Ischaemic Heart Disease

Reference Determination Content

Suggested draft · fictitious patient

Example document — fictitious patient. This is a suggested draft determination prepared by the Veterans Health Centre from the matching example Diagnostic Assessment, to show how a DVA delegate could determine the claim. The veteran is fictitious: names, dates, service details and clinicians have been invented. It is not a decision of the Department of Veterans' Affairs and must not be relied upon as a record of any real claim.

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 August 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 August 2025;
A haematology consultation and CT report by the haematologist, dated 16 October 2000;
A radiotherapy completion summary by the radiation oncologist, dated 12 February 2001;
A psychiatric assessment by the consultant psychiatrist, dated 14 March 2004;
An endocrinology consultation by the endocrinologist, dated 14 March 2004;
A dental record by the dental officer, dated 11 August 2005;
A gastroenterology consultation by the gastroenterologist, dated 3 May 2006;
A periodic health examination by the medical officer, dated 9 March 2009;
A polysomnography report by the sleep physician, dated 18 March 2009;
A vascular surgery consultation by the vascular surgeon, dated 19 May 2010;
A ship's medical record and ECG by the medical officer, dated 18 July 2012;
A coronary angiography and echocardiography reports by the cardiologist, dated 20 July 2012;
A dietetic assessment by the dietitian, dated 30 July 2012;
A CT angiography report and rheumatology consultation by the rheumatologist, dated 8 August 2012;
An exercise test and echocardiography reports by the cardiologist, dated 21 August 2017;
A coronary angiography report by the interventional cardiologist, dated 26 August 2022;
An emergency angiography report and discharge summary by the interventional cardiologist, dated 14 September 2022.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

15 January 1996 and 15 March 2023

Ischaemic Heart Disease

You have stated that your condition was caused by:

having hypertension before clinical onset or clinical worsening
having diabetes mellitus before clinical onset or clinical worsening
being obese or overweight for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
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
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
an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
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
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
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
having hypothyroidism for at least 2 years within the 10 years before clinical onset or clinical worsening
having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening
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
having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening
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
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
having infective endocarditis at the time of the clinical onset of myocardial infarction
having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening
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
having thromboangiitis obliterans (Buerger disease) before the clinical onset of myocardial infarction
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
having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening
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
taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina
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
being treated with antipsychotic agents or macrolide antibiotics within the 24 hours before the clinical onset or clinical worsening of myocardial infarction
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
having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening
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
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
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
inhaling chronically polluted air for at least 1,000 hours, within the 5 years before clinical onset or clinical worsening
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
having periodic, heavy alcohol consumption for the 1 year before clinical onset or clinical worsening
having sleep apnoea for at least the 1 year before clinical onset or clinical worsening
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
undertaking night shift work on at least 120 nights per year, for at least the 10 years before clinical onset or clinical worsening
having infection with human immunodeficiency virus for at least the 5 years before clinical onset or clinical worsening
having periodontitis for at least the 5 years before clinical onset or clinical worsening
having gout or hyperuricaemia for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
having bilateral oophorectomy before the age of 45 years, before clinical onset or clinical worsening

Diagnosis: Ischaemic Heart Disease

Basis of diagnosis: The diagnosis was made in the Diagnostic Assessment by Dr Thomas Perkins dated 21 August 2025, and is supported by a coronary angiography and echocardiography reports by the cardiologist, dated 20 July 2012.

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Ischaemic Heart Disease (Reasonable Hypothesis) (No. 27 of 2025)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having hypertension before clinical onset or clinical worsening
having diabetes mellitus before clinical onset or clinical worsening
being obese or overweight for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
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
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
an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
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
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
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
having hypothyroidism for at least 2 years within the 10 years before clinical onset or clinical worsening
having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening
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
having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening
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
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
having infective endocarditis at the time of the clinical onset of myocardial infarction
having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening
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
having thromboangiitis obliterans (Buerger disease) before the clinical onset of myocardial infarction
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
having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening
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
taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina
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
being treated with antipsychotic agents or macrolide antibiotics within the 24 hours before the clinical onset or clinical worsening of myocardial infarction
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
having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening
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
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
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
inhaling chronically polluted air for at least 1,000 hours, within the 5 years before clinical onset or clinical worsening
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
having periodic, heavy alcohol consumption for the 1 year before clinical onset or clinical worsening
having sleep apnoea for at least the 1 year before clinical onset or clinical worsening
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
undertaking night shift work on at least 120 nights per year, for at least the 10 years before clinical onset or clinical worsening
having infection with human immunodeficiency virus for at least the 5 years before clinical onset or clinical worsening
having periodontitis for at least the 5 years before clinical onset or clinical worsening
having gout or hyperuricaemia for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
having bilateral oophorectomy before the age of 45 years, before clinical onset or clinical worsening

I have noted your contention as to the cause of this condition. The available evidence indicates, I have noted your contention to the cause of your condition. Your service medical records indicate that you presented to the health facility with central crushing chest pain radiating to the left arm and jaw, breathlessness, sweating and nausea, which did not settle with rest or glyceryl trinitrate on 18 July 2012.

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.

This has then led to further investigations and the diagnosis of your condition of Ischaemic Heart Disease. I have accepted your condition of Ischaemic Heart Disease.

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that this condition is related to your wartime service.

I have therefore accepted that this condition is related to your service with effect from 18 July 2012.

Ischaemic Heart Disease (Worsening)

Evidence

The evidence that I have considered in making this decision includes:

Formal Claim with supporting statements;
A Statement of your Service from the Department of Defence;
Copies of your Service Medical Records.
A Diagnostic Assessment by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 August 2025;
A Diagnosis Form (D9287) by Dr Thomas Perkins, General Practitioner, Veterans Health Centre, dated 21 August 2025;
A haematology consultation and CT report by the haematologist, dated 16 October 2000;
A radiotherapy completion summary by the radiation oncologist, dated 12 February 2001;
A psychiatric assessment by the consultant psychiatrist, dated 14 March 2004;
An endocrinology consultation by the endocrinologist, dated 14 March 2004;
A dental record by the dental officer, dated 11 August 2005;
A gastroenterology consultation by the gastroenterologist, dated 3 May 2006;
A periodic health examination by the medical officer, dated 9 March 2009;
A polysomnography report by the sleep physician, dated 18 March 2009;
A vascular surgery consultation by the vascular surgeon, dated 19 May 2010;
A ship's medical record and ECG by the medical officer, dated 18 July 2012;
A coronary angiography and echocardiography reports by the cardiologist, dated 20 July 2012;
A dietetic assessment by the dietitian, dated 30 July 2012;
A CT angiography report and rheumatology consultation by the rheumatologist, dated 8 August 2012;
An exercise test and echocardiography reports by the cardiologist, dated 21 August 2017;
A coronary angiography report by the interventional cardiologist, dated 26 August 2022;
An emergency angiography report and discharge summary by the interventional cardiologist, dated 14 September 2022.

Your service

I have identified that you have the following service:
Australian Defence Force service between :

15 January 1996 and 15 March 2023

Ischaemic Heart Disease (Worsening)

You have stated that the worsening of your condition was caused by:

having hypertension before clinical onset or clinical worsening
having diabetes mellitus before clinical onset or clinical worsening
being obese for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
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
having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening
having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening
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
having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening
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
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
having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening
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
taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina
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
being treated with antipsychotic within the 24 hours before the clinical onset or clinical worsening of myocardial infarction
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
having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening
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
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
having infection with human immunodeficiency virus for at least the 5 years before the clinical onset or clinical worsening of myocardial infarction
having gout at the time of clinical onset or clinical worsening of myocardial infarction
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
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
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
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
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
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)
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
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
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
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
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
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
inability to obtain appropriate clinical management for ischaemic heart disease before clinical worsening

Diagnosis: Ischaemic Heart Disease (Worsening)

I am satisfied this is the appropriate diagnosis.
In determining your claim for this condition, I have applied the SOP:

Statement of Principles concerning Ischaemic Heart Disease (Balance of Probabilities) (No. 28 of 2025)

which sets out the factors that can connect the condition with service.

I am satisfied that you have met the following factor:

having hypertension before clinical onset or clinical worsening
having diabetes mellitus before clinical onset or clinical worsening
being obese for at least the 5 years before clinical onset or clinical worsening
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
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
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
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
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
an inability to undertake any physical activity greater than 3 METs for at least the 5 years before clinical onset or clinical worsening
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
having Hashimoto thyroiditis for at least 2 years within the 10 years before clinical onset or clinical worsening
having radiotherapy for cancer, where the heart was in the field of radiation, before clinical onset or clinical worsening
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
having syphilis involving the coronary arteries at the time of clinical onset or clinical worsening
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
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
having a hypercoagulable state that results in thrombosis of a coronary artery at the time of clinical onset or clinical worsening
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
taking combined estrogen-progestogen contraception within the 4 weeks before clinical onset or clinical worsening of myocardial infarction or unstable angina
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
being treated with antipsychotic within the 24 hours before the clinical onset or clinical worsening of myocardial infarction
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
having bilateral orchidectomy (orchiectomy) before clinical onset or clinical worsening
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
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
having infection with human immunodeficiency virus for at least the 5 years before the clinical onset or clinical worsening of myocardial infarction
having gout at the time of clinical onset or clinical worsening of myocardial infarction
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
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
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
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
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
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)
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
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
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
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
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
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
inability to obtain appropriate clinical management for ischaemic heart disease before clinical worsening

After the condition arose, it was worsened during your service. 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. Type 2 diabetes mellitus diagnosed on 9 March 2009 was present before onset and before the worsening during peacetime service in 2022. Your BMI was 30 or more, between 31 and 34, from April 2004 to onset and between 32 and 35 from 2017 to 2022, so you were obese for at least the 5 years before onset and before the worsening. 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. You 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. Having smoked about 15 pack-years, you stopped on 1 January 2014, and the worsening on 14 September 2022 occurred within 20 years of cessation, meeting limb (b). 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. Exposure to second-hand smoke ceased on 1 January 2014 after more than 5,000 hours in enclosed spaces between 1996 and 2013, meeting limb (b) for the worsening. From August 2017 ischaemic cardiomyopathy limited you 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. 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). 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. 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. 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. Late syphilis with aortitis narrowing the left main coronary ostium, confirmed in August 2022, was present at the worsening on 14 September 2022. Takayasu arteritis, sub-factor (k), confirmed by CT angiography on 8 August 2012, was active at onset. Chronic plaque psoriasis, sub-factor (c), diagnosed in 2003 during peacetime service, was active at onset and at the worsening in 2022. 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. 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 you were in peacetime service. You 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. 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. Quetiapine 50 mg, an antipsychotic, was taken on the night of 17 July 2012, within the 24 hours before the myocardial infarction. 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. 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. Cyproterone acetate, an androgen receptor blocker, was taken at 2 mg daily continuously from 2005 to onset, far longer than the 7 days required. You 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. 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. Gout, with recurrent attacks since 22 September 2006 and a flare in July 2012, was present at the onset of the myocardial infarction. 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. 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. 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. You had intense fear and distress after being fired upon, and at 1300 on 18 July 2012 you were 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. Your father died on 13 July 2012, five days before onset, within the 1 week required. You smoked cannabis, sub-factor (c), on the evening of 13 September 2022, within the 24 hours before the worsening during peacetime service. 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. 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). COVID-19 confirmed on 2 July 2022 was within the 3 months before the worsening on 14 September 2022. Influenza A confirmed on 6 July 2012, with a lower respiratory tract infection from 15 July 2012, was within the 30 days before onset. 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. 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. 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 your referral was lost on a peacetime posting.

This has then led to further investigations and the diagnosis of your condition of Ischaemic Heart Disease (Worsening). I have accepted your condition of Ischaemic Heart Disease (Worsening).

Having considered your service records and the available medical evidence, I am satisfied the SOP is met and that the worsening of this condition is related to your peacetime service.

I have therefore accepted that the worsening of this condition is related to your service with effect from 14 September 2022.

Ischaemic Heart Disease — example determination letter

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Reference Determination Content

Ischaemic Heart Disease

Evidence

Your service

Ischaemic Heart Disease

Ischaemic Heart Disease (Worsening)

Evidence

Your service

Ischaemic Heart Disease (Worsening)