Arteriosclerotic heart disease, when associated with congestive heart failure, persistent major rhythm disturbances, repeated angina attacks, silent ischemia at a low to moderate workload or objective evidence of myocardial infarction. The following considerations pertain to myocardial infarction:
Maintenance on any type of medication for the treatment or prevention of angina, congestive heart failure, or major rhythm disturbances (ventricular tachycardia, ventricular fibrillation, symptomatic paroxysmal supraventricular tachycardia, atrial flutter, or atrial fibrillation).
Individuals sustaining a myocardial infarct will have MEB processing within 90 calendar days.
Final evaluation of cases for continued active duty, and where time permits, for separation or retirement, is conducted not more than 1 year postinfarct, provided the member's clinical course is uneventful.
Treadmill is required by medical and disability reviewing authorities in adjudication of infarction cases.
Exercise Treadmill Test (ETT).
Must achieve minimum of 85% maximum predicted heart rate for age unless heart rate is limited by medically necessary beta blockers, in which case 3 Bruce stages (9 minutes exercise) should be attained.
Normal blood pressure response.
No reversible ischemic ST changes (i.e., no flat or downsloping ST depressions at 80 ms past the J point; applicable only if baseline ST segments are normal; if not, imaging study is necessary.
No significant arrhythmias.
No symptoms or objective evidence of ischemia, angina or congestive heart failure.
Thallium, stress echocardiogram or stress MUGA imaging if indicated by ETT (see above).
No evidence of significant territories of reversible ischemia.
Additional testing (if indicated).
Baseline echocardiogram or MUGA.
Evaluate left ventricular systolic function and wall motion.
No angina or evidence of ischemia.
No evidence of congestive heart failure.
No major rhythm disturbances.
No more than mild reduction in ejection fraction (i.e., greater than 45%) NOTE: MEBs on cardiac cases must include the New York Heart Association (NYHA) or Canadian Heart classification.
Paroxysmal ventricular tachycardia, ventricular fibrillation.
Pacemakers or implantable cardioverterdefibrillators.
Paroxysmal supraventricular tachycardia, atrial flutter unless successfully ablated by catheter based method (radiofrequency ablation) and not associated with structural heart disease.
. Atrial fibrillation, other than infrequent "lone" atrial fibrillation, not associated with structural heart disease and not requiring medication.
Myocarditis and degeneration of the myocardium..
Cardiomyopathy, any etiology, including hypertrophic obstructive type, idiopathic dilated type, toxic, restrictive.
Endocarditis, infectious (acute or subacute), and marantic.
Chronic constrictive pericarditis, unless successful surgery has been performed and return of normal hemodynamics objectively documented.
Chronic serous pericarditis.
Acute rheumatic valvulitis or sequelae of chronic rheumatic heart disease (see also, valvular heart disease below).
Premature ventricular contractions. When they interfere with the satisfactory performance of duty.
Atrioventricular block, other than first degree or asymptomatic Type I second degree AV block without structural heart disease. Higher degrees of block must be individually evaluated, even if asymptomatic.
Peripheral vascular disease, if symptomatic, including claudication, skin changes or cerebrovascular events.
Chronic venous insufficiency (postphlebitic syndrome). When symptomatic or requiring elastic support or chronic anticoagulation.
Raynaud's phenomenon, if frequent, severe, associated with systemic disease or would limit worldwide assignability.
Deep venous thrombosis with repeated attacks requiring treatment or prophylaxis, or pulmonary embolus.
Varicose veins. Severe and symptomatic.
Congenital anomalies. Coarctation of aorta, atrial or ventricular septal defect and other congenital anomalies unless satisfactorily treated by surgical correction.
Valvular heart disease, including:
Symptomatic mitral valve prolapse requiring treatment.
Moderate to severe aortic stenosis (valvular, subvalvular or supravalvular), even if asymptomatic.
Moderate to severe mitral regurgitation, any etiology, if symptomatic or associated with subnormal ejection fraction. Successful mitral repair with preservation of ejection fraction, no need for anticoagulants or antiarrhythmics may be waived if exercise tolerance is normal, but MEB processing should precede surgery.
Severe valvular or subvalvular pulmonic stenosis. Successful correction of valvular pulmonic stenosis with balloon valvuloplasty may be waiverable, but MEB processing should precede the procedure.
Symptomatic mitral stenosis, generally associated with mitral valve area less than 1.0 cm sq.
Severe aortic insufficiency if symptomatic, associated with left ventricular dilation or dysfunction.
Diastolic pressure consistently more than 110 mmHg following an adequate period of therapy in an ambulatory status or history of hypertension associated with any of the following:
More than minimal demonstrable changes in the brain.
Heart disease related to the hypertension, including atrial fibrillation, moderate to severe left ventricular hypertrophy, and symptomatic systolic or diastolic dysfunction.
Unequivocal impairment of renal function.
. Grade III (KeithWagenerParker) changes in the fundi.
Multiple drug therapy with the requirement for an inordinate amount of medical supervision.
Aneurysm or history of repair.
Reconstructive surgery, including:
Prosthetic devices that are attached to or implanted for cardiovascular therapeutic purposes, regardless of result. Intracoronary stents may in certain instances be acceptable without MEB if associated with a good result, no myocardial infarction has occurred and a six month postprocedure treadmill is nonischemic. MEB is required for ANG members.
Surgery of the heart, pericardium, or vascular system.
Member has undergone coronary vascular surgery, regardless of the result. Coronary angioplasty may in certain instances be acceptable without MEB if no myocardial infarction has occurred, a good result is obtained and six month postprocedure treadmill or equivalent test is nonischemic. MEB is required for ANG members. Notes: 1. Conditions above must have MEB processing within 90 calendar days of surgery regardless of the results, unless stated otherwise. 2. Refer to paragraph 10.10.2. when managing cases on ARC members.