[Federal Register Volume 62, Number 238 (Thursday, December 11, 1997)]
[Rules and Regulations]
[Pages 65207-65224]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-32413]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AE40


Schedule for Rating Disabilities; The Cardiovascular System

AGENCY: Department of Veterans Affairs.

ACTION: Final rule.

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SUMMARY: This document amends that portion of the Department of 
Veterans Affairs (VA) Schedule for Rating Disabilities addressing the 
cardiovascular system. The effect of this action is to update the 
cardiovascular system portion of the rating schedule to ensure that it 
uses current medical terminology and unambiguous criteria, and that it 
reflects medical advances that have occurred since the last review.

EFFECTIVE DATE: This amendment is effective January 12, 1998.

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Regulations Staff (213A), Compensation and Pension Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Avenue NW, Washington, DC 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of the 
rating schedule, VA published, in the Federal Register of January 19, 
1993 (58 FR 4954-60), a proposal to amend 38 CFR 4.100, 4.101, 4.102, 
and 4.104. Interested persons were invited to submit written comments, 
suggestions, or objections on or before March 22, 1993. We received 
comments from the Disabled American Veterans, the Veterans of Foreign 
Wars, the Paralyzed Veterans of America, the American Legion, and 
several VA employees.
    One commenter, stating that the primary objective of the review is 
to update the medical terminology and criteria used to evaluate 
disabilities rather than to amend the percentage evaluations, 
contended, without being specific, that a substantial number of the 
proposed changes go beyond the stated purpose and expressed general 
opposition to any changes that are inconsistent with the stated 
objective. The commenter also stated that the proposed criteria retain, 
and in some cases expand upon, the vague, indefinite, and arbitrary 
elements previously found in the schedule and felt that substantial 
revision of the proposed rules is required.
    The purpose of the review was to update the cardiovascular system 
portion of the rating schedule to ensure that it uses current medical 
terminology and unambiguous criteria, and that it reflects medical 
advances that have occurred since the last review. The proposed 
revisions published January 19, 1993, were intended to update the 
medical terminology; revise the criteria, including the length of 
convalescence evaluations, based on medical advances; and make criteria 
more objective, i.e., less ambiguous and, thereby, assure more 
consistent ratings. These proposed changes were consistent with the 
stated purposes of the revision. However, since establishing less 
ambiguous criteria to assure consistent evaluations is one of the 
purposes of this revision, and a number of commenters stated that the 
proposed criteria contained language that is too subjective to provide 
effective guidance in evaluating cardiovascular disabilities, we have 
further revised the proposed evaluation criteria to eliminate 
indefinite terminology and establish more objective and quantifiable 
criteria wherever possible. These changes will be discussed in detail 
under the individual codes affected.
    One commenter suggested that the proposed criteria will 
discriminate against veterans of Desert Storm and future veterans 
because their conditions will be evaluated under criteria that he 
perceived as less generous than those in the prior rating schedule.
    Significant medical advances, including new surgical and anesthetic 
techniques, new medications, and earlier diagnoses, have occurred, 
which we must take into account in revising the rating schedule. Doing 
so is, in fact, one of the primary reasons for conducting this review. 
Since recently discharged veterans clearly benefit from the application 
of these new techniques, in our judgment they are not discriminated 
against by having their disabilities evaluated under criteria which 
reflect the effects of these same medical advances.
    One commenter objected that the rating schedule fails to take into 
consideration the disabling effects of the veteran's shortened life 
expectancy.
    To consider a factor so far removed from ``the average impairments 
of earning capacity'' as the effect of various conditions on life 
expectancy would clearly exceed the parameters established by Congress 
in 38 U.S.C. 1155.
    One commenter, citing a statistical economic validation study from 
the 1960s, implied that statistical studies may justify increased 
disability evaluations.
    The statute (38 U.S.C. 1155) authorizing establishment of the 
rating schedule directs that ``[t]he Secretary shall from time to time 
readjust the schedule of ratings in accordance with experience'' 
(emphasis supplied). Rather than requiring statistical studies or any 
other specific type of data, the statute clearly leaves the nature of 
the experience which warrants an adjustment, and by extension the 
manner in which any review is conducted, to the discretion of the 
Secretary. Although during the 1970s VA considered adjusting the rating 
schedule based on the same statistical studies cited by the commenter, 
that approach proved to be unsatisfactory, and the proposed changes 
based on that study were not adopted.
    One commenter agreed that ambiguous words such as ``severe'' should 
be deleted, but cautioned against making the evaluation criteria too 
objective.
    Providing clear and objective criteria is the best way to assure 
that disabilities will be evaluated fairly and consistently. Judgment 
and flexibility cannot be eliminated from the evaluation process, 
however, because patients do not commonly present as textbook models of 
disease, and rating agencies have the task of assessing which 
evaluation level best represents the overall disability picture. (See 
Sec. 4.7.)
    The previous schedule provided convalescence evaluations for six

[[Page 65208]]

months for the following conditions: rheumatic heart disease (DC 7000); 
arteriosclerotic heart disease, following coronary occlusion (DC 7005); 
myocardial infarction (DC 7006); and soft tissue sarcoma (of vascular 
origin) (DC 7123). It provided convalescence evaluations for one year 
for the following conditions: Auriculoventricular block, with 
implantation of a pacemaker (DC 7015); heart valve replacement (DC 
7016); coronary artery bypass (DC 7017); and aortic aneurysm, following 
surgical correction (DC 7110). We proposed to change the duration of 
convalescence evaluations for DC 7000, DC 7005, and DC 7006 to three 
months; for DC 7018 (pacemaker implantation, formerly DC 7015) to two 
months; and for DC 7017 to three months. We proposed an indefinite 
period of convalescence evaluation with an examination at six months 
for DC 7016, DC 7110, DC 7011 (now ventricular arrhythmias), DC 7111 
(aneurysm of any large artery), and DC 7123. We also proposed an 
indefinite period of convalescence evaluation, but with an examination 
at one year, for cardiac transplantation (DC 7019).
    One commenter stated that VA should justify the proposed changes in 
periods of convalescence evaluation by citing medical experts or texts.
    A report from Jefferson Medical College that included a clinical 
review of the cardiovascular portion of the rating schedule and 
recommendations for changes was available to us when we undertook the 
revision of this body system. In addition, we received advice from the 
Veterans Health Administration and consulted standard medical texts 
such as ``Cecil Textbook of Medicine'' (James B. Wyngaarden, M.D. et 
al. eds., 19th ed. 1992), ``Heart Disease'' (Eugene Braunwald, M.D. 
ed., 4th ed. 1992), and ``The Heart'' (J. Willis Hurst, M.D. et al. 
eds., 7th ed. 1990). We published the proposed revision only after 
reviewing all of these sources of information. We have provided 
specific citations supporting many of the changes in the length of 
convalescence evaluations later in this document under the discussions 
of convalescence evaluation periods that have been changed.
    One commenter stated that the proposed periods of convalescence 
evaluation do not represent the average impairment, but only the 
optimal recovery times. This commenter also stated that the changes in 
the duration of convalescence evaluations do not take into account 
advanced age, poor state of health, or the presence of etiologically 
related or concomitant disease.
    The periods of convalescence evaluation we have established 
reflect, according to the sources noted above, the average periods of 
recovery needed by the average person following certain procedures and 
illnesses. These periods can be extended, when medically warranted, 
under the authority of 38 CFR 4.29 and 4.30.
    One commenter said that the proposed changes in the length of 
convalescence evaluations appear to have been developed from a purely 
economic perspective.
    As previously discussed, revisions to periods of convalescence 
evaluations were based on medical considerations rather than cost 
projections.
    One of the commenters suggested that where the length of 
convalescence evaluations has been reduced to two, three, or six 
months, all claims should be referred to the Adjudication Officer for a 
possible extension of the convalescence rating under 38 CFR 4.30(b)(2).
    The rating agency itself has the authority to extend the period of 
convalescence evaluations for up to three months under the provisions 
of Sec. 4.30; the approval of the Adjudication Officer is required only 
when extending a convalescence evaluation for a longer period. 
Referring claims to the Adjudication Officer when the medical evidence 
does not warrant any extension, or when the rating agency can extend 
the evaluation for a sufficient period on its own authority, would 
cause needless delay, and we have made no change based on this 
suggestion.
    Several commenters objected to indefinite periods of convalescence 
evaluation with a mandatory VA examination at a prescribed time. In our 
judgment, however, this method of determining the length of the total 
evaluation is both fairer and more accurate than assigning a total 
evaluation for a specified length of time, since the evaluation will be 
based on actual residual disability as documented by the examination, 
and the veteran will receive advance notice of any change and have the 
opportunity to submit additional evidence showing that the change is 
not warranted.
    One set of comments reflected the view that applying Sec. 3.105(e) 
to indefinite periods of convalescence evaluations will cause 
significant administrative problems and, in some instances, 
significantly lengthen the period for which a convalescence evaluation 
is assigned. These concerns appear to be based on the assumption that 
if medical information justifying a certain period of convalescence 
evaluation is not submitted until months or even years after the event, 
the condition must be evaluated as totally disabling from the date 
entitlement is established, through the entire intervening period, and 
until such time as an examination can be performed, advance notice be 
provided, and the effective date provisions of Sec. 3.105(e) be 
observed.
    Section 3.105(e) applies only to reductions in ``compensation 
payments currently being made;'' it does not apply in cases where a 
total evaluation is both assigned and reduced retroactively. We have 
established convalescence evaluations for indefinite periods under 
other portions of the rating schedule (See DC 7528, malignant neoplasms 
of the genitourinary system, in 38 CFR 4.115b and DC 7627, malignant 
neoplasms of gynecological system or breast, in 38 CFR 4.116), some 
having been in effect for over two years, and there is no evidence that 
they cause the type of administrative problems that the commenters 
foresee.
    There were three introductory sections to the cardiovascular system 
in the previous rating schedule. Section 4.100, Necessity for complete 
diagnosis, named common types of heart disease and discussed the need 
for accurate diagnosis. Section 4.101, Rheumatic heart disease, 
discussed the course of rheumatic heart disease, the significance of a 
diagnosis of mitral insufficiency, possible etiologies for later 
developing aortic insufficiency, and the need for accurate diagnosis of 
a service-connected condition. Section 4.102, Varicose veins and 
phlebitis, discussed the need to determine impairment of deep 
circulation due to varicosities and included a requirement to assign a 
higher evaluation when there is phlebitis or deep impairment of 
circulation. We proposed to retitle the introductory sections: 4.100, 
as ``Forms of heart disorder;'' 4.101, as ``Hypertension;'' and 4.102, 
as ``Varicose veins.'' We proposed to include in Sec. 4.100 a list of 
common forms of heart abnormalities, a discussion of how to evaluate 
service-connected valvular heart disease or arrhythmia in the presence 
of nonservice-connected arteriosclerotic heart disease, and a statement 
that the identification of coronary artery disease (without occlusion 
or thrombosis) early in service is not a basis for service connection, 
but that any sudden development of coronary occlusion or thrombosis 
during service would be service-connected. However, as explained below, 
we have either deleted or relocated all of the material we had proposed 
to include in Secs. 4.100, 4.101,

[[Page 65209]]

and 4.102, and we have, therefore, removed those sections and reserved 
them for future use.
    One commenter suggested that we remove all material in Secs. 4.100, 
4.101, and 4.102 that refer to the issue of service connection because 
it is inappropriate to place criteria for determining entitlement to 
service connection in the rating schedule. A second commenter suggested 
that the material about the identification of coronary artery disease 
early in service not being a basis for service connection should be 
removed because the provision violates the statutory presumption of 
soundness at induction as set forth in 38 U.S.C. 1111.
    The rules governing determinations of service connection are found 
in the regulations beginning at 38 CFR 3.303, rather than in the rating 
schedule, which is a guide to evaluating disabilities. We agree that 
rules affecting determinations of service connection are inappropriate 
in the rating schedule, and we have removed that portion of the 
material in Sec. 4.100 that addressed the issue of service connection 
for coronary artery disease for that reason. We have also removed other 
provisions of Secs. 4.101 and 4.102 that addressed service connection 
for cardiovascular conditions, as discussed below.
    We had proposed including in Sec. 4.102, varicose veins, a 
provision from VA's Adjudication Procedures Manual, M21-1, Part VI, 
that if varicose veins developed during active service in one leg, 
varicose veins developing in the other leg within three years, in the 
absence of an intercurrent cause, will also be service-connected. 
However, in response to this comment, we have determined that since it 
addresses the issue of service connection, it is not appropriate in the 
rating schedule, and we have removed it.
    Two commenters suggested that these introductory sections specify 
which cardiovascular diseases should be service-connected when they 
develop subsequent to certain amputations.
    38 CFR 3.310(b) provides that ``ischemic heart disease or other 
cardiovascular diseases'' developing in veterans who have suffered a 
service-connected amputation of one lower extremity at or above the 
knee, or service-connected amputations of both lower extremities at or 
above the ankles, shall be held to be the result of the service-
connected amputation or amputations. Since that issue is addressed 
elsewhere in VA's regulations, it is unnecessary to address it here. 
Furthermore, as previously discussed, it would be inappropriate to 
include material about the determination of service connection in the 
rating schedule.
    One commenter recommended that we include more discussion of 
pertinent clinical and nonclinical factors to be considered in 
assigning evaluations within this portion of the rating schedule.
    We have made a number of changes along these lines that will assist 
in the evaluation of cardiovascular conditions. Most significantly, we 
have adopted more objective evaluation criteria based on specific 
clinical (and, in some cases, laboratory) findings, e.g., by using the 
level of METs (metabolic equivalents, discussed in detail below) to 
assess the severity of heart disease. In addition, we have retained or 
added notes, as appropriate, containing clinical information, e.g., by 
adding a note defining characteristic attacks of Raynaud's syndrome.
    One commenter suggested that Sec. 4.100 discuss forms of heart 
disorder, Sec. 4.101 discuss hypertension, and Sec. 4.102 discuss 
varicose veins.
    A regulation is an agency statement of general applicability and 
future effect, which the agency intends to have the force and effect of 
law, that is designed to implement, interpret, or prescribe law or 
policy, or to describe the procedure or practice requirements of an 
agency (Executive Order 12866, Regulatory Planning and Review). 
Background material, such as general medical information that is 
available in standard textbooks, or other material that neither 
prescribes VA policy nor establishes procedures a rating activity must 
follow, falls outside of those parameters and is, therefore, not 
appropriate in a regulation. The material about the age of onset, 
course, etc., of rheumatic fever in former Sec. 4.101 is general 
medical information which has no bearing on evaluating the condition, 
and we have deleted this material as not appropriate in a regulation. 
Upon further review, we have deleted the list of heart abnormalities 
from proposed Sec. 4.100 because it too is general medical information 
that we do not intend to have the force and effect of law.
    We proposed to retitle Sec. 4.101 ``Hypertension,'' and to revise 
the content to include a prohibition against separately evaluating 
hypertension that is secondary to thyroid or renal disease; and a 
requirement that, in a veteran with service-connected hypertension, 
arteriosclerotic manifestations are to be service-connected. One 
commenter suggested adding more information to Sec. 4.101 about 
secondary hypertension, to include specifying when secondary 
hypertension can be evaluated separately from the condition causing it.
    The rule regarding evaluation of hypertension secondary to renal 
disease is included in the part of the rating schedule addressing the 
genitourinary system at Sec. 4.115; secondary hypertension associated 
with aortic insufficiency or thyroid disease, and isolated systolic 
hypertension, which may be secondary to arteriosclerosis, are addressed 
under DC 7101 (hypertensive vascular disease). Since the issue of 
service connection of secondary hypertension is addressed in more 
appropriate areas of the regulations, it should not be addressed here, 
and rather than expanding this material, we have deleted it from 
Sec. 4.101.
    The material in proposed Sec. 4.101 about conditions that are 
complications of hypertension or other medical conditions is also 
general medical information available in standard texts. As discussed 
above, it is not appropriate in a regulation, and we have, therefore, 
removed it. The issue of service connection for conditions that are 
proximately due to or the result of a service-connected condition is 
addressed at 38 CFR 3.310(a). It is, therefore, unnecessary to address 
the issue in Sec. 4.101, and we have removed that material also.
    In the former schedule, Sec. 4.102, which was titled ``Varicose 
veins and phlebitis,'' discussed the necessity of testing for 
impairment of deep circulation in varicose veins. We proposed to 
retitle it ``Varicose veins'' but to retain the material about deep 
circulation. Under the revised evaluation criteria for varicose veins 
adopted in this rule, however, determining whether the deep circulation 
is impaired is unnecessary because the evaluation criteria focus on 
functional impairment rather than the location of the venous 
insufficiency. We have, therefore, deleted that material from 
Sec. 4.102.
    Another commenter requested that we address in Sec. 4.101 the 
advances in medical science or objective foundation for requiring that 
adjudicators attempt to apportion cardiac signs and symptoms that are 
attributable to nonservice-connected arteriosclerotic heart disease 
that is superimposed on service-connected rheumatic heart disease.
    While it is often possible through modern technology to determine 
the separate effects of coexisting heart diseases, such a determination 
requires a medical assessment on a case-by-case basis and cannot be 
determined by regulation. We have, therefore, revised the material to 
require that the rating agency request a medical opinion when it is 
necessary to determine whether

[[Page 65210]]

current signs and symptoms can be attributed to one of the coexisting 
conditions. Since the material is not relevant to the entire 
cardiovascular portion of the rating schedule, we have moved it to a 
note under DC 7005, arteriosclerotic heart disease.
    One commenter suggested adding a section to explain which 
diagnostic codes should not be combined in the case of coexisting 
cardiovascular diseases.
    As in the case of coexisting heart diseases, determining whether 
coexisting cardiovascular diseases have functional impairments that can 
be separately evaluated must be determined on a case-by-case basis, 
depending on the particular manifestations of each condition. We, 
therefore, make no change based on this suggestion.
    One commenter recommended that we include cor pulmonale in the 
cardiovascular portion of the schedule.
    Cor pulmonale is a combination of hypertrophy and dilatation of the 
right ventricle secondary to pulmonary hypertension, which is due to 
disease of the lung parenchyma or pulmonary vascular system (Braunwald, 
1581). Since cor pulmonale is always secondary to a lung condition, and 
since it is included in the evaluation criteria for various conditions 
of the respiratory system, in our judgment it is not appropriate to 
include it in the cardiovascular portion of the rating schedule. For 
the sake of clarity, however, we have placed a note in Sec. 4.104 
before DC 7000 instructing rating agencies to evaluate cor pulmonale as 
part of the pulmonary condition that causes it.
    The previous rating schedule provided a 100-percent evaluation for 
rheumatic heart disease (DC 7000) ``as active disease and, with 
ascertainable cardiac manifestation, for a period of six months.'' We 
proposed to retitle DC 7000 ``valvular heart disease,'' and to provide 
a 100-percent evaluation for ``active infections with valvular heart 
damage for three months following cessation of therapy.''
    Three commenters objected to the proposed change in the length of 
the convalescence evaluation for DC 7000 (valvular heart disease).
    Rheumatic fever is the condition most commonly associated with 
valvular heart damage, and its acute phase rarely lasts longer than 
three months (Braunwald, 1729). The level of activity following this 
period depends on the severity of residual disease (Cecil, 1637). While 
in the past patients with acute rheumatic fever were put to bed for 
several months, bed rest is no longer considered necessary unless there 
is significant carditis (Hurst, 1527). In addition, most rebounds of 
rheumatic fever (that is, reappearances of clinical or laboratory 
evidence of acute rheumatic fever following cessation of treatment) 
occur within two weeks after cessation of therapy, and do not occur 
more than five weeks after complete cessation of anti-rheumatic therapy 
(Braunwald, 1730). In our judgment, three months following cessation of 
therapy is a reasonable period to allow for stabilization of valvular 
damage due to infection, and we have retained the convalescence 
provision as proposed, except for minor editorial changes.
    We proposed that valvular heart disease (DC 7000) be evaluated on 
the basis of the level of physical activity, i.e., ``any,'', 
``ordinary,'' or ``strenuous,'' required to produce cardiac symptoms, 
such as ``dyspnea,'' ``fatigue,'' etc. We received three comments 
objecting to the proposed criteria.
    One commenter suggested that although the proposed general rating 
formula for rheumatic heart disease (DC 7000), arteriosclerotic heart 
disease (DC 7005), and ventricular arrhythmia (DC 7011) is consistent 
with the classifications of the New York Heart Association, they are 
mostly for subjective complaints, and the commenter suggested that the 
current criteria be retained except for deleting words like 
``characteristic'' and ``definitely.'' Another commenter stated that 
the proposed criteria for valvular heart disease are highly subjective 
and urged that we adopt objectively confirmable criteria at every 
level.
    We agree that more objective criteria would result in more 
consistent evaluations. In our judgment, however, simply removing such 
terms as ``characteristic'' and ``definitely'' from the criteria in the 
previous schedule would not have the intended effect. We have, 
therefore, revised the criteria to incorporate objective measurements 
of the level of physical activity, expressed in METs (metabolic 
equivalents), at which cardiac symptoms develop. This does not 
represent a substantive change in the method of evaluating cardiac 
disabilities that we proposed, i.e., basing evaluations on the level of 
physical activity that causes symptoms, but is an objective method for 
measuring the level of activity that causes symptoms.
    The exercise capacity of skeletal muscle depends on the ability of 
the cardiovascular system to deliver oxygen to the muscle, and 
measuring exercise capacity can, therefore, also measure cardiovascular 
function. The most accurate measure of exercise capacity is the maximal 
oxygen uptake, which is the amount of oxygen, in liters per minute, 
transported from the lungs and used by skeletal muscle at peak effort 
(Braunwald, 1382). Because measurement of the maximal oxygen uptake is 
impractical, multiples of resting oxygen consumption (or METs) are used 
to calculate the energy cost of physical activity. One MET is the 
energy cost of standing quietly at rest and represents an oxygen uptake 
of 3.5 milliliters per kilogram of body weight per minute. The 
calculation of work activities in multiples of METs is a useful 
measurement for assessing disability and standardizing the reporting of 
exercise workloads when different exercise protocols are used 
(Braunwald, 162).
    We have revised the evaluation criteria for the major types of 
heart disease based on: the level of physical activity, expressed in 
METs, that leads to cardiac symptoms; whether there is heart failure; 
the extent of any left ventricular dysfunction; the presence of cardiac 
hypertrophy or dilatation; and the need for continuous medication. We 
had proposed that valvular heart disease (DC 7000) be evaluated on the 
basis of the level of physical activity that produces symptoms--100 
percent if ``any,'' 60 percent if ``ordinary,'' and 30 percent if 
``strenuous'' activity produces symptoms. We have revised those 
criteria to assign a 100-percent evaluation if a workload of three METs 
or less produces dyspnea, fatigue, angina, dizziness, or syncope. A 
workload of three METs represents such activities as level walking, 
driving, and very light calisthenics. We have revised the criteria to 
assign a 60-percent evaluation if a workload of greater than three METs 
but not greater than five METs results in cardiac symptoms. Activities 
that fall into this range include walking two and a half miles per 
hour, social dancing, light carpentry, etc. We have revised the 
criteria to assign a 30-percent evaluation if a workload of greater 
than five METs but not greater than seven METs produces symptoms. 
Activities that fall into this range include slow stair climbing, 
gardening, shoveling light earth, skating, bicycling at a speed of nine 
to ten miles per hour, carpentry, and swimming (Fox, S. M. III, 
Naughton, J.P., Haskell, W.L.: Physical activity and the prevention of 
coronary heart disease. Ann. Clin. Res., 3:404, 1971 and Goldman, L. et 
al.: Comparative reproducibility and validity of systems for assessing 
cardiovascular functional class: Advantages of a new specific activity

[[Page 65211]]

scale. Circulation 64:1227, 1981). METs are measured by means of a 
treadmill exercise test, which is the most widely used test for 
diagnosing coronary artery disease and for assessing the ability of the 
coronary circulation to deliver oxygen according to the metabolic needs 
of the myocardium (Cecil, 175 and Harrison, 966).
    Administering a treadmill exercise test may not be feasible in some 
instances, however, because of a medical contraindication, such as 
unstable angina with pain at rest, advanced atrioventricular block, or 
uncontrolled hypertension. We have, therefore, provided objective 
alternative evaluation criteria, such as cardiac hypertrophy or 
dilatation, decreased left ventricular ejection fraction, and 
congestive heart failure, for use in those cases. We have also 
indicated that when a treadmill test cannot be done for medical 
reasons, the examiner's estimation of the level of activity, expressed 
in METs and supported by examples of specific activities, such as slow 
stair climbing or shoveling snow that results in dyspnea, fatigue, 
angina, dizziness, or syncope, is acceptable.
    The other objective criteria that we have added as alternatives to 
the METs-based criteria for valvular heart disease are a left 
ventricular ejection fraction of less than 30 percent or chronic 
congestive heart failure for a 100-percent evaluation; a left 
ventricular ejection fraction of 30 to 50 percent, or more than one 
episode of acute congestive heart failure in the past year for a 60-
percent evaluation; evidence of cardiac hypertrophy or dilatation on 
electrocardiogram, echocardiogram, or X-ray for a 30-percent 
evaluation, and a requirement for continuous medication for a 10-
percent evaluation.
    Since neurologic, gastrointestinal, and other cardiovascular 
disorders may result in symptoms similar to those for valvular heart 
disease, we have also added a requirement that valvular heart disease 
be documented by findings on physical examination and by 
echocardiogram, Doppler echocardiogram, or cardiac catheterization.
    Another commenter felt that the proposed criteria for the 100-
percent level for valvular heart disease (DC 7000), arteriosclerotic 
heart disease (DC 7005), and ventricular arrhythmias (DC 7011)--that 
``any'' physical activity results in specified cardiac symptoms--
correlates not with total industrial impairment but with being 
housebound or helpless. Similarly, the commenter objected that the 
requirement for the 60-percent level--that ``ordinary'' physical 
activity results in symptoms--actually represents total impairment.
    The proposed criteria for the 100-percent level of these conditions 
were meant to indicate a severe level of impairment, but the language 
was imprecise and perhaps suggested a degree of impairment beyond total 
impairment. Under the more objective criteria that we are adopting 
here, a 100-percent evaluation requires that a workload of three METs 
or less produces dyspnea, fatigue, angina, dizziness, or syncope. A 
workload of three METs includes such activities as level walking, 
driving, and very light calisthenics. While the development of cardiac 
symptoms at this level of activities indicates total impairment, it 
does not suggest that the patient is either housebound or helpless. 
Similarly, under the more objective criteria, a 60-percent evaluation 
requires that a workload of greater than three METs but not greater 
than five METs produces cardiac symptoms. Since activities that fall 
into this range include walking two and a half miles per hour, social 
dancing, and light carpentry, this range does not represent total 
impairment. In our judgment, by adopting more objective criteria, we 
have eliminated the problem that the commenter identified.
    The prior schedule assigned a 10-percent evaluation under DC 7000 
(rheumatic heart disease, now designated as valvular heart disease), 
when there was an identifiable valvular lesion, with little dyspnea and 
no cardiomegaly. We proposed to delete the 10-percent level and to 
evaluate the condition as zero percent disabling if it does not limit 
physical activity.
    Two commenters objected to the proposed deletion of a 10-percent 
level of evaluation for valvular heart disease. One suggested a 10-
percent evaluation when dietary adjustments and medication are 
necessary to control symptoms or prevent emboli; the other suggested a 
10-percent evaluation for asymptomatic valvular heart disease or 
arrhythmias that require medication.
    Upon further consideration, we have added a 10-percent evaluation, 
which will be assigned when symptoms develop at a workload of greater 
than 7 METs but not greater than 10 METs. Activities that fall into 
this range include jogging, playing basketball, digging ditches, and 
sawing hardwood. When symptoms develop only during such activities, 
there may be some impairment of earning capacity, but it is likely to 
be slight. We have also established an alternative criterion for a 10-
percent evaluation--the need for continuous medication--consistent with 
the 10-percent evaluations assigned under other body systems, e.g., 
gynecological and endocrine conditions, when continuous medication is 
required. We have also deleted the zero-percent level of evaluation as 
unnecessary, since zero percent may be assigned under any diagnostic 
code when the criteria for a compensable evaluation are not met (38 CFR 
4.31).
    DC 7000 was titled ``rheumatic heart disease'' in the previous 
schedule. We proposed to retitle it ``valvular heart disease,'' and to 
specify that it included rheumatic heart disease, syphilitic heart 
disease, and sequelae involving valvular heart damage from 
endocarditis, pericarditis, or trauma. Because each of the conditions 
listed under DC 7000 (except trauma) has its own diagnostic code and 
criteria, we have revised the title to ``valvular heart disease 
(including rheumatic heart disease)'' and deleted the list of 
conditions. The term ``valvular heart disease'' encompasses all types 
of valvular disease not otherwise specified, including those due to 
trauma.
    We proposed to require that endocarditis (DC 7001), pericarditis 
(DC 7002), and pericardial adhesions (DC 7003) be rated as valvular 
heart disease. We have instead repeated the evaluation criteria under 
each diagnostic code to which they apply. We have also deleted the 
three-month period of convalescence evaluation that would have been 
available for pericardial adhesions if evaluated strictly under the 
criteria for valvular heart disease (DC 7000); pericardial adhesions 
are a chronic condition rather than an acute infection, and a 
convalescence evaluation is, therefore, inappropriate.
    We proposed that syphilitic heart disease (DC 7004) be evaluated 
under the criteria for either valvular heart disease or aortic aneurysm 
(DC 7110). We have now provided criteria for DC 7004 that are based on 
the same objective measurements of the level of physical activity that 
causes symptoms. We placed a note following this diagnostic code 
directing that syphilitic aortic aneurysms be evaluated under DC 7110 
(aortic aneurysm), since the criteria under DC 7110 apply to aortic 
aneurysm of any etiology. Since syphilitic heart disease has no phase 
of active infection, being the late result of a much earlier syphilitic 
infection, we have omitted the criteria based on active infection, as 
we did under DC 7003.
    We proposed to revise the length of convalescence evaluation 
following a myocardial infarction (DC 7005 or 7006) from six months to 
three months. One commenter objected that three months represents the 
optimal, rather than the

[[Page 65212]]

average, recovery period following myocardial infarction.
    The interval between an uncomplicated myocardial infarction and 
return to work is 70-90 days (Braunwald, 1390), and a return to work 
evaluation can be performed within five weeks after an uncomplicated 
myocardial infarction (``The Heart'' 1115 (J. Willis Hurst, M.D. et al. 
eds., 7th ed. 1990)). Complete healing of the myocardium, i.e., 
replacement of the infarcted area by scar tissue, takes six to eight 
weeks, and most patients will be able to return to work by 12 weeks, 
many much earlier (``Harrison's Principles of Internal Medicine'' 956-
57 (Jean D. Wilson, M.D. et al. eds., 12th ed. 1991)). This information 
clearly establishes that most patients with myocardial infarction 
recover within three months, and, in our judgment, that is an adequate 
period for a convalescence evaluation.
    Another individual said that three months is not an adequate length 
of convalescence evaluation following myocardial infarction because it 
takes six months, which according to the commenter is the normally 
accepted recovery time, for ancillary circulation patterns to develop.
    The development of collateral circulation represents a long-range 
adaptation to ischemia due to coronary artery disease (Hurst, 944). It 
is, therefore, more relevant in predicting whether an infarction will 
occur or how severe it might be, than in determining the length of 
convalescence after infarction, and we have made no change based on 
this comment.
    In response to requests for more objective criteria, we have 
adopted criteria for the 10-, 30-, 60-, and 100-percent levels for 
arteriosclerotic heart disease using the same METs-based criteria we 
have adopted for DC 7000 (valvular heart disease). We have also adopted 
similar alternative criteria based either on chronic or multiple 
episodes of congestive heart failure, left ventricular dysfunction with 
decreased ejection fraction percentages, or cardiac hypertrophy or 
dilatation.
    The prior rating schedule assigned 30-percent evaluations under DCs 
7005 (arteriosclerotic heart disease) and 7006 (myocardium, infarction 
of, due to thrombosis or embolism) ``following typical coronary 
occlusion or thrombosis,'' or ``with history of substantiated anginal 
attack, ordinary manual labor feasible,'' but provided neither a 10-
percent level nor specific criteria for a zero-percent evaluation. We 
proposed to assign a 30-percent evaluation for those with cardiac 
symptoms appearing after strenuous physical activity, and to establish 
a zero-percent level for those with no limitation of physical activity.
    Two commenters objected to the proposed changes. One suggested we 
provide a 20-percent level under DC 7005 for some limitation of 
activities and a 30-percent level for one or more symptoms. One felt 
that 30 percent should be the minimum under DC 7005 or DC 7006 because 
permanent disability results.
    In keeping with the objective evaluation criteria we are adopting, 
it is feasible to establish additional levels of impairment based on an 
objective measurement of the workload at which symptoms develop. We 
have added a 10-percent evaluation under DC's 7005 and 7006 for those 
who have cardiac symptoms at a workload greater than 7 METs but not 
greater than 10 METs, which includes such activities as gardening and 
skating. The 10-percent evaluation may also be assigned when continuous 
medication is required, which is consistent with the evaluation of 
other heart conditions. As a result, if, for different conditions, the 
same workload elicits symptoms, the conditions will be assigned the 
same evaluation. A 30-percent minimum evaluation is not warranted. 
Arteriosclerotic heart disease may be mild enough that it imposes 
little or no functional impairment, and, in our judgment, the most 
equitable way to evaluate the condition is to do so objectively 
according to the physical workload that causes symptoms.
    We proposed that arteriosclerotic heart disease (DC 7005) and 
myocardial infarction (DC 7006) be evaluated under the same criteria. 
That was reasonable under the subjective evaluation criteria that were 
proposed, but there are some condition-specific differences that the 
criteria must reflect. We have provided for a three-month convalescence 
evaluation following a myocardial infarction (DC 7006), a condition of 
sudden onset. Arteriosclerotic heart disease (DC 7005), on the other 
hand, is a chronic condition that does not warrant a convalescence 
evaluation. We have added a requirement to DC 7005 that the veteran 
have ``documented'' coronary artery disease. Similarly, we have headed 
DC 7006 with the statement ``with history of myocardial infarction, 
documented by laboratory tests.'' This replaces the requirement that 
the myocardial infarction be ``typical'' in order to assign the 
convalescence evaluation. Since atypical myocardial infarctions may be 
just as disabling as typical ones, we have revised the criteria for a 
convalescence rating to require that an infarction be ``documented'' 
rather than ``typical.''
    We have deleted the instruction proposed under DC 7005 that 
cardiomyopathies (DC 7020) and hypertensive heart disease (DC 7007) are 
to be rated as arteriosclerotic heart disease because we have provided 
each of these conditions with criteria under its own diagnostic code.
    We proposed that hypertensive heart disease (DC 7007) be evaluated 
under the criteria for arteriosclerotic heart disease, i.e., percentage 
evaluations based on the level of activity that causes symptoms, and we 
have revised the criteria using the same objective evaluation criteria 
as for arteriosclerotic heart disease.
    We have made minor editorial changes under DC 7008 (hyperthyroid 
heart disease).
    We proposed that a 30-percent evaluation under DC 7010 
(supraventricular arrhythmias) require paroxysmal atrial fibrillation 
or other supraventricular tachycardia, with severe frequent attacks 
despite therapy, and that the 10-percent evaluation require permanent 
atrial fibrillation or infrequent or mild attacks documented by 
electrocardiogram (ECG) or Holter monitor.
    Two commenters pointed out that such phrases as ``severe, frequent 
attacks'' are indefinite, and one suggested that we replace these terms 
with more objective ones.
    We agree and have revised the criteria to require more than four 
episodes a year of paroxysmal atrial fibrillation or other 
supraventricular tachycardia for the 30-percent level, and permanent 
atrial fibrillation or one to four episodes a year of paroxysmal atrial 
fibrillation or other supraventricular tachycardia for the 10-percent 
level. Both sets of criteria require documentation by ECG or Holter 
monitor.
    We proposed to evaluate sustained ventricular arrhythmias (DC 7011) 
according to whether ``ordinary'' or ``strenuous'' activity results in 
palpitations or symptoms of arrhythmia. A commenter objected to the 
subjectivity of the proposed criteria for DC 7011.
    Based on this comment, we have revised the criteria using the same 
objective measurements that we are using for arteriosclerotic heart 
disease. We have, however, retained specific provisions for a total 
evaluation while an Automatic Implantable Cardioverter-Defibrillator 
(AICD) is in place. The use of AICDs is associated with the potential 
for serious complications such as myocardial infarction, stroke, 
cardiogenic shock, and complications

[[Page 65213]]

associated with the thoracotomy required for its insertion (Braunwald, 
750). We have revised the language slightly to make it clear that a 
100-percent evaluation will be assigned for as long as the AICD is in 
place. We have also made other nonsubstantive changes in the language 
at 100 percent for the sake of clarity.
    The previous schedule provided a 100-percent evaluation for DC 
7015, atrioventricular block, for one year following implantation of a 
pacemaker when required by a complete heart block with attacks of 
syncope, and a 60-percent evaluation for complete heart block with 
Stokes-Adams attacks several times a year despite medication or a 
pacemaker. We proposed to eliminate the 100-percent level while 
retaining essentially the same criteria for the other levels.
    One commenter stated that a 100-percent evaluation is warranted 
under DC 7015 when there is a complete heart block with syncopal 
attacks despite therapy or a pacemaker. Another commenter suggested 
that we replace the requirement for ``several'' attacks a year for the 
60-percent evaluation under DC 7015 with a definite number.
    Upon further review, in response both to these comments and to the 
requests for more objective criteria, we have revised the criteria for 
DC 7015 by providing the same objective evaluation criteria we have 
used for ventricular arrhythmias (DC 7011) and many other heart 
conditions, since heart block may result in a variety of cardiac signs 
and symptoms and a wide range of disabilities. This change restores the 
100-percent evaluation level. These criteria replace evaluation 
criteria based on the electrocardiographic designation of complete or 
incomplete block. Because both complete and incomplete heart blocks can 
differ in severity, basing evaluations on the degree of heart block 
could lead to different evaluations for similar symptoms. In our 
judgment, the revised criteria are a better measure of the disabling 
effects of atrioventricular block than whether the block is complete or 
incomplete.
    The only difference in the criteria for atrioventricular block (DC 
7015) and ventricular arrhythmias (DC 7011) is that a 10-percent 
evaluation for DC 7015 will be assigned when either a pacemaker, a 
common method of treatment for this condition, or continuous medication 
is required. We have deleted the proposed zero-percent evaluation, 
since under the provisions of 38 CFR 4.31a, a zero-percent evaluation 
may be assigned when the findings are less than those needed for a 
compensable level. We have also edited the note requiring that certain 
unusual cases of associated arrhythmias are to be submitted to the 
Director of the Compensation and Pension Service for evaluation, for 
the sake of clarity.
    The previous schedule established a minimum 30-percent evaluation 
for heart valve replacement (DC 7016); we proposed a 30-percent 
evaluation when strenuous activity causes specific cardiac symptoms, 
and a zero-percent evaluation when the condition imposes no limitation 
of physical activity. One commenter suggested that we retain the 30-
percent minimum evaluation, but gave no rationale for the suggestion.
    The level of residual disability following valve replacement can 
also be objectively determined based on the level of activity that 
results in symptoms in the same manner as for valvular heart disease. 
We have, therefore, revised the criteria to assign a 30-percent 
evaluation when a workload of greater than 5 METs but not greater than 
7 METs results in symptoms, or when there is evidence of cardiac 
hypertrophy or dilatation. For the sake of consistency with the 
evaluation criteria for other heart conditions evaluated based on the 
level of physical activity that causes symptoms, we have added a ten-
percent evaluation when a workload of greater than 7 METs but not 
greater than 10 METs results in symptoms. In our judgment, specific 
symptoms warrant the same evaluation whether they occur before or after 
valve replacement, and we are not aware of any special circumstances 
following valve replacement that would justify a 30-percent minimum 
evaluation.
    We have edited the language of the note regarding the assignment of 
100 percent following admission for heart valve replacement to assure 
that the provisions of Sec. 3.105(e) will be followed whether the 
reduction from the 100-percent evaluation is based upon the mandatory 
examination six months following discharge or following a subsequent 
examination.
    The previous schedule called for a total evaluation for one year 
following heart valve replacement (DC 7016). We proposed a total 
evaluation for an indefinite period, with a mandatory VA examination 
six months after the surgery, with any change in evaluation based on 
that or any subsequent examination to be made under the provisions of 
38 CFR 3.105(e).
    One commenter objected to the proposed change, stating that heart 
valve replacement is a high risk surgical procedure, and many patients 
have post-operative congestive heart failure for a considerable time. 
Another commenter said that the proposed reduction in length of the 
convalescence evaluation is arbitrary, that it goes beyond the purpose 
of the review, and that no justification has been provided.
    We recognize that it ordinarily takes patients longer to recover 
from valve replacement than from acute valvular infection, 
endocarditis, or pericarditis and, therefore, proposed an indefinite 
period of total evaluation. We believe that six months following 
discharge from the hospital is a reasonable time at which to examine a 
patient to determine whether the condition has stabilized and the 
extent of residual disability. If the results of that or any subsequent 
examination warrant a reduction in evaluation, the reduction will be 
implemented under the notice and effective date provisions of 38 CFR 
3.105(e), which require a 60-day notice before VA reduces an evaluation 
and an additional 60-day notice before the reduced evaluation takes 
effect. By requiring an examination, the revised procedure will assure 
that all residuals are documented; it also ensures that the veteran 
receive timely notice of any proposed action and have an opportunity to 
present evidence showing that the proposed action should not be taken. 
In our judgment, this method will better ensure that actual residual 
disabilities and recuperation times are taken into account because they 
will be documented on examination.
    We proposed to change the length of the total evaluation following 
coronary artery bypass surgery (DC 7017) from one year to three months. 
One commenter objected, stating that unspecified medical textbooks 
suggest resumption of sedentary activity over the two-to three-month 
period following surgery, with resumption of full activity after three 
months. Another expressed his belief that a reduction to three months 
is unreasonably restrictive and does not reflect the average impairment 
for those in poor health or those who have cardiomyopathies or 
pulmonary and systemic organ congestion.
    An article in the Journal of the American College of Cardiology 
(1029 vol. 14, no. 4, Oct. 1989) entitled ``Insurability and 
Employability of the Patient with Ischemic Heart Disease'' states that 
return to work evaluations are appropriate seven weeks after bypass 
surgery. Neither this article nor the unidentified information cited by 
the commenter justifies the need for a convalescence evaluation longer 
than three months. For the individual who requires a longer than 
average period of convalescence, a total evaluation may be assigned for 
a longer period under the provisions of Secs. 4.29 and 4.30 of the

[[Page 65214]]

rating schedule. We have, therefore, retained the provision assigning a 
total evaluation for three months following surgery as proposed.
    We proposed that coronary artery bypass surgery be evaluated using 
the evaluation criteria for arteriosclerotic heart disease, which was 
not a change from the previous schedule. One commenter suggested that 
30 percent be the minimum evaluation following bypass surgery, 
analogous to arteriosclerotic heart disease (DC 7005).
    We have provided objective criteria for evaluation following 
coronary bypass surgery that are the same as the criteria we have 
provided for arteriosclerotic heart disease (DC 7005). The surgery 
itself does not necessarily produce a 30-percent level of impairment; 
in fact, it often alleviates the disability from arteriosclerotic heart 
disease. In our judgment, an evaluation based on the workload at which 
symptoms develop is a reasonable and consistent way to assess the 
extent of disability; a 30-percent evaluation will be assigned if 
symptoms develop at the same workload that warrants a 30-percent 
evaluation for other cardiac conditions.
    One commenter suggested that we add a convalescence evaluation 
following balloon angioplasty for coronary artery disease.
    Most patients who undergo balloon angioplasty are discharged from 
the hospital 24 hours or less after surgery, and many can return to 
work in a week or less after a successful and uncomplicated angioplasty 
(Hurst, 2145 and Braunwald, 1367). In our judgment, a total evaluation 
for a specified period to allow for convalescence is, therefore, not 
warranted.
    We proposed changing the duration of the total evaluation following 
implantation of a cardiac pacemaker (currently Note (2) under DC 7015, 
proposed as DC 7018) from one year to two months. One commenter said 
that the total evaluation should continue for one year; another said 
that pacemakers require close monitoring postoperatively and that 
patients should not concern themselves with a return to activity sooner 
than medically advisable.
    Pacemaker implantation is not major surgery, nor is it associated 
with debilitating or long-term residuals. Those who undergo a cardiac 
pacemaker implantation are usually discharged from the hospital the 
following day and are seen in follow-up two weeks after surgery to 
check the wound and to test the pacing system (Hurst, 2103-4). They are 
subsequently evaluated two months after implantation, and virtually all 
patients will have definitive pacemaker programming for long-term 
function at that time (Braunwald, 747). Thereafter, there is periodic 
monitoring, often conducted by telephone. In our judgment, a two-month 
convalescence evaluation is adequate for a normal recovery from 
pacemaker implantation.
    One commenter suggested that we add a 100-percent evaluation under 
DC 7018, implantable cardiac pacemakers, for those patients who require 
frequent follow-up and adjustment after pacemaker implant.
    DC 7018 allows evaluation of a patient's condition following 
implantation of a pacemaker under supraventricular arrhythmias (DC 
7010), ventricular arrhythmias (DC 7011), or atrioventricular block (DC 
7015), if appropriate. A 100-percent evaluation may, therefore, be 
assigned based either on symptoms or on the number of episodes of 
arrhythmia, depending on the diagnostic code used. These criteria are a 
better indicator of residual disability than the frequency of 
adjustments or follow-up, and we have made no change based on this 
suggestion.
    Another commenter felt that 30 percent should be the minimum 
evaluation for DC 7018 after a pacemaker has been implanted.
    A pacemaker requires regular checkups and monitoring, often by 
telephone, but the patient may, in fact, be asymptomatic. An evaluation 
of 10 percent rather than 30 percent is more appropriate for such 
cases, and we have added a minimum evaluation of 10 percent to the 
criteria under DC 7018. This is comparable to the assignment of 10 
percent for other cardiac conditions when continuous medication is 
required.
    One commenter suggested that we add a caveat under pacemaker 
implantation (DC 7018) that reimplantation or replacement of a 
pacemaker does not warrant a 100-percent evaluation.
    The total evaluation for two months following implantation of a 
pacemaker is to provide a period of recuperation from the surgery and 
any possible side-effects, as well as to provide a period to adjust the 
device itself and test the response of the individual's heart. These 
considerations apply as well to the replacement of a pacemaker, and, in 
our judgment, limiting convalescence evaluations to the initial 
implantation only is not warranted.
    We proposed to add a new diagnostic code (DC 7019) for cardiac 
transplantation allowing a total evaluation for an indefinite period 
following the transplant, with a mandatory VA examination to be 
conducted one year later. In the past, with no provision for cardiac 
transplantation in the rating schedule, a fixed period of convalescence 
evaluation for two years was assigned, analogous to what the rating 
schedule provided following renal transplant prior to the revisions to 
the genitourinary portion of the rating schedule published January 18, 
1994.
    One commenter stated that the total evaluation following cardiac 
transplantation (DC 7019) should continue for two years because the 
risk of rejection and survival data show that this is dangerous 
surgery.
    Because more than 85 percent of one-year survivors of a cardiac 
transplant have been rehabilitated and return to work or to school by 
the end of one year after transplant (Hurst, 2253-54), in our judgment, 
one year following hospital discharge is a reasonable time to conduct 
an examination in order to assess residual disability. As with other 
indefinite periods of convalescence evaluation, any change in 
evaluation based on the results of the examination will be implemented 
under the notice and effective date provisions of Sec. 3.105(e), which 
require VA to notify the claimant of any proposed reduction, once the 
examination has been carried out and reviewed, and allows 60 days for 
the claimant to provide additional evidence to show that a reduction 
should not be carried out.
    We proposed to evaluate cardiac transplantation (DC 7019) under the 
same criteria as arteriosclerotic heart disease (DC 7005), i.e., 
according to the level of activity that causes symptoms; we have, 
therefore, revised the criteria using the same objective measurements 
that we have adopted for evaluating arteriosclerotic heart disease. We 
proposed a minimum 30-percent evaluation following cardiac 
transplantation as long as the veteran is on immunosuppressive 
medication. Because almost every patient will permanently require 
immunosuppressive therapy following cardiac transplantation, we have 
simply made 30 percent the minimum evaluation and deleted the 
requirement that the veteran be taking immunosuppressive medication. 
This is consistent with the minimum evaluation for kidney transplant 
(DC 7531), which was published in the Federal Register of January 18, 
1994 (59 FR 2523).
    We also proposed to evaluate cardiomyopathy (DC 7020) under the 
same criteria as arteriosclerotic heart disease (DC 7005), i.e., 
according to the level of activity that causes symptoms;

[[Page 65215]]

we have, therefore, revised the criteria using the same objective 
measurements that we have adopted for evaluating arteriosclerotic heart 
disease.
    The previous schedule had a diagnostic code, DC 7100, for 
generalized arteriosclerosis, which we proposed to delete. One 
commenter objected, stating that this condition, which is often present 
in geriatric cases, produces total industrial incapacity with 
involutional changes such as cerebral ischemia with reduced mentation, 
bone and muscle atrophy, etc.
    The effects of generalized arteriosclerosis are so widespread that, 
in our judgment, a single diagnostic code is neither appropriate nor 
necessary. Many diagnostic codes, such as DC 7005, arteriosclerotic 
heart disease, DC 7114, arteriosclerosis obliterans, and DC 9305, 
multi-infarct dementia associated with cerebral arteriosclerosis, 
represent potential effects of arteriosclerosis on end organs, and 
evaluating each disability resulting from generalized arteriosclerosis 
under an appropriate code will result in more accurate assessments of 
the actual disabilities caused by the condition. We have, therefore, 
made no change based on this comment.
    Two commenters requested that we define the term hypertension (DC 
7101).
    In response to this comment, we have revised Note (1) under DC 7101 
to state that, for purposes of this section, hypertension means that 
the diastolic blood pressure is predominantly 90mm. or greater, and 
that isolated systolic hypertension means that the systolic blood 
pressure is predominantly 160mm. or greater with a diastolic blood 
pressure of less than 90mm. (Cecil, 253, based on the 1988 report of 
the Joint National Committee on Detection, Evaluation, and Treatment of 
High Blood Pressure).
    Since both essential hypertension and secondary types of 
hypertension, such as isolated systolic hypertension due to 
arteriosclerosis, may be evaluated under this diagnostic code, we have 
revised the title of DC 7101 from Hypertensive vascular disease 
(essential arterial hypertension) to Hypertensive vascular disease 
(hypertension and isolated systolic hypertension).
    In the previous schedule, Note (1) under DC 7101 (hypertensive 
vascular disease) stated that the 40- and 60-percent evaluations 
required careful attention to diagnosis and repeated blood pressure 
readings. We proposed to revise the note to state that careful and 
repeated measurements of blood pressure readings are required prior to 
the assignment of any compensable evaluation.
    Two commenters requested that we clarify the meaning of the note. 
Standard medical texts recommend multiple blood pressure readings for 
the diagnosis of hypertension, although the number of measurements 
recommended varies, with ``at least three sets over at least a three-
month interval'' (Braunwald, 818) and ``at least two measurements on 
two separate examinations'' (Harrison, 1001) among the specific 
recommendations. We have revised the note to require that hypertension 
be confirmed by readings taken two or more times on each of at least 
three different days. This will assure that the existence of 
hypertension is not conceded based solely on readings taken on a 
single, perhaps unrepresentative, day.
    In a note under DC 7101 (hypertensive vascular disease), the 
previous schedule established a minimum evaluation of ten percent when 
medication is necessary to control hypertension with a history of 
diastolic blood pressure predominantly 100 or more. We proposed to keep 
this note.
    One commenter asked if 10 percent should be assigned whenever 
continuous medication is required for any disorder; another asked if 
the assignment of 10 percent for hypertension should depend on the 
amount of medication required.
    In our judgment, it would not be appropriate to assign a ten-
percent evaluation for every condition which requires continuous 
treatment by medication. Whether a ten-percent evaluation is warranted 
when continuous medication is required is based on a case-by-case 
assessment of each condition and the usual effects of treatment. As to 
the second comment, the evaluation for hypertension is based not on the 
amount of medication required to control it, but on the level of 
control that can be achieved. While there may be more side effects with 
higher levels of medication or with combined antihypertensive 
medications, the disabling side effects of medication may be separately 
evaluated under the provisions of 38 CFR 3.310(a).
    Since the provision concerning the assignment of a minimum ten-
percent evaluation when there is a history of diastolic pressure 
predominantly 100 or more and continuous medication is required 
represents part of the evaluation criteria, we have included it in the 
criteria for a ten-percent evaluation, rather than in a separate note, 
as proposed.
    The previous schedule called for a 100-percent evaluation for 
aortic aneurysm (DC 7110) when there are markedly disabling symptoms 
and for one year following surgical correction. Because of a 
typographical error, omission of a semicolon, the proposed criteria as 
published implied that a total evaluation would be assigned following 
surgery only if the aneurysm had been 5 cm. or more in diameter. One 
commenter pointed out this error. We had intended to propose that 
veterans be evaluated as totally disabled under either of two 
circumstances: (1) If the aneurysm is 5 cm. or greater in diameter, or 
(2) for six months following resection of an aneurysm of any size. We 
have corrected the error in the final rule.
    In addition, to assure internal consistency, we have revised the 
criteria to allow a 100-percent evaluation under DC 7110 in an 
additional situation: when an aortic aneurysm is symptomatic. Under DC 
7111, aneurysm of any large artery is evaluated at 100 percent if it is 
symptomatic. Since the aorta is the largest artery in the body, it 
would be inconsistent and inequitable not to allow the same evaluation 
that the schedule provides for symptomatic aneurysms of other large 
arteries.
    The previous schedule assigned a minimum 20-percent evaluation 
following surgical correction of aortic aneurysm (DC 7110). We proposed 
to evaluate residuals following surgical correction on actual residual 
disability, according to the organ system affected, in lieu of 
assigning a minimum evaluation. A commenter recommended that we retain 
the 20-percent minimum evaluation following surgery, contending that 
after such surgery individuals lead a tenuous and extremely sedentary 
existence, often requiring revision of the graft.
    There is a wide range of possible complications and residual 
disability following surgical correction of an aortic aneurysm, 
depending on such factors as the location of the aneurysm, its type 
(dissecting or not), etc. Because some would warrant a higher, and some 
a lower, evaluation than 20 percent, in our judgment it is preferable 
to evaluate the actual residuals rather than provide a minimum 
evaluation, and we have made no change based on this comment.
    We proposed to eliminate the fixed one-year period of convalescence 
evaluation following surgical correction of an aortic aneurysm (DC 
7110) in favor of a 100-percent evaluation for an indefinite period 
from the date of admission for surgical correction, with a mandatory VA 
examination six months following discharge, and with any change in 
evaluation subject to the notice and effective date provisions of

[[Page 65216]]

Sec. 3.105(e). One commenter urged that we retain the one-year 
convalescence evaluation, but gave no specific reasons. We also 
proposed an indefinite total evaluation following repair of an aneurysm 
of a large artery (DC 7111) although the previous schedule had provided 
no post-surgical total evaluation. One commenter suggested that a one-
year period of convalescence evaluation would be appropriate following 
repair of an aneurysm of a large artery because, as after aortic 
aneurysm repair, these patients lead a tenuous and sedentary existence 
after surgery.
    The period of total evaluation following surgery under DCs 7110 and 
7111 will continue indefinitely under the revised schedule, and an 
examination six months following the date of admission for surgical 
correction will determine whether a change in evaluation is warranted, 
based on actual residuals documented at that time. Since any change 
will be implemented under the notice and effective date provisions of 
Sec. 3.105 (e), the veteran will have the opportunity to present 
medical evidence if he or she disagrees with the proposed change in 
evaluation. These provisions assure an evaluation that reflects the 
actual disability as documented by medical examination, and we have 
made no change based on these comments.
    The previous schedule assigned a 10-percent evaluation for aneurysm 
of any small artery (DC 7112); we proposed that such an aneurysm be 
assigned a zero-percent evaluation. One commenter stated that the 
proposed change is based on empirical, as opposed to statistical, 
evidence and that evaluations that have stood the test of time should 
not be routinely reduced or discontinued.
    Small artery aneurysms may produce symptoms such as headaches or 
visual abnormalities due to local pressure effects, and an aneurysm 
that ruptures may result in a wide variety of symptoms. However, small 
artery aneurysms that are asymptomatic are found in about five percent 
of the population (Cecil, 2165). Because of the wide range of possible 
disabling effects, it is appropriate to rate each one on the actual 
findings rather than provide a 10-percent evaluation in all cases. In 
our judgment, an asymptomatic aneurysm of a small artery has no 
disabling effects and does not warrant a compensable evaluation.
    Another commenter asked where and how to rate cerebral aneurysms. 
Aneurysms of cerebral arteries are evaluated under DC 7112, as are all 
other aneurysms of small arteries. We have made no change in response 
to this comment.
    The previous schedule specified a minimum evaluation of 60 percent 
for traumatic arteriovenous aneurysm (DC 7113) when there is cardiac 
involvement, and we proposed no change. One commenter, noting that 
designating a minimum evaluation implied that a higher one could be 
assigned, asked what findings would warrant an evaluation higher than 
60 percent, since 60 percent was also the highest evaluation under DC 
7113.
    The most serious potential consequence of arteriovenous aneurysm is 
congestive heart failure due to high output, which would warrant a 100-
percent evaluation. We have, therefore, added a 100-percent evaluation, 
to be assigned if there is high output heart failure.
    In response to the request for more objective criteria, we have 
revised the criteria for a 60-percent evaluation under DC 7113 to 
require an enlarged heart, wide pulse pressure, and tachycardia rather 
than the ambiguous term ``cardiac involvement'' that we had proposed. 
We have revised the criteria for the 50-percent level for lower 
extremity involvement or the 40-percent level for upper extremity 
involvement, which were proposed as ``without cardiac involvement with 
marked vascular symptoms,'' to require edema, stasis dermatitis, and 
either ulceration or cellulitis. We have revised the criteria for the 
30-percent level for lower extremity involvement or the 20-percent 
level for upper extremity involvement, which were proposed as ``with 
definite vascular symptoms,'' to require edema or stasis dermatitis. 
These are not substantive changes, but more specific designations of 
the cardiac and vascular signs that warrant these evaluations. We have 
also revised the title of DC 7113 from ``arteriovenous aneurysm, 
traumatic'' to ``arteriovenous fistula, traumatic,'' the currently 
accepted term for the condition, which is a direct communication 
between an artery and a vein.
    One commenter requested that we add a paragraph under 
arteriosclerosis obliterans (DC 7114) addressing the evaluation of 
aorto-femoral bypass grafts.
    To assure consistent evaluations of the residuals of aortic and 
large arterial bypass surgery, we have added a note under DC 7114 
stating that the residuals of aortic and large arterial bypass surgery 
or arterial grafts are to be rated under that code. Since the most 
common residuals of bypass surgery are signs and symptoms of arterial 
insufficiency, it is appropriate to evaluate them under the criteria 
for arteriosclerosis obliterans.
    Two commenters suggested we provide a specific period of 
convalescence evaluation following bypass surgery for aortoiliac and 
femoral-popliteal artery disease.
    The evaluation criteria for serious complications that might result 
from bypass surgery and, therefore, be service-connected under the 
provisions of 38 CFR 3.310(a), such as myocardial infarction, have 
their own periods of convalescence evaluation. For the milder 
complications, or the uncomplicated cases, the standard periods of 
convalescence evaluation authorized under Sec. 4.30 of this part are 
adequate, and we have made no change based on these comments.
    The criterion for the 40-percent evaluation for arteriosclerosis 
obliterans (DC 7114) in the previous schedule was ``well-established 
cases with intermittent claudication or recurrent episodes of 
superficial phlebitis;'' we proposed to revise this criterion to 
``well-established cases of intermittent claudication with associated 
physical findings (hair loss, skin changes).'' We proposed for the 100-
percent level: ``severe, with marked physical signs producing total 
incapacity''; for the 60-percent level: ``claudication on minimal 
walking (less than three miles per hour on a level grade) with 
persistent coldness of the extremity''; and for the 20-percent level: 
``minimal circulatory impairment, with paresthesias, temperature 
changes and occasional claudication.'' One commenter noted that the 
phrase ``well-established cases'' is one of the vague, indefinite, and 
arbitrary elements in the schedule.
    In response to both that comment and the requests for more 
objective criteria, we have revised the criteria under this diagnostic 
code: To specify at each evaluation level the distance that can be 
covered before claudication occurs; and to base evaluations on 
objective physical findings, such as peripheral pulses, trophic 
changes, persistent coldness, and deep ischemic ulcers. We have also 
added an objective alternative criterion, the ankle/brachial index, at 
each level, and a note explaining that this index is obtained by 
dividing the systolic blood pressure at the ankle by the systolic blood 
pressure in the arm. The ratio is normally one or greater; but because 
arterial occlusive disease obstructs the blood flow in the legs, the 
ratio in patients with that condition is less than one. A ratio of less 
than 0.5 is consistent with severe ischemia (Harrison, 1019). The 
ankle/brachial index thus allows a noninvasive

[[Page 65217]]

objective assessment of the severity of peripheral vascular disease.
    We proposed to evaluate Raynaud's syndrome (DC 7117) as 100-
percent, 60-percent, 40-percent, or 20-percent disabling, using 
measures such as ``marked'' circulatory changes, ``multiple'' ulcerated 
areas, ``frequent'' vasomotor disturbances, and ``occasional'' attacks 
of blanching or flushing. One commenter suggested that we replace 
subjective terms with more objective requirements.
    Simply replacing the indefinite words would not result in truly 
objective criteria. We have, therefore, defined ``characteristic 
attacks'' of Raynaud's disease for VA purposes as consisting of 
sequential color changes of the digits lasting minutes to hours, 
sometimes with pain and paresthesias, and precipitated by exposure to 
cold or by emotional upsets. We have revised the evaluation criteria 
based on the frequency of characteristic attacks, the number of digital 
ulcers, and whether autoamputation in one or more digits has occurred. 
While we proposed no change in the former 20-percent level, which 
required ``occasional attacks of blanching or flushing,'' under the 
more objective criteria we have provided both a 20- and a 10-percent 
level, with 20-percent requiring characteristic attacks four to six 
times a week, and 10-percent requiring characteristic attacks one to 
three times a week. This will ensure more consistent evaluations in 
milder cases of Raynaud's, where, in the former schedule, the 
assignment of zero percent or 20 percent depended on an individual 
rater's interpretation of ``occasional.''
    One commenter suggested that we include neurologic symptoms 
associated with exposure to low or subfreezing temperatures under the 
evaluation criteria for DC 7117.
    In response to this comment, we have included pain and 
paresthesias, which are neurologic symptoms, among the possible 
manifestations of the characteristic attacks of Raynaud's syndrome.
    We proposed to assign 40-percent, 20-percent, and zero-percent 
evaluations for angioneurotic edema (DC 7118), based generally on the 
frequency, severity, and duration of attacks. One commenter recommended 
that we add a 10-percent evaluation; another recommended that we 
replace language such as ``frequent'' and ``infrequent'' with more 
definite terms.
    Angioneurotic edema is a condition that is ordinarily self-limited, 
with attacks subsiding in one to seven days (Merck, 333), but at times 
palliative treatment is used. There are also unusual types that are 
more persistent and resistant to therapy. We have established more 
objective criteria based on the typical duration of attacks, their 
frequency, and on whether there is laryngeal involvement. We have added 
a 10-percent evaluation, to be assigned if attacks without laryngeal 
involvement occur two to four times a year. These criteria will foster 
more consistent evaluations for angioneurotic edema, since different 
raters will not be required to interpret subjective terms such as 
``mild,'' ``moderate,'' ``frequent,'' and ``infrequent.''
    One commenter suggested that when angioneurotic edema affects the 
larynx even briefly, a 10-percent evaluation is warranted.
    In our judgment, angioneurotic edema affecting the larynx does 
warrant separate consideration in the evaluation criteria because 
laryngeal edema commonly causes respiratory distress due to airway 
obstruction and requires emergency treatment. This situation is serious 
enough that if it occurs once or twice a year, it warrants a 20-percent 
evaluation; if it occurs more than twice a year, it warrants a 40-
percent evaluation.
    A second commenter objected that the proposed changes to DC 7118 
were based on empirical, as opposed to statistical, information.
    As noted under the response to comments about DC 7122, 38 U.S.C. 
1155 gives the Secretary the authority to revise the rating schedule 
periodically in accordance with experience. The revisions of these 
criteria are based on the usual effects of the disease, which is 
consistent with the basis of revisions throughout the current 
comprehensive revision of the rating schedule. They are medically, 
rather than statistically, based, and no statistical studies were done 
in conjunction with the revision.
    Under the previous schedule, there were a variety of methods used 
to evaluate vascular diseases affecting the extremities, particularly 
when more than one extremity was affected. For example, the criteria 
for thrombophlebitis (DC 7121) applied to a single extremity, and if 
other extremities were affected, they were separately evaluated. For 
varicose veins (DC 7120), the criteria for a 10-percent evaluation 
applied to either unilateral or bilateral involvement; but at other 
evaluation levels, different percentages were assigned for unilateral 
and bilateral involvement, with no direction for evaluation if one 
extremity were more severely affected than the other. The criteria for 
intermittent claudication (DC 7116) applied to a single extremity; 
determining the evaluation for multiple extremities required 
application of a complex set of rules (contained in a note following DC 
7117) that sometimes produced an evaluation for involvement of multiple 
extremities no higher than that for involvement of a single extremity. 
We proposed no substantive change in either the methods of evaluating 
these conditions or in the percentage levels.
    One commenter questioned why the percentage evaluations and the 
method of determining the evaluation when more than one extremity is 
affected differ for arterial and venous diseases. He suggested that we 
use 20-, 40,-and 60-percent levels for both peripheral arterial 
diseases (DCs 7114 through 7117), and venous diseases (DCs 7120 and 
7121) instead of the variety of levels proposed, and that we adopt a 
uniform and simple method of determining evaluations when more than one 
extremity is involved, such as adding ten percent for each additional 
extremity involved.
    We proposed evaluations levels of 20, 40, 60, and 100 percent for 
DCs 7114, 7115, and 7117, and we have kept those levels in this rule, 
with the addition of a 10-percent level for DC 7117. (We removed DC 
7116, ``intermittent claudication,'' which was in the previous 
schedule, because it was a symptom of disease rather than a disease.) 
In response to the comment, we have further revised DCs 7120 (varicose 
veins) and 7121 (post-phlebitic syndrome of any etiology) to provide 
percentage evaluation levels of 10, 20, 40, 60, and 100 percent. In 
addition, we have revised the method of evaluating DCs 7114 
(arteriosclerosis obliterans), 7115 (thromboangiitis obliterans), and 
7120 (varicose veins) so that the criteria apply to a single extremity, 
as the criteria for DC 7121 do. If the paired extremity is also 
affected, the evaluation for each extremity will be separately 
determined and combined using the combined ratings table (see 38 CFR 
4.25) and the bilateral factor (see 38 CFR 4.26) when applicable. 
Section 4.26 also provides instructions on applying the bilateral 
factor when there is involvement of upper and lower extremities. While 
we have made the percentage levels similar, the signs, symptoms, and 
effects of venous and arterial diseases differ greatly and, therefore, 
require different evaluation criteria.
    In order to adopt the more consistent method of separately 
evaluating each extremity affected by vascular disease and to assure 
that venous conditions with similar findings receive consistent 
evaluations, further revisions of the evaluation criteria for varicose 
veins

[[Page 65218]]

(DC 7120) and post-phlebitic syndrome of any etiology (DC 7121) were 
required.
    Varicose veins are ordinarily asymptomatic or mildly symptomatic, 
but may produce prolonged venous insufficiency and progress to 
thrombophlebitis and postphlebitic syndrome. Signs of venous 
insufficiency, such as edema, stasis pigmentation, ulceration, eczema, 
and induration, and symptoms such as aching and fatigue, are the major 
disabling effects of varicose veins. The size, location, extent, etc., 
of varicose veins do not correlate with symptoms (Merck, 590), and we 
have removed those criteria as factors in evaluation. The presence or 
absence of impairment of the deep circulation is more an indicator of 
the feasibility of surgical repair than of functional impairment, and 
we have, therefore, removed references to the deep circulation from the 
evaluation criteria. We have replaced these criteria with criteria 
based on symptoms (such as aching and fatigue after prolonged standing 
or walking) or objective physical findings (such as edema, stasis 
pigmentation, eczema, or ulceration).
    The effects of chronic venous insufficiency are the same, whether 
from varicosities, thrombophlebitis, or some other cause. The 
postphlebitic syndrome may itself lead to the development of 
varicosities because of chronic venous insufficiency (Cecil, 363-7). 
Therefore, the possible manifestations and disabling effects of 
varicose veins and postphlebitic syndrome are very similar, and we have 
used the same criteria to evaluate both conditions, with evaluation 
levels of 0, 10, 20, 40, 60, and 100 percent for involvement of a 
single extremity, and the same method of evaluation for multiple 
extremity involvement as that used in arterial vascular disease of the 
extremities.
    We added under DC 7120: ``With the following findings attributed to 
the effects of varicose veins,'' and under DC 7121: ``With the 
following findings attributed to venous disease'' in order to assure 
that the examiner has determined that the abnormal findings are 
attributed to venous disease.
    One commenter suggested that we clarify how to assign bilateral 
evaluations for frozen feet (DC 7122) and varicose veins (DC 7120) when 
one extremity is more severely affected than the other.
    The changes described above that we have made in the evaluation 
criteria, evaluation percentages, and method of determining an 
evaluation for multiple extremity involvement will allow accurate and 
consistent evaluations when more than one extremity is affected by 
varicose veins, but to different degrees. We have made similar changes 
in the method of evaluating cold injury, DC 7122, in order to assure 
accurate and consistent evaluations when there is multiple extremity 
involvement, and this is further discussed below.
    We proposed no change in the previous evaluation criteria for 
frozen feet (DC 7122). One commenter suggested that we expand the 
criteria to include cold injuries to the hands, face, and ears; another 
suggested that higher ratings may be warranted for loss of use of 
multiple fingers or one or both hands.
    We have revised the title of DC 7122 from ``frozen feet, residuals 
of'' to ``cold injury, residuals of'' to indicate that it may be used 
to evaluate any cold injury. Because cold injury produces similar 
tissue changes wherever it occurs, a single diagnostic code and set of 
evaluation criteria are adequate; we have, however, revised the 
criteria to more accurately reflect the range of effects that cold 
injury may produce, such as arthralgia, tissue loss, nail 
abnormalities, and color changes. We have also deleted the bilateral 
evaluations contained in the prior schedule in favor of evaluating each 
affected part separately and combining them for the overall evaluation 
for cold injury, a change which is similar to changes we have made in 
the method of evaluating peripheral arterial and venous diseases of the 
extremities. In the case of paired extremities, the evaluations will be 
combined, if appropriate, in accordance with Secs. 4.25 and 4.26 (as 
described in Note (2), added following DC 7122).
    The proposed note following DC 7122 directed that higher ratings 
could be assigned, if warranted, because of loss of toes, by reference 
to amputation ratings. We have edited this Note (1) for clarity and 
added a statement about the evaluation of complications such as 
peripheral neuropathy or squamous cell carcinoma of the skin at the 
site of a scar.
    One commenter requested that we include neurologic symptoms 
associated with exposure to low or subfreezing temperatures in the 
evaluation criteria for DC 7122, cold injuries.
    In response to this suggestion, we have added numbness or locally 
impaired sensation, which are neurologic symptoms, to the evaluation 
criteria.
    One individual suggested that cold injuries of the hands are 
generally more disabling than those of the lower extremities.
    The severity of cold injuries to various parts of the body depends 
on such factors as the extent and duration of exposure, more than on 
the particular part affected. We have provided evaluation criteria 
that, applied with the notes regarding amputations and complications, 
are flexible enough to cover a broad range of severity and allow 
evaluation of any extent of tissue damage from cold injury to any body 
part, so we have not adopted any changes based on this comment.
    The current schedule provides six months of convalescence 
evaluation for soft tissue sarcoma of vascular origin (DC 7123). We 
proposed that a total evaluation be assigned indefinitely, with a 
mandatory VA examination to be conducted six months following the 
completion of therapy. One commenter recommended that we allow one year 
of convalescence evaluation.
    We believe that an examination six months following the cessation 
of treatment affords sufficient time for convalescence and 
stabilization of residuals, particularly since the rule requires only 
an examination, not a reduction, at that time. In our judgment, this 
method of determining the length of the total evaluation is both fairer 
and more accurate than assigning a total evaluation for a specified 
length of time, since the evaluation will be based on actual residual 
disability as documented by the examination, and the veteran will 
receive advance notice of any change and have the opportunity to submit 
additional evidence showing that the change is not warranted.
    Two commenters requested that VA provide a zero-percent evaluation 
for all diagnostic codes.
    On October 6, 1993, VA revised its regulation addressing the issue 
zero-percent evaluations (38 CFR 4.31) to authorize assignment of a 
zero-percent evaluation for any disability in the rating schedule when 
minimum requirements for a compensable evaluation are not met. In 
general, that regulatory provision precludes the need for zero-percent 
evaluation criteria.
    On further review, we have revised the title of DC 7121 from 
``phlebitis or thrombophlebitis'' to ``post-phlebitic syndrome of any 
etiology'' because both superficial and deep acute thrombophlebitis are 
transient conditions, but it is the chronic form of thrombophlebitis 
with venous insufficiency, known as ``postphlebitic leg,'' 
``postphlebitic sequelae of chronic venous insufficiency,'' 
``postphlebitic syndrome,'' or ``stasis syndrome,'' that may follow 
thrombophlebitis. This is not a substantive change.

[[Page 65219]]

    For the sake of clarity, we have made nonsubstantive changes in the 
notes under ventricular arrhythmias (DC 7011), heart valve replacement 
(DC 7016), cardiac transplantation (DC 7019), aortic aneurysm (DC 
7110), aneurysm, any large artery (DC 7111), and soft tissue sarcoma 
(DC 7123).
    VA appreciates the comments submitted in response to the proposed 
rule, which is now adopted with the amendments noted above.
    The Secretary hereby certifies that this regulatory amendment will 
not have a significant economic impact on a substantial number of small 
entities as they are defined in the Regulatory Flexibility Act (RFA), 5 
U.S.C. 601-612. The reason for this certification is that this 
amendment would not directly affect any small entities. Only VA 
beneficiaries could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604.
    This regulatory amendment has been reviewed by the Office of 
Management and Budget under the provisions of Executive Order 12866, 
Regulatory Planning and Review, dated September 30, 1993.

The Catalog of Federal Domestic Assistance program numbers are 
64.104 and 64.109.

List of Subjects in 38 CFR Part 4

    Disability benefits, Individuals with disabilities, Pensions, 
Veterans.

    Approved: August 7, 1997.
Hershel W. Gober,
Acting Secretary of Veterans Affairs.

    For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
is amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority: 38 U.S.C. 1155, unless otherwise noted.

Subpart B--Disability Ratings


Secs. 4.100 through 4.102  [Removed and Reserved]

    2. Sections 4.100, 4.101, 4.102 are removed and reserved.
    3. Section 4.104 is revised to read as follows:


Sec. 4.104  Schedule of ratings--cardiovascular system.

Diseases of the Heart

Note (1): Evaluate cor pulmonale, which is a form of secondary heart 
disease, as part of the pulmonary condition that causes it.
Note (2): One MET (metabolic equivalent) is the energy cost of 
standing quietly at rest and represents an oxygen uptake of 3.5 
milliliters per kilogram of body weight per minute. When the level 
of METs at which dyspnea, fatigue, angina, dizziness, or syncope 
develops is required for evaluation, and a laboratory determination 
of METs by exercise testing cannot be done for medical reasons, an 
estimation by a medical examiner of the level of activity (expressed 
in METs and supported by specific examples, such as slow stair 
climbing or shoveling snow) that results in dyspnea, fatigue, 
angina, dizziness, or syncope may be used.

------------------------------------------------------------------------
                                                                Rating  
------------------------------------------------------------------------
7000  Valvular heart disease (including rheumatic heart                 
 disease):                                                              
    During active infection with valvular heart damage and              
     for three months following cessation of therapy for                
     the active infection..................................          100
    Thereafter, with valvular heart disease (documented by              
     findings on physical examination and either                        
     echocardiogram, Doppler echocardiogram, or cardiac                 
     catheterization) resulting in:                                     
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electro-cardiogram, echocardiogram, or X-            
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7001  Endocarditis:                                                     
    For three months following cessation of therapy for                 
     active infection with cardiac involvement.............          100
    Thereafter, with endocarditis (documented by findings               
     on physical examination and either echocardiogram,                 
     Doppler echocardiogram, or cardiac catheterization)                
     resulting in:                                                      
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7002  Pericarditis:                                                     
    For three months following cessation of therapy for                 
     active infection with cardiac involvement.............          100
    Thereafter, with documented pericarditis resulting in:              
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electro-cardiogram, echocardiogram, or X-            
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10

[[Page 65220]]

                                                                        
7003  Pericardial adhesions:                                            
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electro-cardiogram, echocardiogram, or X-            
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7004  Syphilitic heart disease:                                         
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
                                                                        
Note: Evaluate syphilitic aortic aneurysms under DC 7110                
 (aortic aneurysm).                                                     
                                                                        
7005  Arteriosclerotic heart disease (Coronary artery                   
 disease):                                                              
    With documented coronary artery disease resulting in:               
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
                                                                        
Note: If nonservice-connected arteriosclerotic heart                    
 disease is superimposed on service-connected valvular or               
 other non-arteriosclerotic heart disease, request a                    
 medical opinion as to which condition is causing the                   
 current signs and symptoms.                                            
                                                                        
7006  Myocardial infarction:                                            
    During and for three months following myocardial                    
     infarction, documented by laboratory tests............          100
    Thereafter:                                                         
                                                                        
    With history of documented myocardial infarction,                   
     resulting in:                                                      
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7007  Hypertensive heart disease:                                       
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7008  Hyperthyroid heart disease:                                       
    Include as part of the overall evaluation for                       
     hyperthyroidism under DC 7900. However, when atrial                
     fibrillation is present, hyperthyroidism may be                    
     evaluated either under DC 7900 or under DC 7010                    
     (supraventricular arrhythmia), whichever results in a              
     higher evaluation.                                                 
7010  Supraventricular arrhythmias:                                     
    Paroxysmal atrial fibrillation or other                             
     supraventricular tachycardia, with more than four                  
     episodes per year documented by ECG or Holter monitor.           30
    Permanent atrial fibrillation (lone atrial                          
     fibrillation), or; one to four episodes per year of                
     paroxysmal atrial fibrillation or other                            
     supraventricular tachycardia documented by ECG or                  
     Holter monitor........................................           10
7011  Ventricular arrhythmias (sustained):                              
    For indefinite period from date of hospital admission               
     for initial evaluation and medical therapy for a                   
     sustained ventricular arrhythmia, or; for indefinite               
     period from date of hospital admission for ventricular             
     aneurysmectomy, or; with an automatic implantable                  
     Cardioverter-Defibrillator (AICD) in place............          100
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100

[[Page 65221]]

                                                                        
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
                                                                        
  Note: A rating of 100 percent shall be assigned from the              
   date of hospital admission for initial evaluation and                
 medical therapy for a sustained ventricular arrhythmia or              
    for ventricular aneurysmectomy. Six months following                
   discharge, the appropriate disability rating shall be                
   determined by mandatory VA examination. Any change in                
  evaluation based upon that or any subsequent examination              
  shall be subject to the provisions of Sec.  3.105(e) of               
                       this chapter.                                    
                                                                        
7015  Atrioventricular block:                                           
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication or a pacemaker               
     required..............................................           10
                                                                        
Note: Unusual cases of arrhythmia such as atrioventricular              
 block associated with a supraventricular arrhythmia or                 
 pathological bradycardia should be submitted to the                    
 Director, Compensation and Pension Service. Simple delayed             
 P-R conduction time, in the absence of other evidence of               
 cardiac disease, is not a disability.                                  
                                                                        
7016  Heart valve replacement (prosthesis):                             
    For indefinite period following date of hospital                    
     admission for valve replacement.......................          100
    Thereafter:                                                         
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
                                                                        
Note: A rating of 100 percent shall be assigned as of the               
 date of hospital admission for valve replacement. Six                  
 months following discharge, the appropriate disability                 
 rating shall be determined by mandatory VA examination.                
 Any change in evaluation based upon that or any subsequent             
 examination shall be subject to the provisions of Sec.                 
 3.105(e) of this chapter.                                              
                                                                        
7017  Coronary bypass surgery:                                          
    For three months following hospital admission for                   
     surgery...............................................          100
    Thereafter:                                                         
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload greater than 7 METs but not greater than 10                
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
7018  Implantable cardiac pacemakers:                                   
    For two months following hospital admission for                     
     implantation or reimplantation........................          100
    Thereafter:                                                         
    Evaluate as supraventricular arrhythmias (DC 7010),                 
     ventricular arrhythmias (DC 7011), or atrioventricular             
     block (DC 7015). Minimum..............................           10
                                                                        
Note: Evaluate implantable Cardioverter-Defibrillators                  
 (AICD's) under DC 7011.                                                
                                                                        
7019  Cardiac transplantation:                                          
    For an indefinite period from date of hospital                      
     admission for cardiac transplantation.................          100
    Thereafter:                                                         
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
        Minimum............................................           30
                                                                        
Note: A rating of 100 percent shall be assigned as of the               
 date of hospital admission for cardiac transplantation.                
 One year following discharge, the appropriate disability               
 rating shall be determined by mandatory VA examination.                
 Any change in evaluation based upon that or any subsequent             
 examination shall be subject to the provisions of Sec.                 
 3.105(e) of this chapter.                                              
                                                                        
7020  Cardiomyopathy:                                                   

[[Page 65222]]

                                                                        
    Chronic congestive heart failure, or; workload of 3                 
     METs or less results in dyspnea, fatigue, angina,                  
     dizziness, or syncope, or; left ventricular                        
     dysfunction with an ejection fraction of less than 30              
     percent...............................................          100
    More than one episode of acute congestive heart failure             
     in the past year, or; workload of greater than 3 METs              
     but not greater than 5 METs results in dyspnea,                    
     fatigue, angina, dizziness, or syncope, or; left                   
     ventricular dysfunction with an ejection fraction of               
     30 to 50 percent......................................           60
    Workload of greater than 5 METs but not greater than 7              
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; evidence of cardiac hypertrophy or                 
     dilatation on electrocardiogram, echocardiogram, or X-             
     ray...................................................           30
    Workload of greater than 7 METs but not greater than 10             
     METs results in dyspnea, fatigue, angina, dizziness,               
     or syncope, or; continuous medication required........           10
Diseases of the Arteries and Veins                                      
7101  Hypertensive vascular disease (hypertension and                   
 isolated systolic hypertension):                                       
    Diastolic pressure predominantly 130 or more...........           60
    Diastolic pressure predominantly 120 or more...........           40
    Diastolic pressure predominantly 110 or more, or;                   
     systolic pressure predominantly 200 or more...........           20
    Diastolic pressure predominantly 100 or more, or;                   
     systolic pressure predominantly 160 or more, or;                   
     minimum evaluation for an individual with a history of             
     diastolic pressure predominantly 100 or more who                   
     requires continuous medication for control............           10
                                                                        
Note (1): Hypertension or isolated systolic hypertension                
 must be confirmed by readings taken two or more times on               
 at least three different days. For purposes of this                    
 section, the term hypertension means that the diastolic                
 blood pressure is predominantly 90mm. or greater, and                  
 isolated systolic hypertension means that the systolic                 
 blood pressure is predominantly 160mm. or greater with a               
 diastolic blood pressure of less than 90mm.                            
Note (2): Evaluate hypertension due to aortic insufficiency             
 or hyperthyroidism, which is usually the isolated systolic             
 type, as part of the condition causing it rather than by a             
 separate evaluation.                                                   
                                                                        
7110  Aortic aneurysm:                                                  
    If five centimeters or larger in diameter, or; if                   
     symptomatic, or; for indefinite period from date of                
     hospital admission for surgical correction (including              
     any type of graft insertion)..........................          100
    Precluding exertion....................................           60
    Evaluate residuals of surgical correction according to              
     organ systems affected.                                            
                                                                        
Note: A rating of 100 percent shall be assigned as of the               
 date of admission for surgical correction. Six months                  
 following discharge, the appropriate disability rating                 
 shall be determined by mandatory VA examination. Any                   
 change in evaluation based upon that or any subsequent                 
 examination shall be subject to the provisions of Sec.                 
 3.105(e) of this chapter.                                              
                                                                        
7111  Aneurysm, any large artery:                                       
    If symptomatic, or; for indefinite period from date of              
     hospital admission for surgical correction............          100
    Following surgery:                                                  
    Ischemic limb pain at rest, and; either deep ischemic               
     ulcers or ankle/brachial index of 0.4 or less.........          100
    Claudication on walking less than 25 yards on a level               
     grade at 2 miles per hour, and; persistent coldness of             
     the extremity, one or more deep ischemic ulcers, or                
     ankle/brachial index of 0.5 or less...................           60
    Claudication on walking between 25 and 100 yards on a               
     level grade at 2 miles per hour, and; trophic changes              
     (thin skin, absence of hair, dystrophic nails) or                  
     ankle/brachial index of 0.7 or less...................           40
    Claudication on walking more than 100 yards, and;                   
     diminished peripheral pulses or ankle/brachial index               
     of 0.9 or less........................................           20
Note (1): The ankle/brachial index is the ratio of the                  
 systolic blood pressure at the ankle (determined by                    
 Doppler study) divided by the simultaneous brachial artery             
 systolic blood pressure. The normal index is 1.0 or                    
 greater.                                                               
Note (2): These evaluations are for involvement of a single             
 extremity. If more than one extremity is affected,                     
 evaluate each extremity separately and combine (under Sec.             
  4.25), using the bilateral factor, if applicable.                     
Note (3): A rating of 100 percent shall be assigned as of               
 the date of hospital admission for surgical correction.                
 Six months following discharge, the appropriate disability             
 rating shall be determined by mandatory VA examination.                
 Any change in evaluation based upon that or any subsequent             
 examination shall be subject to the provisions of Sec.                 
 3.105(e) of this chapter.                                              
                                                                        
7112  Aneurysm, any small artery:                                       
    Asymptomatic...........................................            0
                                                                        
Note: If symptomatic, evaluate according to body system                 
 affected. Following surgery, evaluate residuals under the              
 body system affected.                                                  
                                                                        
7113  Arteriovenous fistula, traumatic:                                 
    With high output heart failure.........................          100
    Without heart failure but with enlarged heart, wide                 
     pulse pressure, and tachycardia.......................           60
    Without cardiac involvement but with edema, stasis                  
     dermatitis, and either ulceration or cellulitis:                   
        Lower extremity....................................           50
        Upper extremity....................................           40
    With edema or stasis dermatitis:                                    
        Lower extremity....................................           30
        Upper extremity....................................           20
7114  Arteriosclerosis obliterans:                                      
    Ischemic limb pain at rest, and; either deep ischemic               
     ulcers or ankle/brachial index of 0.4 or less.........          100
    Claudication on walking less than 25 yards on a level               
     grade at 2 miles per hour, and; either persistent                  
     coldness of the extremity or ankle/brachial index of               
     0.5 or less...........................................           60
    Claudication on walking between 25 and 100 yards on a               
     level grade at 2 miles per hour, and; trophic changes              
     (thin skin, absence of hair, dystrophic nails) or                  
     ankle/brachial index of 0.7 or less...................           40
    Claudication on walking more than 100 yards, and;                   
     diminished peripheral pulses or ankle/brachial index               
     of 0.9 or less........................................           20
                                                                        
Note (1): The ankle/brachial index is the ratio of the                  
 systolic blood pressure at the ankle (determined by                    
 Doppler study) divided by the simultaneous brachial artery             
 systolic blood pressure. The normal index is 1.0 or                    
 greater.                                                               
Note (2): Evaluate residuals of aortic and large arterial               
 bypass surgery or arterial graft as arteriosclerosis                   
 obliterans.                                                            
Note (3): These evaluations are for involvement of a single             
 extremity. If more than one extremity is affected,                     
 evaluate each extremity separately and combine (under Sec.             
  4.25), using the bilateral factor (Sec.  4.26), if                    
 applicable.                                                            
                                                                        

[[Page 65223]]

                                                                        
7115  Thrombo-angiitis obliterans (Buerger's Disease):                  
    Ischemic limb pain at rest, and; either deep ischemic               
     ulcers or ankle/brachial index of 0.4 or less.........          100
    Claudication on walking less than 25 yards on a level               
     grade at 2 miles per hour, and; either persistent                  
     coldness of the extremity or ankle/brachial index of               
     0.5 or less...........................................           60
    Claudication on walking between 25 and 100 yards on a               
     level grade at 2 miles per hour, and; trophic changes              
     (thin skin, absence of hair, dystrophic nails) or                  
     ankle/brachial index of 0.7 or less...................           40
    Claudication on walking more than 100 yards, and;                   
     diminished peripheral pulses or ankle/brachial index               
     of 0.9 or less........................................           20
                                                                        
Note (1): The ankle/brachial index is the ratio of the                  
 systolic blood pressure at the ankle (determined by                    
 Doppler study) divided by the simultaneous brachial artery             
 systolic blood pressure. The normal index is 1.0 or                    
 greater.                                                               
Note (2): These evaluations are for involvement of a single             
 extremity. If more than one extremity is affected,                     
 evaluate each extremity separately and combine (under Sec.             
  4.25), using the bilateral factor (Sec.  4.26), if                    
 applicable.                                                            
                                                                        
7117  Raynaud's syndrome:                                               
    With two or more digital ulcers plus autoamputation of              
     one or more digits and history of characteristic                   
     attacks...............................................          100
    With two or more digital ulcers and history of                      
     characteristic attacks................................           60
    Characteristic attacks occurring at least daily........           40
    Characteristic attacks occurring four to six times a                
     week..................................................           20
    Characteristic attacks occurring one to three times a               
     week..................................................           10
Note: For purposes of this section, characteristic attacks              
 consist of sequential color changes of the digits of one               
 or more extremities lasting minutes to hours, sometimes                
 with pain and paresthesias, and precipitated by exposure               
 to cold or by emotional upsets. These evaluations are for              
 the disease as a whole, regardless of the number of                    
 extremities involved or whether the nose and ears are                  
 involved.                                                              
                                                                        
7118  Angioneurotic edema:                                              
    Attacks without laryngeal involvement lasting one to                
     seven days or longer and occurring more than eight                 
     times a year, or; attacks with laryngeal involvement               
     of any duration occurring more than twice a year......           40
    Attacks without laryngeal involvement lasting one to                
     seven days and occurring five to eight times a year,               
     or; attacks with laryngeal involvement of any duration             
     occurring once or twice a year........................           20
    Attacks without laryngeal involvement lasting one to                
     seven days and occurring two to four times a year.....           10
7119  Erythromelalgia:                                                  
    Characteristic attacks that occur more than once a day,             
     last an average of more than two hours each, respond               
     poorly to treatment, and that restrict most routine                
     daily activities......................................          100
    Characteristic attacks that occur more than once a day,             
     last an average of more than two hours each, and                   
     respond poorly to treatment, but that do not restrict              
     most routine daily activities.........................           60
    Characteristic attacks that occur daily or more often               
     but that respond to treatment.........................           30
    Characteristic attacks that occur less than daily but               
     at least three times a week and that respond to                    
     treatment.............................................           10
                                                                        
Note: For purposes of this section, a characteristic attack             
 of erythromelalgia consists of burning pain in the hands,              
 feet, or both, usually bilateral and symmetrical, with                 
 increased skin temperature and redness, occurring at warm              
 ambient temperatures. These evaluations are for the                    
 disease as a whole, regardless of the number of                        
 extremities involved.                                                  
                                                                        
7120  Varicose veins:                                                   
    With the following findings attributed to the effects               
     of varicose veins: Massive board-like edema with                   
     constant pain at rest.................................          100
    Persistent edema or subcutaneous induration, stasis                 
     pigmentation or eczema, and persistent ulceration.....           60
    Persistent edema and stasis pigmentation or eczema,                 
     with or without intermittent ulceration...............           40
    Persistent edema, incompletely relieved by elevation of             
     extremity, with or without beginning stasis                        
     pigmentation or eczema................................           20
    Intermittent edema of extremity or aching and fatigue               
     in leg after prolonged standing or walking, with                   
     symptoms relieved by elevation of extremity or                     
     compression hosiery...................................           10
    Asymptomatic palpable or visible varicose veins........            0
                                                                        
Note: These evaluations are for involvement of a single                 
 extremity. If more than one extremity is involved,                     
 evaluate each extremity separately and combine (under Sec.             
  4.25), using the bilateral factor (Sec.  4.26), if                    
 applicable.                                                            
                                                                        
7121  Post-phlebitic syndrome of any etiology:                          
    With the following findings attributed to venous                    
     disease:                                                           
        Massive board-like edema with constant pain at rest          100
        Persistent edema or subcutaneous induration, stasis             
         pigmentation or eczema, and persistent ulceration.           60
        Persistent edema and stasis pigmentation or eczema,             
         with or without intermittent ulceration...........           40
        Persistent edema, incompletely relieved by                      
         elevation of extremity, with or without beginning              
         stasis pigmentation or eczema.....................           20
        Intermittent edema of extremity or aching and                   
         fatigue in leg after prolonged standing or                     
         walking, with symptoms relieved by elevation of                
         extremity or compression hosiery..................           10
        Asymptomatic palpable or visible varicose veins....            0
                                                                        
Note: These evaluations are for involvement of a single                 
 extremity. If more than one extremity is involved,                     
 evaluate each extremity separately and combine (under Sec.             
  4.25), using the bilateral factor (Sec.  4.26), if                    
 applicable.                                                            
                                                                        
7122  Cold injury residuals:                                            
    With pain, numbness, cold sensitivity, or arthralgia                
     plus two or more of the following: tissue loss, nail               
     abnormalities, color changes, locally impaired                     
     sensation, hyperhidrosis, X-ray abnormalities                      
     (osteoporosis, subarticular punched out lesions, or                
     osteoarthritis) of affected parts.....................           30
    With pain, numbness, cold sensitivity, or arthralgia                
     plus tissue loss, nail abnormalities, color changes,               
     locally impaired sensation, hyperhidrosis, or X-ray                
     abnormalities (osteoporosis, subarticular punched out              
     lesions, or osteoarthritis) of affected parts.........           20
    With pain, numbness, cold sensitivity, or arthralgia...           10
                                                                        
Note (1): Amputations of fingers or toes, and complications             
 such as squamous cell carcinoma at the site of a cold                  
 injury scar or peripheral neuropathy should be separately              
 evaluated under other diagnostic codes.                                
Note (2): Evaluate each affected part (hand, foot, ear,                 
 nose) separately and combine the ratings, if appropriate,              
 in accordance with Secs.  4.25 and 4.26.                               
                                                                        

[[Page 65224]]

                                                                        
7123  Soft tissue sarcoma (of vascular origin).............          100
                                                                        
Note: A rating of 100 percent shall continue beyond the                 
 cessation of any surgical, X-ray, antineoplastic                       
 chemotherapy or other therapeutic procedure. Six months                
 after discontinuance of such treatment, the appropriate                
 disability rating shall be determined by mandatory VA                  
 examination. Any change in evaluation based upon that or               
 any subsequent examination shall be subject to the                     
 provisions of Sec.  3.105(e) of this chapter. If there has             
 been no local recurrence or metastasis, rate on residuals.             
------------------------------------------------------------------------

(Authority: 38 U.S.C. 1155)

[FR Doc. 97-32413 Filed 12-10-97; 8:45 am]
BILLING CODE 8320-01-P