Ischaemic Heart Disease

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been invented and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Ischaemic Heart Disease

Example 1 of 1 · fictitious patient (Veteran BY)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been invented and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

BOP Code: 28 of 2025 (Ischaemic Heart Disease)
RH Code: 27 of 2025 (Ischaemic Heart Disease)

ADF History

Veteran BY, date of birth 03 April 1978, Royal Australian Navy, Weapons Electrical Technician (torpedo maintainer), enlisted 15 January 1996, medically discharged 15 March 2023. Operational service: East Timor, 20 September 1999 to 23 February 2000 (warlike); Persian Gulf, 18 February 2003 to 30 August 2003 (warlike); Middle East Area of Operations, 12 February 2008 to 25 August 2008 (warlike); Middle East Area of Operations, 05 March 2012 to 21 July 2012 (warlike), aeromedically evacuated.

Occupational History

As a torpedo maintainer the veteran prepared, fuelled, defuelled and maintained torpedoes, handling Otto fuel II and solvents in confined workshops, and served at sea on frigates on rotating 1-in-3 watches with frequent night work, broken sleep and long periods of high heat in machinery spaces and on deck. She was a member of the ship's boarding party and damage-control teams, wearing breathing apparatus and fire-fighting ensembles in drills and incidents. Before trade training she worked in a naval air station grounds and environmental section, spraying herbicides and clearing a legacy chemical store.

Shipboard life of the period involved enclosed smoking areas, a processed and salty diet with little fresh fruit and vegetables on long patrols, limited dental and medical access at sea, and a drinking culture ashore. Boarding operations in the Persian Gulf exposed crews to armed confrontation, the recovery of the dead, extreme heat, dust storms and polluted air near oil infrastructure.

History

Veteran BY, a torpedo maintainer in the Royal Australian Navy, had a non-ST-elevation myocardial infarction on 18 July 2012 aboard a frigate on warlike service in the Persian Gulf, hours after her boarding party came under fire, on a background of hypertension, diabetes, obesity, dyslipidaemia, smoking, prior mediastinal radiotherapy and many other risk factors. Her ischaemic heart disease worsened with an ST-elevation myocardial infarction from stent thrombosis on 14 September 2022.

Timeline

12 Feb 2001 — The veteran completed mediastinal radiotherapy to 30 Gy, after chemotherapy, for stage IIA Hodgkin lymphoma diagnosed on 16 October 2000 while she was serving. The radiation oncologist recorded that the heart lay within the treatment field and warned of an increased long-term risk of coronary disease. She returned to sea in 2002. "mediastinal RT 30 Gy completed"
14 Mar 2004 — A psychiatrist diagnosed posttraumatic stress disorder arising from a boarding operation on warlike service in the Persian Gulf in May 2003, in which she was fired upon. Sertraline was commenced, with quetiapine added at night in 2007. On the same day autoimmune hypothyroidism from Hashimoto thyroiditis was diagnosed and thyroxine commenced. "PTSD, Hashimoto hypothyroidism"
09 Mar 2009 — At her periodic health examination the veteran's cardiovascular risk profile was recorded: hypertension since 2006, newly diagnosed type 2 diabetes with an HbA1c of 7.6 per cent, BMI 33.4, LDL cholesterol 4.6 mmol/L on atorvastatin, smoking 15 cigarettes a day and daily snus, gout, Crohn's disease on a low-residue diet and chronic periodontitis. Polysomnography on 18 March 2009 showed obstructive sleep apnoea. "multiple cardiovascular risk factors"
18 Jul 2012 — On warlike service in the Persian Gulf, nine hours after her boarding party came under small-arms fire and after she had been stung by a jellyfish with an anaphylactic reaction, the veteran developed central crushing chest pain at 1500. The ship's ECG showed lateral ST depression and her troponin I rose to 4,800 ng/L. She had influenza and a lower respiratory tract infection and had taken pseudoephedrine, sumatriptan, azithromycin and ibuprofen. Her blood pressure had been 230/135 mmHg two hours earlier. "chest pain, troponin 4800, NSTEMI"
20 Jul 2012 — After transfer to a facility with a catheter laboratory, angiography showed thrombotic occlusion of the circumflex artery, which was stented, and a 70 per cent stenosis of the left anterior descending artery. Transoesophageal echocardiography showed a mitral vegetation with Streptococcus mitis bacteraemia. A beta-hCG confirmed an early pregnancy, which miscarried on 26 July 2012. She was aeromedically evacuated to Australia on 21 July 2012. "circumflex occlusion stented, endocarditis"
08 Aug 2012 — CT angiography of the aorta showed thickening of the aortic arch wall and left subclavian stenosis, and a rheumatologist diagnosed Takayasu arteritis. The cardiologist confirmed ischaemic heart disease after non-ST-elevation myocardial infarction, with a left ventricular ejection fraction of 45 per cent. She completed cardiac rehabilitation and stopped smoking and snus on 01 January 2014. "NSTEMI confirmed, Takayasu arteritis"
21 Aug 2017 — Exercise testing for progressive breathlessness and angina stopped at 2.8 METs with ischaemic ST changes, and echocardiography showed ischaemic cardiomyopathy with an ejection fraction of 32 per cent. She was confined to a desk-bound shore posting. HIV infection had been diagnosed on 14 June 2016, and she underwent bilateral oophorectomy for endometriosis on 11 November 2019. "ischaemic cardiomyopathy, EF 32 per cent"
26 Aug 2022 — After recurrent angina from November 2021 and a delay caused by the suspension of elective procedures, coronary angiography showed progression of the left anterior descending stenosis to 90 per cent and syphilitic narrowing of the left main ostium, and a drug-eluting stent was inserted in the left anterior descending artery. She had had COVID-19 on 02 July 2022. "LAD 90 per cent, stented"
14 Sep 2022 — The veteran presented by ambulance with chest pain and anterior ST elevation. Emergency angiography showed thrombosis of the stent inserted 19 days earlier, treated with thrombectomy and balloon angioplasty. The peak troponin I was 38,000 ng/L and the ejection fraction fell to 25 per cent. She was medically discharged on 15 March 2023. "anterior STEMI, stent thrombosis"

Symptoms

At onset the veteran had central crushing chest pain radiating to the left arm and jaw, breathlessness, sweating and nausea, which did not settle with rest or glyceryl trinitrate. After the infarction she had exertional angina when climbing ladders and carrying loads, fatigue and reduced exercise tolerance.

From 2017 she had angina and breathlessness on minimal exertion, including walking 100 metres or climbing one flight of stairs, with orthopnoea and ankle swelling from ischaemic cardiomyopathy. After the 2022 infarction she now reports breathlessness walking on level ground, angina several times a week requiring glyceryl trinitrate, fatigue, and anxiety about further cardiac events.

Imaging

20 Oct 2000 — CT chest: "Bulky anterior mediastinal lymphadenopathy consistent with lymphoma."
20 Jul 2012 — Coronary angiography: "Thrombotic occlusion of the proximal circumflex artery, stented. 70 per cent stenosis of the mid left anterior descending artery."
20 Jul 2012 — Transoesophageal echocardiogram: "9 mm mobile vegetation on the anterior mitral leaflet. Lateral wall hypokinesis, LVEF 45 per cent."
08 Aug 2012 — CT angiography aorta: "Concentric thickening of the aortic arch wall and stenosis of the left subclavian artery consistent with large-vessel vasculitis."
21 Aug 2017 — Transthoracic echocardiogram: "Dilated left ventricle with lateral and anterior hypokinesis, LVEF 32 per cent."
26 Aug 2022 — Coronary angiography: "90 per cent stenosis of the mid left anterior descending artery, stented. Patent circumflex stent. Ostial narrowing of the left main coronary artery from aortitis."
14 Sep 2022 — Coronary angiography: "Acute thrombotic occlusion of the left anterior descending artery stent. Thrombectomy and balloon angioplasty with restoration of flow."

Onset Date

The most likely date of onset of this condition is 18 Jul 2012.

At that date the veteran was on warlike service in the Persian Gulf aboard a frigate conducting maritime security operations. That morning her boarding party came under fire, she helped recover the bodies of two men, and she was stung by a jellyfish with an anaphylactic reaction. At 1500 she developed central chest pain, with ECG changes and a rise in troponin confirming a non-ST-elevation myocardial infarction.

This date is appropriate because myocardial infarction has a defined moment of onset. The last record before it, her pre-deployment medical of 20 February 2012, recorded no chest pain and a normal resting ECG, and she presented to the ship's medical officer within an hour of the pain beginning on 18 July 2012. It falls within warlike service.

For the long-term factors, the 10 years before onset run from 18 Jul 2002 to 18 Jul 2012, during which she kept night watches on more than 150 nights a year and had hypothyroidism from March 2004. The 5 years before onset run from 18 Jul 2007 to 18 Jul 2012, during which she was obese, had posttraumatic stress disorder, ate less than 100 grams of fruit and vegetables and about 14 grams of salt a day, and was exposed to chronically polluted air on warlike deployments. The 1 year before onset runs from 18 Jul 2011 to 18 Jul 2012, during which she smoked 15 cigarettes a day, slept an average of 4.3 hours, drank heavily each week and had sleep apnoea. The exposures to Otto fuel II from 1999 to 2011 and to herbicides from 1996 to 1999 began more than 5 years before onset and ended less than 25 years before it.

For the acute factors, the 6 weeks before onset run from 06 Jun 2012 to 18 Jul 2012, when she was pregnant. The 30 days run from 18 Jun 2012 to 18 Jul 2012, covering atrial fibrillation on 03 July and influenza from 06 July. The 4 weeks cover her oral contraceptive and the week from 11 Jul 2012 covers her father's death on 13 July, the dichlorvos poisoning on 14 July, the heat from 12 July and the polluted air on 15 and 16 July. The 48, 24 and 12 hours before 1500 on 18 July cover the firefighting exercise on 17 July, the attack at 0600, the recovery of bodies at 0800, the jellyfish sting and anaphylaxis from 0630, the medications taken that morning and the hypertensive emergency at 1300.

For the worsening, the documented worsening is the ST-elevation myocardial infarction of 14 Sep 2022. The 5 years before it run from 14 Sep 2017 to 14 Sep 2022, during which she could not exceed 3 METs, was sedentary for 10 or more hours a day and had HIV infection from June 2016. The 3 months before it run from 14 Jun 2022 to 14 Sep 2022, covering COVID-19 on 02 July, and the 30 days run from 15 Aug 2022 to 14 Sep 2022, covering the catheterisation on 26 August. She stopped smoking and snus on 01 January 2014, within 20 years of the worsening, and the oophorectomy at 41 on 11 November 2019 preceded it.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is ischaemic heart disease (ICD-10 I25.9), presenting as non-ST-elevation myocardial infarction and progressing to ischaemic cardiomyopathy and ST-elevation myocardial infarction, under the Statements of Principles concerning ischaemic heart disease, Balance of Probabilities No. 28 of 2025 and Reasonable Hypothesis No. 27 of 2025.

Ischaemic heart disease is a cardiac disease in which inadequate coronary blood supply to part of the heart causes infarction or periodic ischaemia. It is most often due to atherosclerosis of the coronary arteries, with plaque rupture and thrombosis causing acute coronary syndromes, but it can also result from embolism, vasculitis, vasospasm, radiation injury and hypercoagulable states. It presents as angina, acute coronary syndrome or myocardial infarction, and loss of heart muscle leads to ischaemic cardiomyopathy, heart failure, arrhythmias and sudden death.

In this veteran the disease began with a myocardial infarction on warlike service in the Persian Gulf on 18 July 2012, on a background of multiple long-standing risk factors and acute triggers. It was confirmed by angiography on 20 July 2012 and worsened with a further infarction on 14 September 2022.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

18 July 2012.

When did the veteran first present to a health / medical provider for this condition?

18 July 2012.

When was the condition confirmed / formally diagnosed?

20 July 2012.

When did the veteran first present to you (or your practice) for this condition?

21 August 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by the onset of ischaemic chest pain on 18 July 2012, lateral ST depression on the ECG and a rise of troponin I to 4,800 ng/L, meeting the universal definition of non-ST-elevation myocardial infarction, and by coronary angiography on 20 July 2012, which showed thrombotic occlusion of the circumflex artery and a significant left anterior descending stenosis, with lateral wall hypokinesis on echocardiography. This meets the Statement of Principles definition of ischaemic heart disease: inadequate coronary blood supply to part of the heart leading to infarction.

The worsening was confirmed on 14 September 2022 by anterior ST elevation, a peak troponin I of 38,000 ng/L, angiographic stent thrombosis of the left anterior descending artery and a fall in ejection fraction from 32 to 25 per cent. A cardiologist has confirmed ischaemic heart disease with ischaemic cardiomyopathy.

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 18 July 2012, after 1 July 2004, during warlike service in the Middle East Area of Operations. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 1999 and the Persian Gulf in 2003, 2008 and 2012, where the onset, its acute triggers and much of the long-term exposure occurred. The Balance of Probabilities instrument applies to her peacetime service, including the shore and sea service in which many risk factors accrued and the worsening on 14 September 2022.

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 Ischaemic Heart Disease, No. 28 of 2025

Causative and worsening factors (clinical onset or clinical worsening)

Factor 9(1): having hypertension before clinical onset or clinical worsening; — MET

- Hypertension diagnosed on 14 June 2006 was present before onset and before the worsening on 14 September 2022, which occurred during peacetime service in Australia.

Factor 9(2): having diabetes mellitus before clinical onset or clinical worsening; — MET

- Type 2 diabetes mellitus diagnosed on 09 March 2009 was present before onset and before the worsening during peacetime service in 2022.

Factor 9(3): being obese for at least the 5 years before clinical onset or clinical worsening; — MET

- The veteran's BMI was 30 or more, between 31 and 34, from April 2004 to onset and between 32 and 35 from 2017 to 2022, so she was obese for at least the 5 years before onset and before the worsening. The weight gain arose during peacetime postings ashore and at sea.

Factor 9(4): having persistently abnormal blood lipid levels before clinical onset or clinical worsening, as indicated by any of the following: (a) a serum high density lipoprotein cholesterol level less than 1.0 mmol/L; (b) a serum low density lipoprotein cholesterol level greater than 4.0 mmol/L; (c) a total serum cholesterol level greater than 5.5 mmol/L; (d) the regular administration of drug therapy to normalise previously elevated blood lipid levels; — MET

- LDL cholesterol of 4.6 mmol/L and total cholesterol of 6.9 mmol/L on 12 November 2007, with atorvastatin from February 2008 continued to 2022, were present before onset and worsening.

Factor 9(5): where smoking has not ceased before clinical onset or clinical worsening: (a) smoking an average of at least 1 cigarette per day, or the equivalent thereof in other tobacco products, for at least the 1 year before clinical onset or clinical worsening; or (b) smoking at least one half of one pack-year before clinical onset or clinical worsening; — MET

- The veteran smoked 15 cigarettes a day without stopping for the year before onset, from 18 July 2011 to 18 July 2012, and by then had smoked about 13 pack-years, much of it during peacetime service.

Factor 9(6): where smoking has ceased before clinical onset or clinical worsening: (a) having smoked at least one half of one pack-year but less than 5 pack-years, before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of smoking cessation; or (b) having smoked at least 5 pack-years but less than 20 pack-years, before clinical onset or clinical worsening, and the clinical onset or clinical worsening occurred within 20 years of smoking cessation; or (c) having smoked at least 20 pack-years before clinical onset or clinical worsening; — MET

- Having smoked about 15 pack-years, the veteran stopped on 01 January 2014, and the worsening on 14 September 2022 occurred within 20 years of cessation, meeting limb (b).

Factor 9(7): where exposure to second-hand tobacco smoke has not ceased, being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 1,000 hours before clinical onset or clinical worsening; — MET

- Exposure to second-hand smoke in enclosed messes and workshops, about 3 hours a day from 1996, had not ceased at onset and exceeded 1,000 hours, much of it during peacetime service.

Factor 9(8): where exposure to second-hand tobacco smoke has ceased: (a) being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 1,000 hours but less than 5,000 hours before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of the last exposure to second-hand tobacco smoke; or (b) being exposed to second-hand tobacco smoke exhaled by others in an enclosed space for at least 5,000 hours before clinical onset or clinical worsening; — MET

- Exposure to second-hand smoke ceased on 01 January 2014 after more than 5,000 hours in enclosed spaces between 1996 and 2013, meeting limb (b) for the worsening.

Factor 9(9): an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening; — MET

- From August 2017 ischaemic cardiomyopathy limited the veteran to activity below 3 METs, confirmed on exercise testing on 21 August 2017, throughout the 5 years before the worsening on 14 September 2022, during peacetime service.

Factor 9(10): having chronic kidney disease before clinical onset or clinical worsening as indicated by one of the following: (a) a glomerular filtration rate of less than 45 mL/min/1.73 m2 for at least 3 months; (b) albuminuria with an albumin to creatinine ratio of at least 3 milligrams/millimole for at least 3 months; (c) kidney damage, as evidenced by renal biopsy, imaging studies, urinary sediment abnormalities or other markers of abnormal renal function; (d) having had a kidney transplant; — MET

- Diabetic nephropathy with an albumin to creatinine ratio of 5 to 9 mg/mmol from 14 April 2010, persisting for more than 3 months, was present before onset, meeting indicator (b).

Factor 9(11): having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening; — MET

- Hashimoto thyroiditis, confirmed on 14 March 2004 by a thyroid peroxidase antibody titre of 640 IU/mL, was present for 8 years within the 10 years before onset and for more than 2 years within the 10 years before the worsening.

Factor 9(12): having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening; — MET

- Mediastinal radiotherapy for Hodgkin lymphoma, with the heart in the field, was given from 08 January to 12 February 2001 during peacetime service, before onset and worsening.

Factor 9(13): undergoing a procedure involving catheterisation of the affected coronary artery within the 30 days before clinical onset or clinical worsening of myocardial infarction or unstable angina; — MET

- Coronary angiography with stenting of the left anterior descending artery on 26 August 2022, during peacetime service, preceded the stent thrombosis and myocardial infarction in the same artery on 14 September 2022 by 19 days.

Factor 9(14): having infective endocarditis at the time of the clinical onset of myocardial infarction; — MET

- Streptococcus mitis endocarditis of the mitral valve, confirmed on 20 July 2012, was present at the onset of the myocardial infarction on 18 July 2012.

Factor 9(15): having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening; — MET

- Late syphilis with aortitis narrowing the left main coronary ostium, confirmed in August 2022, was present at the worsening on 14 September 2022. The infection was acquired in 1998 during peacetime service.

Factor 9(16): having one of the following vasculitides at the time of clinical onset or clinical worsening: (a) antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis; (b) Behcet disease; (c) eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome); (d) giant cell (temporal) arteritis; (e) granulomatosis with polyangiitis (Wegener granulomatosis); (f) IgA vasculitis (Henoch-Schönlein purpura); (g) microscopic polyangiitis; (h) mucocutaneous lymph node syndrome (Kawasaki disease); (i) non-specific autoimmune vasculitis; (j) polyarteritis nodosa; (k) Takayasu arteritis; — MET

- Takayasu arteritis, sub-factor (k), confirmed by CT angiography on 08 August 2012, was active at onset.

Factor 9(17): having one of the following systemic inflammatory rheumatological diseases at the time of clinical onset or clinical worsening: (a) dermatomyositis; (b) polymyositis; (c) psoriasis; (d) psoriatic arthritis; (e) rheumatoid arthritis; (f) Sjögren syndrome; (g) systemic lupus erythematosus; (h) systemic sclerosis; — MET

- Chronic plaque psoriasis, sub-factor (c), diagnosed in 2003 during peacetime service, was active at onset and at the worsening in 2022.

Factor 9(18): having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening; — MET

- Secondary thrombocytosis with a platelet count of 740 x 10^9/L from active Crohn's disease, with thrombotic occlusion of the circumflex artery on angiography, was present at onset.

Factor 9(19): having one of following clinically significant disorders of mental health for at least the 5 years before clinical onset or clinical worsening; (a) adjustment disorder; (b) agoraphobia; (c) anxiety disorder; (d) depressive disorder; (e) panic disorder; (f) posttraumatic stress disorder; (g) schizophrenia; or (h) social anxiety disorder; — MET

- Posttraumatic stress disorder, diagnosed on 14 March 2004 and continuously treated, was present for the 5 years before onset and for the 5 years before the worsening on 14 September 2022, during which she was in peacetime service.

Factor 9(20): taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina; — MET

- The veteran took a combined estrogen-progestogen oral contraceptive daily up to 18 July 2012, within the 4 weeks before the myocardial infarction, prescribed by a Defence medical officer during peacetime service in 2005 and continued.

Factor 9(21): taking any of the following medications, within the 24 hours before clinical onset or clinical worsening: (a) alemtuzumab; (b) aromatase inhibitors; (c) bevacizumab; (d) capecitabine; (e) docetaxel; (f) ephedrine; (g) ergotamine; (h) fluorouracil; (i) paclitaxel; (j) phentermine; (k) pseudoephedrine; (l) the kinase inhibitors, axitinib, cabozantinib, dasatinib, erlotinib, lenvatinib, midostaurin, nilotinib, nintedanib, pazopanib, ponatinib, regorafenib, sorafenib; or (m) triptans, including sumatriptan; — MET

- Pseudoephedrine 60 mg, sub-factor (k), and sumatriptan 50 mg, sub-factor (m), were both taken on the morning of 18 July 2012, within the 24 hours before onset.

Factor 9(22): being treated with antipsychotic within the 24 hours before the clinical onset or clinical worsening of myocardial infarction; — MET

- Quetiapine 50 mg, an antipsychotic, was taken on the night of 17 July 2012, within the 24 hours before the myocardial infarction.

Factor 9(23): taking a non-topical, non-steroidal, anti-inflammatory drug, excluding aspirin and paracetamol, for a continuous period of at least 7 days before clinical onset or clinical worsening, where the last dose of the drug was taken within the 7 days before clinical onset or clinical worsening; — MET

- Ibuprofen 400 mg three times daily was taken for 11 consecutive days, from 08 July to 18 July 2012, more than the 7 days required, with the last dose on the morning of onset.

Factor 9(24): having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening; — MET

- Bilateral orchidectomy, removal of the testicular tissue of both gonads for 46,XX ovotesticular difference of sex development, was performed in 1992, before onset and worsening.

Factor 9(25): taking one of the following anti-androgen medications for at least the 7 days before clinical onset or clinical worsening: (a) abiraterone; (b) androgen receptor blockers, including apalutamide, bicalutamide, darolutamide, enzalutamide, and cyproterone acetate; or (c) gonadotrophin releasing hormone agonists, including goserelin and leuprorelin; — MET

- Cyproterone acetate, an androgen receptor blocker, was taken at 2 mg daily continuously from 2005 to onset, far longer than the 7 days required.

Factor 9(26): an inability to sleep for an average of at least 5 hours daily for at least the 1 year before clinical onset or clinical worsening; — MET

- The veteran slept an average of 4.3 hours a day for the year before onset on rotating watches, a pattern that began in peacetime sea service in March 2011, before the warlike deployment.

Factor 9(27): having infection with human immunodeficiency virus for at least the 5 years before the clinical onset or clinical worsening of myocardial infarction; — MET

- HIV infection, diagnosed on 14 June 2016 during peacetime service, was present for more than 6 years before the myocardial infarction of 14 September 2022.

Factor 9(28): having gout at the time of clinical onset or clinical worsening of myocardial infarction; — MET

- Gout, with recurrent attacks since 22 September 2006 and a flare in July 2012, was present at the onset of the myocardial infarction.

Factor 9(29): undertaking physical activity of 6 METS or more within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The damage-control firefighting exercise in breathing apparatus on the evening of 17 July 2012, about 8 METs, was within the 24 hours before onset.

Factor 9(30): experiencing a category 1A stressor within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Being fired upon at close range at 0600 on 18 July 2012, a direct threat to life, was a category 1A stressor 9 hours before onset.

Factor 9(31): experiencing a category 1B stressor within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Recovering the bodies of two men killed in the exchange of fire, at about 0800 on 18 July 2012, was a category 1B stressor 7 hours before onset.

Factor 9(32): experiencing an acute severe stressful event that causes a sudden, intense emotional or psychological response within the 12 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The veteran had intense fear and distress after being fired upon, and at 1300 on 18 July 2012 she was told that a second boarding was planned, which caused acute panic recorded by the medical officer, 2 hours before onset and within the 12 hours required.

Factor 9(33): experiencing the death of a family member or close friend within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The veteran's father died on 13 July 2012, five days before onset, within the 1 week required.

Factor 9(34): using one of the following illicit drugs within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease: (a) amphetamines or amphetamine derivatives, including methamphetamine, 3, 4-methylenedioxymethamphetamine (Ecstasy or MDMA); (b) cocaine; (c) marijuana; (d) Khat and synthetic cathinones, including alpha- pyrrolidinopentiophenone, 4- methylmethcathinone (4-MMC), and 3-methylmethcathinone (3-MMC); — MET

- The veteran smoked cannabis, sub-factor (c), on the evening of 13 September 2022, within the 24 hours before the worsening during peacetime service.

Factor 9(35): having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Acute cholinergic poisoning from dichlorvos fumigation on 14 July 2012, with red cell cholinesterase at 55 per cent of baseline, occurred 4 days before onset.

Factor 9(36): being exposed to: (a) an ambient temperature of 38 degrees Celsius or above; or (b) an ambient temperature of zero degrees Celsius or below; for a period of at least 6 hours within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Upper-deck work in ambient temperatures of 42 to 46 degrees Celsius for more than 6 hours a day from 12 to 18 July 2012 was within the week before onset, sub-factor (a).

Factor 9(37): being envenomated by a snake, scorpion, wasp, bee, hornet, spider, centipede, fish or jellyfish within the 24 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The jellyfish sting at about 0630 on 18 July 2012 was within the 24 hours before onset.

Factor 9(38): having an acute hypersensitivity reaction (including anaphylaxis) involving the coronary arteries within the 12 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The anaphylactic reaction with transient ST depression (Kounis syndrome) began at about 0700 on 18 July 2012, 8 hours before onset, within the 12 hours required.

Factor 9(39): having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the 3 months before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) and sudden death from ischaemic heart disease; — MET

- COVID-19 confirmed on 02 July 2022 was within the 3 months before the worsening on 14 September 2022.

Factor 9(40): having influenza or a lower respiratory tract infection within the 30 days before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Influenza A confirmed on 06 July 2012, with a lower respiratory tract infection from 15 July 2012, was within the 30 days before onset.

Factor 9(41): being pregnant within the 6 weeks before the clinical onset or the clinical worsening of acute myocardial infarction or sudden death from ischaemic heart disease; — MET

- An early pregnancy of about 5 weeks, confirmed by a beta-hCG of 2,400 IU/L on 18 July 2012, was present at the time of the myocardial infarction.

Factor 9(42): having a hypertensive emergency or crisis within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- A hypertensive emergency with a blood pressure of 230/135 mmHg and papilloedema at 1300 on 18 July 2012 was within the 24 hours before onset.

Factor 9(43): having atrial fibrillation or atrial flutter within the 30 days before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Atrial fibrillation on 03 July 2012 was within the 30 days before the acute coronary syndrome.

Factor 9(44): inability to obtain appropriate clinical management for ischaemic heart disease before clinical worsening; — MET

- Before the worsening, angiography recommended in November 2021 for recurrent angina was delayed until 26 August 2022 because elective procedures were suspended during the COVID-19 pandemic and her referral was lost on a peacetime posting. The stent thrombosis followed on 14 September 2022. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.

Reasonable Hypothesis — Statement of Principles concerning Ischaemic Heart Disease, No. 27 of 2025

Causative and worsening factors (clinical onset or clinical worsening)

Factor 9(1): having hypertension before clinical onset or clinical worsening; — MET

- Hypertension was diagnosed at a periodic health examination on 14 June 2006, with repeated readings of 156/98 mmHg, and treated with hydrochlorothiazide and then perindopril. It was present before the onset on warlike service in the Persian Gulf on 18 July 2012 and before the worsening on 14 September 2022. Its development followed years of watchkeeping, sleep restriction and high-salt shipboard diet, including on her 2003 and 2008 warlike deployments.

Factor 9(2): having diabetes mellitus before clinical onset or clinical worsening; — MET

- Type 2 diabetes mellitus was diagnosed on 09 March 2009 with an HbA1c of 7.6 per cent and treated with metformin. It was present before the onset on warlike service on 18 July 2012 and before the worsening in 2022.

Factor 9(3): being obese or overweight for at least the 5 years before clinical onset or clinical worsening; — MET

- The veteran's BMI was 31.2 on 22 April 2004 and remained between 31 and 34 at every periodic health examination to the onset, including 33.8 on 18 July 2012. She was obese throughout the 5 years before onset, from 18 July 2007 to 18 July 2012, a period that included her warlike deployment to the Middle East in 2008 and the 2012 deployment on which the onset occurred, and throughout the 5 years before the worsening.

- Fasting lipids on 12 November 2007 showed an LDL cholesterol of 4.6 mmol/L, a total cholesterol of 6.9 mmol/L and an HDL cholesterol of 0.9 mmol/L, and atorvastatin 40 mg daily was commenced in February 2008 and continued, including on warlike service in 2008 and 2012. Each of indicators (a) to (d) was present before onset.

- The veteran smoked 15 cigarettes a day from 1994 and had not stopped at the onset on 18 July 2012. She smoked on average far more than 1 cigarette a day throughout the year before onset, from 18 July 2011 to 18 July 2012, much of it on warlike service in the Persian Gulf, and by onset had smoked about 13 pack-years, well over one half of one pack-year.

- The veteran stopped smoking on 01 January 2014 after cardiac rehabilitation, having smoked 15 cigarettes a day for 20 years, about 15 pack-years. The worsening on 14 September 2022 occurred 8 years and 8 months after cessation, within 20 years of it, meeting limb (b). Her smoking increased during her warlike deployments in 2003, 2008 and 2012.

- From 1996 to the onset in July 2012 the veteran spent about 3 hours a day in enclosed smoking flats, messes and workshops where others smoked, including aboard frigates on warlike service in the Persian Gulf in 2003, 2008 and 2012. The exposure was continuing at onset and exceeded 1,000 hours many times over.

- The veteran's exposure to second-hand smoke in enclosed spaces ceased on 01 January 2014 when she stopped smoking and left the smoking areas. By then she had been exposed for well over 5,000 hours, from 1996 to 2013, including on warlike service aboard ship in 2003, 2008 and 2012, meeting limb (b) for the worsening on 14 September 2022.

Factor 9(9): where the use of smokeless tobacco has not ceased, using smokeless tobacco on more days than not for at least 1 year before clinical onset or clinical worsening; — MET

- From 2005 the veteran used snus daily on watches where smoking was not permitted, including throughout her warlike deployments in 2008 and 2012. She used it on more days than not for the 7 years before onset and had not stopped at onset on 18 July 2012.

Factor 9(10): where the use of smokeless tobacco has ceased: (a) using smokeless tobacco on more days than not for at least 1 year but less than 5 years before clinical onset or clinical worsening, and the clinical onset or clinical worsening has occurred within 5 years of ceasing to use smokeless tobacco; or (b) using smokeless tobacco on more days than not for at least 5 years before clinical onset or clinical worsening; — MET

- The veteran stopped using snus on 01 January 2014, having used it on more days than not for 9 years from 2005, more than 5 years, including on warlike service, meeting limb (b) for the worsening on 14 September 2022.

Factor 9(11): an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening; — MET

- After the myocardial infarction of 2012 the veteran developed ischaemic cardiomyopathy with a left ventricular ejection fraction of 32 per cent and angina on minimal exertion. Exercise testing on 21 August 2017 stopped at 2.8 METs, and from August 2017 she could not undertake any activity greater than 3 METs, throughout the 5 years before the worsening on 14 September 2022. The cardiomyopathy followed the infarction that occurred on warlike service.

Factor 9(12): being sedentary for a cumulative total of at least 10 hours per day on more days than not for at least the 5 years before clinical onset or clinical worsening; — MET

- From August 2017 the veteran worked in a desk-bound shore posting and, because of her cardiac limitation, spent a further 4 to 5 hours sitting at home, a cumulative total of 10 to 12 hours sedentary on more days than not, recorded by the cardiac rehabilitation team, for the 5 years before the worsening on 14 September 2022. The limitation flowed from the infarction on warlike service.

Factor 9(13): an inability to consume an average of at least 100 grams per day of vegetables or fruits, for at least the 5 years before clinical onset or clinical worsening; — MET

- Crohn's disease with a stricture of the terminal ileum was diagnosed on 03 May 2006, and a gastroenterologist prescribed a low-residue diet excluding most fruit and vegetables. A dietitian recorded on 30 July 2012 that her intake of vegetables and fruit had averaged less than 50 grams a day from 2006 to the onset, compounded by limited fresh food at sea on warlike deployments. She was unable to consume 100 grams a day throughout the 5 years before onset.

Factor 9(14): having chronic kidney disease before clinical onset or clinical worsening as indicated by one of the following: (a) a glomerular filtration rate of less than 60 mL/min/1.73 m2 for at least 3 months; (b) albuminuria with an albumin to creatinine ratio of at least 3 milligrams/millimole for at least 3 months; (c) kidney damage, as evidenced by renal biopsy, imaging studies, urinary sediment abnormalities or other markers of abnormal renal function; (d) having had a kidney transplant; — MET

- Diabetic nephropathy was documented with an albumin to creatinine ratio of 6.8 mg/mmol on 14 April 2010 and between 5 and 9 mg/mmol on every test thereafter, persisting for more than 3 months before the onset on 18 July 2012, meeting indicator (b).

Factor 9(15): having hypothyroidism for at least 2 years within the 10 years before clinical onset or clinical worsening; — MET

- Autoimmune hypothyroidism was diagnosed on 14 March 2004, with a TSH of 24 mU/L and a low free T4, and treated with thyroxine. It was present for 8 years within the 10 years before onset, from 18 July 2002 to 18 July 2012, and for more than 2 years within the 10 years before the worsening.

Factor 9(16): having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening; — MET

- Hashimoto thyroiditis was confirmed on 14 March 2004 by a thyroid peroxidase antibody titre of 640 IU/mL and a heterogeneous gland on ultrasound. It was present continuously from 2004 to onset, more than 2 years within the 10 years before onset on 18 July 2012.

Factor 9(17): having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the heart at least 1 year before clinical onset or clinical worsening; — MET

- In January and February 2001, while serving, the veteran received mediastinal radiotherapy to a dose of 30 Gy for Hodgkin lymphoma, with the heart in the field. For photon radiotherapy 30 Gy corresponds to an equivalent dose of 30 sievert, far above 0.5 sievert. This was more than 11 years before onset on 18 July 2012. She returned to sea and served on warlike deployments in 2003, 2008 and 2012.

Factor 9(18): having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening; — MET

- The veteran had mediastinal radiotherapy for Hodgkin lymphoma, diagnosed on 16 October 2000, from 08 January to 12 February 2001, with the heart in the radiation field, as recorded by the radiation oncologist. This was before onset on 18 July 2012 and before the worsening in 2022.

Factor 9(19): inhaling, ingesting or having cutaneous contact with 1,2 propylene glycol dinitrate (Otto fuel II): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and (b) where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or worsening occurred within 25 years of cessation; — MET

- As a torpedo maintainer the veteran handled, decanted and cleaned up Otto fuel II during torpedo preparation and maintenance from September 1999 to 2011, including aboard frigates on warlike service in East Timor in 1999 and the Persian Gulf in 2003 and 2008. Her workshop records show about 1,600 hours of exposure between 2000 and 2010, within a consecutive 10 years. Her first exposure, in September 1999, was more than 5 years before onset, and the exposure ceased in 2011, less than 25 years before onset.

Factor 9(20): undergoing a procedure involving catheterisation of the affected coronary artery within the 30 days before clinical onset or clinical worsening of myocardial infarction or unstable angina; — MET

- On 26 August 2022 the veteran underwent coronary angiography and insertion of a drug-eluting stent in the left anterior descending artery. On 14 September 2022, 19 days later, she had an ST-elevation myocardial infarction from stent thrombosis in the same artery. The catheterisation of the affected artery occurred within the 30 days before the worsening.

Factor 9(21): having infective endocarditis at the time of the clinical onset of myocardial infarction; — MET

- Blood cultures and transoesophageal echocardiography on 20 July 2012 confirmed Streptococcus mitis endocarditis with a 9 mm mitral valve vegetation, which a cardiologist recorded as present at the onset of the myocardial infarction on 18 July 2012 on warlike service, with septic embolism contributing to the circumflex occlusion. The organism came from her periodontitis.

Factor 9(22): having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening; — MET

- CT coronary angiography and serology in August 2022 showed syphilitic aortitis with narrowing of the left main coronary ostium, with a positive treponemal antibody test and an RPR titre of 1:16. An infectious diseases physician diagnosed late syphilis involving the coronary arteries, acquired in 1998 while she was serving, and it was present at the worsening on 14 September 2022.

Factor 9(23): having one of the following vasculitides at the time of clinical onset or clinical worsening: (a) antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis; (b) Behcet disease; (c) eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome); (d) giant cell (temporal) arteritis; (e) granulomatosis with polyangiitis (Wegener granulomatosis); (f) IgA vasculitis (Henoch-Schönlein purpura); (g) microscopic polyangiitis; (h) mucocutaneous lymph node syndrome (Kawasaki disease); (i) non-specific autoimmune vasculitis; (j) polyarteritis nodosa; (k) Takayasu arteritis; — MET

- CT angiography of the aorta on 08 August 2012 showed thickening of the aortic arch wall with left subclavian artery stenosis, with an ESR of 68 mm/h, and a rheumatologist diagnosed Takayasu arteritis, sub-factor (k), recorded as active at the onset on 18 July 2012.

Factor 9(24): having thromboangiitis obliterans (Buerger disease) before the clinical onset of myocardial infarction; — MET

- Thromboangiitis obliterans was diagnosed by a vascular surgeon on 19 May 2010, after digital ulceration of two fingers and segmental occlusion of the digital arteries on angiography in a heavy smoker. It was present before the myocardial infarction of 18 July 2012.

Factor 9(25): having one of the following systemic inflammatory rheumatological diseases at the time of clinical onset or clinical worsening: (a) ankylosing spondylitis; (b) dermatomyositis; (c) inflammatory bowel disease; (d) polymyositis; (e) psoriasis; (f) psoriatic arthritis; (g) rheumatoid arthritis; (h) Sjögren syndrome; (i) systemic lupus erythematosus; (j) systemic sclerosis; — MET

- The veteran had Crohn's disease, an inflammatory bowel disease, diagnosed on 03 May 2006, and chronic plaque psoriasis, diagnosed in 2003, both active at onset on 18 July 2012, when she was in a Crohn's flare on warlike service in the Persian Gulf. Sub-factors (c) and (e) are met.

Factor 9(26): having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening; — MET

- At onset on 18 July 2012 the veteran's platelet count was 740 x 10^9/L, a secondary thrombocytosis from an active Crohn's flare and iron deficiency, and angiography on 20 July 2012 showed thrombotic occlusion of the circumflex artery. A haematologist recorded the thrombocytosis as a hypercoagulable state contributing to the coronary thrombosis.

Factor 9(27): having one of following clinically significant disorders of mental health for at least the 5 years before clinical onset or clinical worsening; (a) adjustment disorder; (b) agoraphobia; (c) anxiety disorder; (d) depressive disorder; (e) panic disorder; (f) posttraumatic stress disorder; (g) schizophrenia; or (h) social anxiety disorder; — MET

- A psychiatrist diagnosed posttraumatic stress disorder on 14 March 2004, arising from a boarding operation on warlike service in the Persian Gulf in May 2003 in which she was fired upon. The disorder was clinically significant and continuous, treated with sertraline and quetiapine, for the 8 years to onset, more than the 5 years before onset on 18 July 2012.

Factor 9(28): taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina; — MET

- The veteran took a combined oral contraceptive containing ethinylestradiol 35 micrograms and cyproterone acetate 2 mg daily, without a break, up to the onset on 18 July 2012, within the 4 weeks before the myocardial infarction. It was prescribed by a Defence medical officer in 2005 for contraception and hirsutism.

Factor 9(29): taking any of the following medications, within the 24 hours before clinical onset or clinical worsening: (a) alemtuzumab; (b) aromatase inhibitors; (c) bevacizumab; (d) capecitabine; (e) dextroamphetamine; (f) docetaxel; (g) ephedrine; (h) ergotamine; (i) fluorouracil; (j) methylphenidate; (k) paclitaxel; (l) phentermine; (m) pseudoephedrine; (n) the kinase inhibitors, axitinib, cabozantinib, dasatinib, erlotinib, lenvatinib, midostaurin, nilotinib, nintedanib, pazopanib, ponatinib, regorafenib, sorafenib; or (o) triptans, including sumatriptan; — MET

- On the morning of 18 July 2012, on warlike service, the veteran took pseudoephedrine 60 mg for nasal congestion from influenza, sub-factor (m), and sumatriptan 50 mg for a migraine, sub-factor (o), both supplied by the ship's medical staff. Both were taken within the 24 hours before the onset that afternoon.

Factor 9(30): being treated with antipsychotic agents or macrolide antibiotics within the 24 hours before the clinical onset or clinical worsening of myocardial infarction; — MET

- The veteran took quetiapine 50 mg on the night of 17 July 2012 for posttraumatic stress disorder, and azithromycin 500 mg on the morning of 18 July 2012 for a lower respiratory tract infection, prescribed by the ship's medical officer. Both an antipsychotic and a macrolide antibiotic were taken within the 24 hours before the myocardial infarction.

Factor 9(31): taking a non-topical, non-steroidal, anti-inflammatory drug, excluding aspirin and paracetamol, for a continuous period of at least 3 days before clinical onset or clinical worsening, where the last dose of the drug was taken within the 7 days before clinical onset or clinical worsening; — MET

- The veteran took ibuprofen 400 mg three times daily from 08 July to 18 July 2012, a continuous period of 11 days, for influenza myalgia and back pain, supplied by the ship's medical staff on warlike service. The last dose was taken on the morning of 18 July 2012, within 7 days of onset.

Factor 9(32): having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening; — MET

- The veteran was born with 46,XX ovotesticular difference of sex development. In 1992, at the age of 14, she underwent bilateral orchidectomy, removal of the testicular tissue of both gonads, with functioning ovarian tissue preserved, as recorded in her enlistment medical documentation. This was before onset and before the worsening.

Factor 9(33): taking one of the following anti-androgen medications for at least the 7 days before clinical onset or clinical worsening: (a) abiraterone; (b) androgen receptor blockers, including apalutamide, bicalutamide, darolutamide, enzalutamide, and cyproterone acetate; or (c) gonadotrophin releasing hormone agonists, including goserelin and leuprorelin; — MET

- The veteran took cyproterone acetate, an androgen receptor blocker, at 2 mg daily in her combined oral contraceptive continuously from 2005 to the onset on 18 July 2012, far more than the 7 days before onset, as prescribed by Defence medical officers.

Factor 9(34): inhaling, ingesting or having cutaneous contact with the phenoxy acid herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) or 2,4,5- trichlorophenoxyacetic acid (2,4,5-T): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and (b) where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or worsening occurred within 25 years of cessation; — MET

- From April 1996 to June 1999, while awaiting trade training, the veteran worked in the grounds and environmental section of a naval air station, mixing and spraying 2,4-D herbicide by hand and vehicle sprayer without respiratory protection, about 1,800 hours in all, within a consecutive 10 years. Her first exposure, in 1996, was 16 years before onset, and the onset in 2012 occurred within 25 years of the last exposure in June 1999.

Factor 9(35): inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD): (a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before clinical onset or clinical worsening; and (b) where the first exposure occurred at least 5 years before clinical onset or clinical worsening; and if that exposure has ceased before clinical onset or clinical worsening, then that onset or worsening occurred within 25 years of cessation; — MET

- In 1997 and 1998 the same section cleared a legacy herbicide store containing drums of 2,4,5-T contaminated with TCDD, and decontaminated the soil around it. The veteran's duty records show about 1,100 hours of handling contaminated drums and soil within a consecutive 10 years. The first exposure, in 1997, was more than 5 years before onset, and onset occurred within 25 years of the last exposure in 1998.

Factor 9(36): inhaling chronically polluted air for at least 1,000 hours, within the 5 years before clinical onset or clinical worsening; — MET

- On warlike service in the Persian Gulf from 12 February to 25 August 2008 and from 05 March to 18 July 2012, the veteran worked on the upper deck and ashore near oil terminals, flare stacks and port cities where airborne particulate levels were chronically high, for well over 1,000 hours, recorded in the ship's environmental monitoring, all within the 5 years before onset.

Factor 9(37): consuming an average daily intake of at least 12 grams (200 millimoles) per day of salt (sodium chloride) for at least the 5 years before clinical onset or clinical worsening; — MET

- A dietitian assessed the veteran on 30 July 2012 and estimated her average salt intake at 14 grams a day from 2007 to 2012, from processed shipboard foods, ration packs and the low-residue processed diet prescribed for her Crohn's disease. This intake continued throughout the 5 years before onset, including on warlike deployments in 2008 and 2012.

Factor 9(38): having periodic, heavy alcohol consumption for the 1 year before clinical onset or clinical worsening; — MET

- Throughout the year before onset, from 18 July 2011 to 18 July 2012, the veteran drank 8 to 10 standard drinks on at least one occasion each week, ashore and at port visits during her warlike deployment, as recorded at her post-infarction assessment. Her drinking increased after the 2003 boarding incident.

Factor 9(39): having sleep apnoea for at least the 1 year before clinical onset or clinical worsening; — MET

- Polysomnography on 18 March 2009 showed obstructive sleep apnoea with an apnoea-hypopnoea index of 24 events per hour. She could not use CPAP at sea, including on warlike service in 2012, and the sleep apnoea was present for more than 3 years before onset.

Factor 9(40): an inability to sleep for an average of at least 5 hours daily for at least the 1 year before clinical onset or clinical worsening; — MET

- On rotating 1-in-3 watches at sea, including on warlike service in the Persian Gulf from 05 March 2012, the veteran's sleep diary and medical records show an average of 4.3 hours of sleep a day from March 2011 to July 2012, throughout the year before onset, compounded by nightmares from posttraumatic stress disorder.

Factor 9(41): undertaking night shift work on at least 120 nights per year, for at least the 10 years before clinical onset or clinical worsening; — MET

- The veteran's watch bills show that she kept night watches, working between midnight and 0600, on more than 150 nights a year at sea from 2002 to 2012, including her warlike deployments in 2003, 2008 and 2012, throughout the 10 years before onset on 18 July 2012.

Factor 9(42): having infection with human immunodeficiency virus for at least the 5 years before clinical onset or clinical worsening; — MET

- HIV infection was diagnosed on 14 June 2016, acquired in early 2016 while the veteran was serving, and treated with antiretroviral therapy. It was present for more than 6 years before the worsening on 14 September 2022, more than the 5 years required.

Factor 9(43): having periodontitis for at least the 5 years before clinical onset or clinical worsening; — MET

- A Defence dental officer diagnosed generalised chronic periodontitis on 11 August 2005, with pocketing of 5 to 7 mm, and it persisted, with limited dental access at sea, throughout the 7 years to onset on 18 July 2012. The same periodontitis seeded the endocarditis present at onset.

Factor 9(44): having gout or hyperuricaemia for at least the 5 years before clinical onset or clinical worsening; — MET

- The veteran had recurrent gout from 22 September 2006, with a serum urate of 0.54 mmol/L, attributed to hydrochlorothiazide and alcohol, and it persisted for the 6 years before onset, with a flare at the onset on warlike service in July 2012.

Factor 9(45): undertaking physical activity of 5 METS or more within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- On the evening of 17 July 2012 the veteran took part in a 90-minute damage-control firefighting exercise in full fire-fighting ensemble and breathing apparatus, an activity of about 8 METs, and at 0600 on 18 July 2012 she climbed into a suspect vessel during a boarding operation. Both were within the 24 hours before the onset that afternoon on warlike service.

Factor 9(46): experiencing a category 1A stressor within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- At 0600 on 18 July 2012, during a boarding operation on warlike service in the Persian Gulf, the boarding party came under small-arms fire at close range and the veteran was directly threatened with death, a category 1A stressor, 9 hours before the onset of the myocardial infarction.

Factor 9(47): experiencing a category 1B stressor within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- At about 0800 on 18 July 2012, after the exchange of fire, the veteran helped recover the bodies of two crew members of the suspect vessel who had been killed, a category 1B stressor, 7 hours before onset on warlike service.

Factor 9(48): experiencing an acute severe stressful event that causes a sudden, intense emotional or psychological response within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The attack on the boarding party at 0600 on 18 July 2012 caused the veteran sudden intense fear and distress, recorded by the ship's medical officer, within the 24 hours before the onset that afternoon.

Factor 9(49): experiencing the death of a family member or close friend within the 4 weeks before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- The veteran's father died suddenly on 13 July 2012, five days before onset. Because of operational commitments on warlike service she could not return to Australia for his funeral.

Factor 9(50): using one of the following illicit drugs within the 24 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease: (a) amphetamines or amphetamine derivatives, including methamphetamine, 3, 4-methylenedioxymethamphetamine (Ecstasy or MDMA); (b) cocaine; (c) D-lysergic acid diethylamide; (d) marijuana; (e) Khat and synthetic cathinones, including alpha- pyrrolidinopentiophenone, 4- methylmethcathinone (4-MMC), and 3-methylmethcathinone (3-MMC); — MET

- On the evening of 13 September 2022 the veteran smoked cannabis to help her sleep, as she disclosed to the treating cardiologist, within the 24 hours before the worsening on 14 September 2022. She had begun using cannabis to manage nightmares from posttraumatic stress disorder arising from warlike service.

Factor 9(51): having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- On 14 July 2012 the ship's galley and mess decks were fumigated with dichlorvos, an organophosphorus ester, and the veteran re-entered early to recover equipment. She developed sweating, miosis, abdominal cramps and bradycardia, and her red cell cholinesterase was 55 per cent of her baseline, confirming acute cholinergic poisoning, 4 days before onset on warlike service.

Factor 9(52): being exposed to: (a) an ambient temperature of 38 degrees Celsius or above; or (b) an ambient temperature of zero degrees Celsius or below; for a period of at least 6 hours within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- From 12 to 18 July 2012, on warlike service in the Persian Gulf, the veteran worked full days on the upper deck in ambient temperatures recorded at 42 to 46 degrees Celsius, for more than 6 hours each day within the week before onset, sub-factor (a).

Factor 9(53): inhaling polluted air, for at least 2 hours within the 1 week before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- On 15 July 2012 a dust storm reduced visibility to under 500 metres and the veteran worked on the upper deck in it for about 4 hours. On 16 July 2012 she spent 3 hours in a machinery space with a diesel exhaust leak. Both exposures to polluted air were within the week before onset on warlike service.

Factor 9(54): being envenomated by a snake, scorpion, wasp, bee, hornet, spider, centipede, fish or jellyfish within the 24 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- At about 0630 on 18 July 2012, while transferring from the boarding boat in the water, the veteran was stung across both forearms by a jellyfish, recorded by the ship's medical officer, within the 24 hours before onset.

Factor 9(55): having an acute hypersensitivity reaction (including anaphylaxis) involving the coronary arteries within the 24 hours before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Within 30 minutes of the jellyfish sting the veteran developed generalised urticaria, hypotension of 82/50 mmHg and chest tightness with transient ST depression, and was treated with intramuscular adrenaline. The cardiologist diagnosed an acute hypersensitivity reaction involving the coronary arteries (Kounis syndrome), within the 24 hours before onset.

Factor 9(56): having infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the 3 months before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) and sudden death from ischaemic heart disease; — MET

- The veteran had COVID-19 confirmed by PCR on 02 July 2022, 10 weeks before the worsening on 14 September 2022, within the 3 months before it.

Factor 9(57): having influenza or a lower respiratory tract infection within the 30 days before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Influenza A was confirmed by PCR on 06 July 2012 during an outbreak aboard ship on warlike service, complicated by a lower respiratory tract infection treated with azithromycin from 15 July 2012, 12 days before onset.

Factor 9(58): being pregnant within the 6 weeks before the clinical onset or the clinical worsening of acute myocardial infarction or sudden death from ischaemic heart disease; — MET

- A serum beta-hCG of 2,400 IU/L on 18 July 2012 confirmed an early pregnancy of about 5 weeks, conceived while she was taking her oral contraceptive, which ended in miscarriage on 26 July 2012. She was pregnant within the 6 weeks before the myocardial infarction.

Factor 9(59): having a hypertensive emergency or crisis within the 48 hours before the clinical onset or the clinical worsening of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- At 1300 on 18 July 2012, two hours before onset, the veteran's blood pressure was 230/135 mmHg with severe headache, blurred vision and papilloedema, recorded by the ship's medical officer as a hypertensive emergency, after pseudoephedrine and the morning's events, within the 48 hours before onset.

Factor 9(60): having atrial fibrillation or atrial flutter within the 30 days before the clinical onset of acute coronary syndrome (including myocardial infarction) or sudden death from ischaemic heart disease; — MET

- Atrial fibrillation was recorded on the ship's ECG on 03 July 2012 during a febrile illness and reverted with flecainide on 04 July 2012, 15 days before the onset of the acute coronary syndrome on warlike service.

Factor 9(61): having bilateral oophorectomy before the age of 45 years, before clinical onset or clinical worsening; — MET

- The veteran underwent bilateral oophorectomy on 11 November 2019, at the age of 41, for severe endometriosis, before the worsening on 14 September 2022.

Factor 9(62): inability to obtain appropriate clinical management for ischaemic heart disease before clinical worsening; — MET

- After the onset on warlike service on 18 July 2012 the veteran waited two days for transfer to a facility with a catheter laboratory. Before the worsening, recurrent angina in November 2021 led to a recommendation for urgent angiography, which was postponed until 26 August 2022 because elective procedures were suspended during the COVID-19 pandemic and her referral was lost on posting. The stent thrombosis followed on 14 September 2022.

The % contribution of the causes is 100% and significant.

Sequelae

Met. The ischaemic heart disease is a sequela of the veteran's hypertension, type 2 diabetes, dyslipidaemia, obesity, posttraumatic stress disorder, obstructive sleep apnoea and diabetic nephropathy, each of which developed during service, and of the mediastinal radiotherapy for Hodgkin lymphoma. In turn the ischaemic heart disease has caused ischaemic cardiomyopathy with heart failure, which should be considered for a separate claim.

Unintended Consequence

Met. The stent thrombosis of 14 September 2022 followed coronary stenting performed 19 days earlier, and the medications taken within 24 hours of onset, including pseudoephedrine, sumatriptan, azithromycin, ibuprofen and quetiapine, were supplied or prescribed by Defence medical staff while the veteran was serving. These are unintended consequences of medical treatment provided by the Commonwealth (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. At onset on warlike service the veteran waited two days at sea for transfer to a facility with a catheter laboratory. Before the worsening, angiography recommended in November 2021 for recurrent angina was postponed until 26 August 2022 because elective procedures were suspended during the COVID-19 pandemic and her referral was lost on posting, and the left anterior descending stenosis progressed from 70 to 90 per cent before it was treated. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational isolation at sea and system-imposed delays to indicated treatment amount to an inability to obtain appropriate clinical management before the clinical worsening.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

16 Oct 2000, Haematology consultation and CT report, Haematologist
12 Feb 2001, Radiotherapy completion summary, Radiation oncologist
14 Mar 2004, Psychiatric assessment, Consultant psychiatrist
14 Mar 2004, Endocrinology consultation, Endocrinologist
11 Aug 2005, Dental record, Dental Officer
03 May 2006, Gastroenterology consultation, Gastroenterologist
09 Mar 2009, Periodic health examination, Medical Officer
18 Mar 2009, Polysomnography report, Sleep physician
19 May 2010, Vascular surgery consultation, Vascular surgeon
18 Jul 2012, Ship's medical record and ECG, Medical Officer
20 Jul 2012, Coronary angiography and echocardiography reports, Cardiologist
30 Jul 2012, Dietetic assessment, Dietitian
08 Aug 2012, CT angiography report and rheumatology consultation, Rheumatologist
21 Aug 2017, Exercise test and echocardiography reports, Cardiologist
26 Aug 2022, Coronary angiography report, Interventional cardiologist
14 Sep 2022, Emergency angiography report and discharge summary, Interventional cardiologist
Statement of Principles concerning Ischaemic Heart Disease (Balance of Probabilities) No. 28 of 2025, Repatriation Medical Authority
Statement of Principles concerning Ischaemic Heart Disease (Reasonable Hypothesis) No. 27 of 2025, Repatriation Medical Authority

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Ischaemic Heart Disease — DVA claim example

Diagnostic Assessment — Ischaemic Heart Disease

Diagnostic Assessment