 14 March 2017 was 22 hours and 30 minutes before the worsening at 11:30 on 15 March 2017, within 24 hours.
Factor 9(47): having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical worsening of heart block; — MET
- Grade III acute graft versus host disease was present at the worsening.
Factor 9(48): undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical worsening of heart block; — MET
- Radiotherapy with the heart in the field, completed on 19 August 2016, preceded the worsening.
Factor 9(49): undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical worsening of heart block; — MET
- The training logs give an average of about 10.4 hours a week above 6 METs over the 5 years before the worsening, from 15 March 2012 to 15 March 2017.
Factor 9(50): having diabetes mellitus at the time of the clinical worsening of heart block; — MET
- Post-transplant diabetes mellitus was present at the worsening, with a blood glucose of 16.2 mmol/L that morning.
Factor 9(51): having hypertension with left ventricular hypertrophy before the clinical worsening of heart block; — MET
- Hypertension with left ventricular hypertrophy was established from 2012, before the worsening.
Factor 9(52): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of heart block; — MET
- Rheumatoid arthritis was present at the worsening.
Factor 9(53): having acute rheumatic fever at the time of the clinical worsening of heart block; — MET
- Acute rheumatic fever was active at the worsening.
Factor 9(54): having rheumatic heart disease at the time of the clinical worsening of heart block; — MET
- Rheumatic heart disease of the mitral valve was present at the worsening.
Factor 9(55): inability to obtain appropriate clinical management for heart block. — MET
- At onset the veteran was in a regional hospital that had no transvenous pacing capability. His first-degree atrioventricular block and new right bundle branch block were recognised at 01:00 on 15 March 2017, but transfer to the transplant centre was delayed for more than 12 hours by the unavailability of a retrieval team, his metoprolol and digoxin were not withheld until 09:00 because of a medication chart error, and the heart block progressed to complete heart block at 11:30 while he awaited transfer. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Heart Block, No. 23 of 2022
Causative factors
Factor 9(1): having ischaemic heart disease at the time of the clinical onset of heart block; — MET
- Ischaemic heart disease of the allograft, with a 70 per cent left anterior descending stenosis on 22 November 2016, was present at onset. The transplant was required for cardiac sarcoidosis that followed dust and burn-pit smoke exposure on warlike service in Afghanistan in 2008.
Factor 9(2): having pulmonary thromboembolism within the 7 days before the clinical onset of heart block; — MET
- Bilateral pulmonary emboli on 09 March 2017, within the 7 days before onset, arose from the central venous catheter placed for treatment of lymphoma that followed the transplant for Afghanistan-related cardiac sarcoidosis.
Factor 9(3): having infiltration of the myocardium due to an infiltrative disease from the specified list of infiltrative diseases at the time of the clinical onset of heart block; — MET
- Sarcoid infiltration of the allograft septum was shown on FDG-PET on 20 February 2017 and biopsy on 06 March 2017. Sarcoidosis, on the specified list, followed dust and burn-pit smoke exposure on warlike service in Afghanistan in 2008.
Factor 9(4): having cardiomyopathy at the time of the clinical onset of heart block; — MET
- Anthracycline cardiomyopathy, with an ejection fraction of 38 per cent on 17 January 2017, was present at onset, following chemotherapy for lymphoma in the transplant required for Afghanistan-related cardiac sarcoidosis.
Factor 9(5): having a benign or malignant neoplasm involving the heart before the clinical onset of heart block; — MET
- The post-transplant lymphoma involving the right atrium and atrioventricular groove was diagnosed on 04 February 2016, before onset, as a complication of the transplant immunosuppression required for Afghanistan-related sarcoidosis.
Factor 9(6): having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical onset of heart block; — MET
- A residual lymphoma mass and an organised haematoma in the atrioventricular groove were shown on cardiac MRI on 02 March 2017 and were present at onset.
Factor 9(7): having non-infectious myocarditis at the time of the clinical onset of heart block; — MET
- Acute cellular rejection of the allograft, grade 2R on 06 March 2017, an immune-mediated myocarditis, was present at onset.
Factor 9(8): having viral myocarditis at the time of the clinical onset of heart block; — MET
- Cytomegalovirus myocarditis, shown on biopsy on 06 March 2017, was present at onset.
Factor 9(9): having a non-viral infection of the myocardium at the time of the clinical onset of heart block; — MET
- Toxoplasma gondii myocarditis, shown on biopsy on 06 March 2017 and transmitted with the donor heart, was present at onset.
Factor 9(10): having infective endocarditis at the time of the clinical onset of heart block; — MET
- Staphylococcus aureus tricuspid endocarditis, diagnosed on 01 March 2017, was present at onset.
Factor 9(11): having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical onset of heart block; — MET
- Hyperkalaemia (potassium 6.3 mmol/L), hypercalcaemia (corrected calcium 2.94 mmol/L) and hypomagnesaemia (magnesium 0.52 mmol/L) were present at 22:00 on 14 March 2017, three hours before onset. The hypercalcaemia arose from Afghanistan-related sarcoidosis.
Factor 9(12): taking a drug from the specified list of drugs within the 3 weeks before the clinical onset of heart block; — MET
- Metoprolol, a beta blocker, and digoxin, a cardiac glycoside, were taken daily within the 3 weeks before onset. The veteran had also taken mefloquine for malaria prophylaxis on warlike service in East Timor.
Factor 9(13): taking chloroquine or hydroxychloroquine for at least 1 year before the clinical onset of heart block; — MET
- Hydroxychloroquine 400 mg daily was taken continuously from 11 April 2011 for rheumatoid arthritis and the sarcoidosis that followed warlike service in Afghanistan, almost 6 years before onset.
Factor 9(14): having ingested a plant containing cardiac glycosides within the 7 days before the clinical onset of heart block; — MET
- A herbal tonic containing foxglove leaf was taken daily from 10 to 14 March 2017, within the 7 days before onset, with a serum digoxin level of 3.1 nmol/L.
Factor 9(15): having acute pyrethroid poisoning after inhaling, ingesting or having cutaneous contact with a pyrethroid insecticide within the 3 days before the clinical onset of heart block; — MET
- On the afternoon of 12 March 2017 the veteran re-treated his deployment-issue mosquito net and field clothing, retained from warlike service in the Middle East in 2013, with permethrin concentrate in a closed garage. That evening he developed facial paraesthesia, dizziness, nausea and vomiting, and the hospital-in-the-home nurse recorded acute pyrethroid poisoning on 13 March 2017. The exposure was about 2 days and 10 hours before onset, within the 3 days from 12 March 2017 to 15 March 2017.
Factor 9(16): experiencing penetrating trauma to the heart within the 1 year before the clinical onset of heart block; — MET
- Perforation of the right ventricle by the bioptome on 10 October 2016, during surveillance of the transplant required for Afghanistan-related sarcoidosis, was penetrating trauma to the heart 5 months before onset.
Factor 9(17): having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical onset of heart block; — MET
- A pericardial window and ventricular repair on 10 October 2016 and endomyocardial biopsies on 12 December 2016 and 06 March 2017 were within the 1 year before onset.
Factor 9(18): experiencing a blunt chest injury within the 60 days before the clinical onset of heart block; — MET
- A fall onto the edge of a step on 25 January 2017, during a hypotensive episode, was a blunt chest injury 49 days before onset.
Factor 9(19): having a heart transplant before the clinical onset of heart block; — MET
- The heart transplant on 18 June 2014, for cardiac sarcoidosis that followed warlike service in Afghanistan, preceded onset.
Factor 9(20): having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical onset of heart block; — MET
- A CD34-selected allogeneic stem cell boost at 13:00 on 14 March 2017 was 12 hours before onset, within 24 hours.
Factor 9(21): having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical onset of heart block; — MET
- Grade III acute graft versus host disease after the allogeneic stem cell transplant of 05 December 2016 was present at onset.
Factor 9(22): undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical onset of heart block; — MET
- Radiotherapy of 36 Gy to the cardiac lymphoma, with the heart in the field, was given from 18 July to 19 August 2016, before onset.
Factor 9(23): undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical onset of heart block; — MET
- Training logs record an average of about 10.4 hours a week above 6 METs over the 5 years before onset, from 15 March 2012 to 15 March 2017, including daily physical training at 8 to 12 METs on warlike service in the Middle East from January to July 2013.
Factor 9(24): being envenomated by a scorpion or snake within the 24 hours before the clinical onset of heart block; — MET
- At about 19:00 on 14 March 2017 the veteran was bitten on the ankle by an eastern brown snake at his rural home. He was taken to hospital, where a venom detection kit was positive for brown snake venom, coagulopathy developed and antivenom was given at 21:15. The envenomation was 6 hours before the onset at 01:00 on 15 March 2017, within 24 hours.
Factor 9(25): having diabetes mellitus at the time of the clinical onset of heart block; — MET
- Post-transplant diabetes mellitus, diagnosed on 03 August 2015 after immunosuppression for the Afghanistan-related transplant, was present at onset.
Factor 9(26): having hypertension before the clinical onset of heart block; — MET
- Hypertension was diagnosed on 19 June 2012, after his return from warlike service in Afghanistan, and was established before onset.
Factor 9(27): having obstructive sleep apnoea at the time of the clinical onset of heart block; — MET
- Polysomnography on 14 September 2016 showed obstructive sleep apnoea with an apnoea-hypopnoea index of 32 events per hour, after weight gain on prednisolone, and he could not tolerate CPAP. It was present at onset.
Factor 9(28): having smoked cannabis products within the 7 days before the clinical onset of heart block; — MET
- The veteran smoked cannabis every evening from 08 to 14 March 2017 to relieve nausea and sleep disturbance, recorded by the hospital-in-the-home nurse, within the 7 days before onset.
Factor 9(29): binge drinking within the 2 days before the clinical onset of heart block; — MET
- On the evening of 13 March 2017, at a memorial gathering for a soldier killed in Afghanistan in 2008 with whom he had served on warlike service, the veteran drank about 9 standard drinks in under 2 hours and was intoxicated, about 30 hours before onset and within the 2 days before it.
Factor 9(30): having a thyroid condition from the specified list of thyroid conditions at the time of the clinical onset of heart block; — MET
- Graves disease with hyperthyroidism was diagnosed on 27 January 2017, with a suppressed TSH, a free T4 of 38 pmol/L and positive TSH receptor antibodies, as an autoimmune complication after the stem cell transplant, and was present at onset.
Factor 9(31): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical onset of heart block; — MET
- Rheumatoid arthritis, on the specified list, was diagnosed on 11 April 2011 and was present at onset.
Factor 9(32): having acute rheumatic fever at the time of the clinical onset of heart block; — MET
- A recurrence of acute rheumatic fever was diagnosed on 01 March 2017 and was active at onset. His first episode followed streptococcal pharyngitis on warlike service in East Timor in January 2000.
Factor 9(33): having rheumatic heart disease at the time of the clinical onset of heart block; — MET
- Rheumatic heart disease, first diagnosed after acute rheumatic fever that followed warlike service in East Timor, with rheumatic mitral valve changes on 01 March 2017, was present at onset.
Worsening factors
Factor 9(34): having ischaemic heart disease at the time of the clinical worsening of heart block; — MET
- Cardiac allograft vasculopathy with ischaemic heart disease persisted and was present when the heart block progressed to complete atrioventricular block at 11:30 on 15 March 2017. The transplant had been required for sarcoidosis that followed warlike service in Afghanistan.
Factor 9(35): having pulmonary thromboembolism within the 7 days before the clinical worsening of heart block; — MET
- The pulmonary emboli of 09 March 2017 were 6 days and 1 hour before the worsening at 11:30 on 15 March 2017, within 7 days, with persisting right ventricular strain on echocardiography that morning.
Factor 9(36): having infiltration of the myocardium due to an infiltrative disease from the specified list of infiltrative diseases at the time of the clinical worsening of heart block; — MET
- Sarcoid infiltration of the allograft septum was present at the worsening and was confirmed again on the explanted biopsy specimens reviewed in April 2017. The sarcoidosis followed warlike service in Afghanistan.
Factor 9(37): having cardiomyopathy at the time of the clinical worsening of heart block; — MET
- Anthracycline cardiomyopathy, with an ejection fraction of 35 per cent on echocardiography at 09:00 on 15 March 2017, was present at the worsening.
Factor 9(38): having a benign or malignant neoplasm involving the heart before the clinical worsening of heart block; — MET
- The lymphoma involving the right atrium and atrioventricular groove was diagnosed on 04 February 2016, before the worsening.
Factor 9(39): having a lesion which compresses the atrioventricular node, bundle of His or the bundle branches of the heart at the time of the clinical worsening of heart block; — MET
- The residual lymphoma mass and organised haematoma in the atrioventricular groove were present at the worsening.
Factor 9(40): having non-infectious myocarditis at the time of the clinical worsening of heart block; — MET
- Acute cellular rejection, grade 2R, persisted at the worsening; repeat biopsy on 17 March 2017 still showed grade 2R.
Factor 9(41): having viral myocarditis at the time of the clinical worsening of heart block; — MET
- Cytomegalovirus myocarditis was present at the worsening, with a blood viral load of 61,000 IU/mL on 15 March 2017.
Factor 9(42): having a non-viral infection of the myocardium at the time of the clinical worsening of heart block; — MET
- Toxoplasma myocarditis was under treatment and present at the worsening.
Factor 9(43): having infective endocarditis at the time of the clinical worsening of heart block; — MET
- Staphylococcus aureus tricuspid endocarditis was present at the worsening, still on intravenous cefazolin.
Factor 9(44): having a mineral or electrolyte abnormality from the specified list of mineral or electrolyte abnormalities at the time of the clinical worsening of heart block; — MET
- Bloods at 10:00 on 15 March 2017 showed hyperkalaemia (potassium 6.5 mmol/L), hypercalcaemia (corrected calcium 2.97 mmol/L) and hypomagnesaemia (magnesium 0.49 mmol/L) at the worsening.
Factor 9(45): taking a drug from the specified list of drugs within the 3 weeks before the clinical worsening of heart block; — MET
- Metoprolol and digoxin were taken every day up to the morning of 15 March 2017, within the 3 weeks before the worsening, and were not withheld until 09:00 that day.
Factor 9(46): taking chloroquine or hydroxychloroquine for at least 1 year before the clinical worsening of heart block; — MET
- Hydroxychloroquine 400 mg daily had been taken continuously from 11 April 2011 to the worsening, almost 6 years.
Factor 9(47): having ingested a plant containing cardiac glycosides within the 7 days before the clinical worsening of heart block; — MET
- The foxglove-containing herbal tonic was last taken on 14 March 2017, the day before the worsening and within 7 days of it.
Factor 9(48): having acute pyrethroid poisoning after inhaling, ingesting or having cutaneous contact with a pyrethroid insecticide within the 3 days before the clinical worsening of heart block; — MET
- The permethrin exposure on 12 March 2017, from re-treating equipment issued for warlike service, was within the 3 days before the worsening at 11:30 on 15 March 2017, and paraesthesia persisted that morning.
Factor 9(49): experiencing penetrating trauma to the heart within the 1 year before the clinical worsening of heart block; — MET
- The right ventricular perforation of 10 October 2016 was 5 months and 5 days before the worsening, within 1 year.
Factor 9(50): having a thoracic surgical procedure or an invasive cardiac procedure within the 1 year before the clinical worsening of heart block; — MET
- The pericardial window of 10 October 2016 and the endomyocardial biopsies of 12 December 2016 and 06 March 2017 were within the 1 year before the worsening.
Factor 9(51): experiencing a blunt chest injury within the 60 days before the clinical worsening of heart block; — MET
- The blunt chest injury of 25 January 2017 was 49 days before the worsening, within 60 days.
Factor 9(52): having a heart transplant before the clinical worsening of heart block; — MET
- The heart transplant of 18 June 2014 preceded the worsening.
Factor 9(53): having a bone marrow transplant or stem cell transplant within the 24 hours before the clinical worsening of heart block; — MET
- The CD34-selected stem cell boost at 13:00 on 14 March 2017 was 22 hours and 30 minutes before the worsening at 11:30 on 15 March 2017, within 24 hours.
Factor 9(54): having graft versus host disease after a bone marrow transplant or stem cell transplant at the time of the clinical worsening of heart block; — MET
- Grade III acute graft versus host disease was present at the worsening.
Factor 9(55): undergoing a course of therapeutic radiation for cancer, where the heart was in the field of radiation, before the clinical worsening of heart block; — MET
- Radiotherapy with the heart in the field, completed on 19 August 2016, preceded the worsening.
Factor 9(56): undertaking strenuous physical activity greater than 6 METs for an average of at least 10 hours per week for a continuous period of at least the 5 years before the clinical worsening of heart block; — MET
- The training logs give an average of about 10.4 hours a week above 6 METs over the 5 years before the worsening, from 15 March 2012 to 15 March 2017.
Factor 9(57): being envenomated by a scorpion or snake within the 24 hours before the clinical worsening of heart block; — MET
- The brown snake envenomation at 19:00 on 14 March 2017 was 16 hours and 30 minutes before the worsening, within 24 hours.
Factor 9(58): having diabetes mellitus at the time of the clinical worsening of heart block; — MET
- Post-transplant diabetes mellitus was present at the worsening, with a blood glucose of 16.2 mmol/L that morning.
Factor 9(59): having hypertension before the clinical worsening of heart block; — MET
- Hypertension, diagnosed on 19 June 2012, preceded the worsening.
Factor 9(60): having obstructive sleep apnoea at the time of the clinical worsening of heart block; — MET
- Untreated obstructive sleep apnoea was present at the worsening.
Factor 9(61): having smoked cannabis products within the 7 days before the clinical worsening of heart block; — MET
- Cannabis was smoked daily up to 14 March 2017, within the 7 days before the worsening.
Factor 9(62): binge drinking within the 2 days before the clinical worsening of heart block; — MET
- The binge drinking on the evening of 13 March 2017, at a memorial for a comrade from warlike service in Afghanistan, was within the 2 days before the worsening.
Factor 9(63): having a thyroid condition from the specified list of thyroid conditions at the time of the clinical worsening of heart block; — MET
- Graves hyperthyroidism was present at the worsening, with a free T4 of 35 pmol/L on 15 March 2017.
Factor 9(64): having an autoimmune disease from the specified list of autoimmune diseases at the time of the clinical worsening of heart block; — MET
- Rheumatoid arthritis was present at the worsening.
Factor 9(65): having acute rheumatic fever at the time of the clinical worsening of heart block; — MET
- Acute rheumatic fever was active at the worsening.
Factor 9(66): having rheumatic heart disease at the time of the clinical worsening of heart block; — MET
- Rheumatic heart disease of the mitral valve was present at the worsening.
Factor 9(67): inability to obtain appropriate clinical management for heart block. — MET
- The regional hospital where the veteran was treated after the snakebite had no transvenous pacing, retrieval to the transplant centre was delayed by more than 12 hours, and his rate-slowing drugs were not withheld until 09:00, so the heart block progressed to complete heart block at 11:30 on 15 March 2017 before he could be paced. The heart block arose in the transplant required for sarcoidosis that followed warlike service in Afghanistan.
The % contribution of the causes is 100% and significant.
Sequelae
The heart block is a sequela of the veteran's accepted conditions: cardiac sarcoidosis and the heart transplant it required, rheumatic heart disease, and the lymphoma, stem cell transplant, rejection, infections and treatment that followed the transplant.
Unintended Consequence
Met. The heart block is in part an unintended consequence of medical treatment paid for by the Commonwealth while the veteran was serving: perforation of the right ventricle during an endomyocardial biopsy, anthracycline chemotherapy and cardiac radiotherapy, tacrolimus-induced hyperkalaemia and hypomagnesaemia, metoprolol and digoxin (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. When first-degree atrioventricular block and right bundle branch block were recognised at 01:00 on 15 March 2017, the regional hospital had no transvenous pacing capability, retrieval to the transplant centre was delayed by more than 12 hours, and his metoprolol and digoxin were not withheld until 09:00 because of a medication chart error. The block progressed to complete heart block with syncope at 11:30 before he could be paced. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of timely specialist care and the failure to withdraw conduction-slowing drugs amount to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 14 Jan 2000, Aeromedical evacuation and physician assessment, Physician
- 11 Apr 2011, Bronchoscopy report and rheumatology consultation, Respiratory physician and rheumatologist
- 02 Jul 2012, Echocardiogram report, Cardiologist
- 18 Jun 2014, Transplant operation report, Cardiothoracic surgeon
- 04 Feb 2016, Cardiac MRI and biopsy report, Radiologist and haematopathologist
- 10 Oct 2016, Procedure and operation report, Transplant cardiologist and cardiothoracic surgeon
- 22 Nov 2016, Coronary angiography report, Interventional cardiologist
- 05 Dec 2016, Stem cell transplant summary, Haematologist
- 01 Mar 2017, Transoesophageal echocardiogram and infectious diseases consultation, Cardiologist and infectious diseases physician
- 06 Mar 2017, Endomyocardial biopsy report, Cardiac pathologist
- 08 Mar 2017, Hospital-in-the-home record and ECG, Registered nurse
- 15 Mar 2017, Emergency department record, ECGs and telemetry, Emergency physician
- 22 Mar 2017, Electrophysiology study and pacemaker implantation report, Cardiac electrophysiologist
- Statement of Principles concerning Heart Block (Balance of Probabilities) No. 24 of 2022, Repatriation Medical Authority
- Statement of Principles concerning Heart Block (Reasonable Hypothesis) No. 23 of 2022, Repatriation Medical Authority
