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Division 1 - Chapter 1

Division 1

Assessment of the Degree of an Employee's Permanent Impairment Resulting from an Injury

Chapter 1 - The Cardiovascular System

1.0 Introduction

1.1 Coronary Artery Disease

1.2 Hypertension

1.2.1 Diastolic Hypertension

1.2.2 Systolic Hypertension

1.3 Arrhythmias

1.4 Peripheral Vascular Disease of the Lower Extremities

1.5 Peripheral Vascular Disease of the Upper Extremities

1.6 Raynaud?s Disease

1.0 Introduction

In conducting an assessment, the assessor must have regard to the Principles of Assessment and the definitions contained in the Glossary.

WPI ratings derived from tables in this Chapter may be combined with WPI ratings from other tables where there is co-existent disease (for example, cardiomyopathy, ischaemic heart disease, congenital heart disease, valvular heart disease).

?Activities of Daily Living? are activities which an employee needs to perform to function in a non-specific environment (that is, to live). Performance of Activities of Daily Living is measured by reference to primary biological and psychosocial function.

For the purposes of Chapter 1, Activities of Daily Living are those in Figure 1-A .

Figure 1-A: Activities of Daily Living

Activity	Examples
Self care, personal hygiene.	Bathing, grooming, dressing, eating, eliminating.
Communication.	Hearing, speaking, reading, writing, using keyboard.
Physical activity.	Standing, sitting, reclining, walking, stooping, squatting, kneeling, reaching, bending, twisting, leaning, carrying, lifting, pulling, pushing, climbing, exercising.
Sensory function.	Tactile feeling.
Hand functions.	Grasping, holding, pinching, percussive movements, sensory discrimination.
Travel.	Driving or travelling as a passenger.
Sexual function.	Participating in desired sexual activity.
Sleep.	Having a restful sleep pattern.
Social and recreational.	Participating in individual or group activities, sports activities, hobbies.

Chapter 1 does not cover impairments arising from cardiomyopathy, congenital heart disease, valvular heart disease, and pericardial heart disease. Where relevant, the degree of impairment arising from these conditions should be assessed in accordance with the appropriate table from the edition of the American Medical Association?s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

For post-thrombotic syndrome, assessments under Tables 1.4 and 1.5 are an alternative to Table 13.4: Thrombotic Disorders (Chapter 13 - The Haematopoietic System). WPI ratings from Tables 1.4 and 1.5 must not be combined with a WPI rating from Table 13.4. Tables 1.4 and 1.5 should be used as the primary guide for assessing peripheral complications of thrombosis.

Employees who have permanent cardiac limitation secondary to massive pulmonary embolism should be assessed under Chapter 1. A WPI rating assessed in these circumstances may not becombined with a rating from Table 13.4.

1.1 Coronary Artery Disease

Steps for assessment are as follows.

Step 1	Using Figure 1-B, determine the symptomatic level of activity in METS according to age and gender. Figure 1-B may be used to assess conditions affecting left ventricular function (LVF) (including ischaemic heart disease, rheumatic heart disease, and hypertension).
Step 2	Using Table 1.1, refer to any one of pathology (column 3), drug therapy (column 4), or intervention (column 5), to identify the degree of impairment within the range of impairments for that symptomatic level of activity.

Figure 1-B may be used for the assessment of symptomatic impairment caused by ischaemic heart disease, hypertension, cardiomyopathy, or rheumatic heart disease.

Figure 1-B: Symptomatic Level of Activity in METS According to Age and Gender

Age and Gender	Symptomatic Level of Activity in METS
Age and Gender	1	1-2	2-3	3-4	4-5	5-6	6-7	7-8	8-9	10+
18-30 M	D	D	D	C	C	B	B	B	A	A
18-30 F	D	D	C	C	B	B	A	A	A
31-40 M	D	D	D	C	C	B	B	A	A
31-40 F	D	D	C	B	B	B	A
41-50 M	D	D	C	C	B	B	A	A
41-50 F	D	D	C	B	B	A	A
51-60 M	D	D	C	B	B	A	A	A
51-60 F	D	D	C	B	B	A	A
61-70 M	D	D	C	B	B	A	A
61-70 F	D	D	B	B	A	A
70+ M	D	C	B	B	A
70+ F	D	C	B	A	A

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Table 1.1: Coronary Artery Disease

See notes to Table 1.1 on following page for further details regarding abbreviations and

symbols used in Columns 3, 4 and 5.

Column 1 % WPI	Column 2 Level of Activity in METS for Age and Gender	Column 3 Pathology	Column 4 Drug Therapy	Column 5 Intervention
5	A	not applicable	not applicable	not applicable
10	A	+	+	not applicable
15	A	++	++	PTCA
20	A	+++	+++	CABG/Tx
25	B	+	+	not applicable
30	B	++	++	PTCA
40	B	+++	+++	CABG/Tx
50	C	+	+	not applicable
60	C	++	++	PTCA
65	C	+++	+++	CABG/Tx
75	D	+	+	not applicable
85	D	++	++	PTCA
95	D	+++	+++	CABG/Tx

Notes to Table 1.1

1. In Table 1.1, not applicable means the criterion is not applicable to the specified level of impairment.

2. Pathology - Column 3.

Coronary Artery Disease:

+ either <50% stenosis in one or more coronary arteries, or single vessel disease > 50% stenosis (except proximal left anterior descending [LAD] and left main coronary artery [LMCA]);

++ either >50% stenosis in two vessels, or >50% stenosis in proximal LAD, or <50% stenosis in LMCA;

+++ either >50% stenosis in 3 vessels, or LMCA >50% stenosis, or severe diffuse end organ disease.

Ischaemic Left Ventricular Dysfunction:

+ left ventricular ejection fraction (LVEF) 40-50%;

++ LVEF 30-40%;

+++ either LVEF < 30%, or LV aneurysm.

Myocardial Infarction (MI):

+ no previous MI;

++ previous possible MI (equivocal changes in ECG/cardiac enzymes);

+++ previous definite MI (unequivocal changes in ECG/cardiac enzymes: typical evolution of ST/T segments, or development of significant Q waves, or enzyme rise > 3 times upper limit of normal).

Arrhythmias

Assessed under Table 1.3 - Arrhythmias (seepage 25).

3. Drug Therapy (continuous) - Column 4.

+ one or two drugs;

++ three or four drugs;

+++ five or more drugs.

4. Intervention - Column 5.

PTCA means percutaneous transluminal coronary angioplasty and/or stenting.

CABG means coronary artery bypass grafting.

Tx means heart transplant.

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1.2 Hypertension

Either diastolic hypertension (section 1.2.1) or systolic hypertension (section 1.2.2) may be assessed, whichever provides the highest WPI rating.

1.2.1 Diastolic Hypertension

Hypertensive cardiomyopathy can be assessed using the edition of the American Medical Association?s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

Functional class (determined in accordance with Figure 1-B) is the primary criterion for assessment. Level of diastolic blood pressure (DBP) and therapy (see Table 1.2.1) are secondary criteria for assessment.

For assessment use either usual DBP, or therapy, for a given functional class, whichever provides the greater WPI rating. If DBP is consistently >120 on optimal therapy, one higher functional class may be assigned.

Table 1.2.1: Diastolic Hypertension

See note immediately following Table 1.2.1 for explanation of symbols

used in the final column (Drug Therapy).

% WPI	Level of Activity in METS for Age and Gender	Usual DBP	Drug Therapy
5	A	>90	+
10	A	>100	++
15	A	>110	+++
20	B	>90	+
25	B	>100	++
30	B	>110	+++
35	C	>90	+
40	C	>100	++
45	C	>110	+++
50	D	>90	+
55	D	>100	++
60	D	>110	+++

Note to Table 1.2.1

1. Drug Therapy (continuous) - final column of Table 1.2.1:

+ one drug;

++ two drugs;

+++ three or more drugs.

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1.2.2 Systolic Hypertension

Hypertensive cardiomyopathy can be assessed using the edition of the American Medical Association?s Guides to the Evaluation of Permanent Impairment current at the time of assessment.

Functional class (determined in accordance with Figure 1-B) is the primary criterion for assessment. Level of systolic blood pressure (SBP) and therapy (see Table 1.2.2) are secondary criteria for assessment.

Table 1.2.2: Systolic Hypertension

See note immediately following Table 1.2.2 for explanation of symbols

used in the final column (Drug Therapy).

% WPI	Symptomatic Level of Activity in METS for Age and Gender	Usual SBP	Drug Therapy
5	A	>160	+
10	A	>160	++
15	A	>160	+++
20	B	>170	+
25	B	>170	++
30	B	>170	+++
35	C	>180	+
40	C	>180	++
45	C	>180	+++
50	D	>190	+
55	D	>190	++
60	D	>190	+++

Note to Table 1.2.2

1. Drug Therapy (continuous):

+ one drug;

++ two drugs;

+++ three or more drugs.

1.3 Arrhythmias

Underlying cardiac disease can be assessed using other tables in Chapter 1.

Functional class (determined under Figure 1-C), and therapy (see Table 1.3), are used to determine the WPI rating.

Figure 1-C: Definitions of Functional Class

Functional Class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light Activities of Daily Living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

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Table 1.3: Arrhythmias

See note immediately following Table 1.3 for explanation of symbols used in the final column (Therapy).

% WPI	Functional Class	Therapy
5	I	Nil
10	I	Drug(s)
15	I	Surgery/cath/PPM/Device
20	II	Nil
30	II	Drug(s)
40	II	Surgery/cath/PPM/Device
45	III	Nil
50	III	Drug(s)
55	III	Surgery/cath/PPM/Device
60	IV	not applicable

Note to Table 1.3

1. Therapy - column 3:

'cath' means either catheter ablation or catheter-associated therapy for arrhythmia;

'PPM' means permanent pacemaker;

'Device' means implanted defibrillator.

1.4 Peripheral Vascular Disease of the Lower Extremities

Amputations should not be assessed under Table 1.4. They should be assessed under Table 9.5: Lower Extremity Amputations (Chapter 9 - The Musculoskeletal System).

A WPI rating from Table 1.4 must not be combined with a WPI rating from Table 13.4: Thrombotic Disorders (Chapter 13 - The Haematopoietic System).

Table 1.4: Peripheral Vascular Disease of the Lower Extremities

% WPI	Signs and Symptoms
0	The employee experiences neither intermittent claudication nor pain at rest.
5	The employee has no difficulty with distances but experiences ischaemic pain on climbing either steps or gradients.
10	The employee experiences claudication on walking 200 metres or more at an average pace on level ground.
20	The employee experiences claudication on walking more than 100 but less than 200 metres at average pace on level ground.
30	The employee experiences claudication on walking more than 75 but less than 100 metres at average pace on level ground.
40	The employee experiences claudication on walking more than 50 but less than 75 metres at average pace on level ground.
50	The employee experiences claudication on walking more than 25 but less than 50 metres at average pace on level ground.
60	The employee experiences claudication on walking less than 25 metres at average pace on level ground.
70	The employee experiences ischaemic pain at rest.

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1.5 Peripheral Vascular Disease of the Upper Extremities

Amputations should not be assessed under Table 1.5. They should be assessed under Table 9.12.1: Upper Extremity Amputations, or Table 9.12.2: Amputation of Digits (Chapter 9 - The Musculoskeletal System).

A WPI rating from Table 1.5 must not be combined with a WPI rating from Table 13.4: Thrombotic Disorders (Chapter 13 - The Haematopoietic System).

Table 1.5 Peripheral Vascular Disease of the Upper Extremities

% WPI	Symptoms	Signs
5	Either no claudication or transient oedema.	Calcification of arteries on X-ray.
10	Either no claudication or persistent oedema controlled by support.	Dilatation of either arteries or veins.
15	As above.	Either loss of pulse or healed ulcer or surgery.
20	Either claudication on strenuous exercise or persistent oedema uncontrolled by support.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
30	As above.	Superficial ulcer.
40	As above.	Either deep or widespread ulcer or surgery.
45	Claudication on mild-moderate exertion.	Either calcification of arteries on X-ray or dilatation of either arteries or veins.
50	As above.	Superficial ulcer.
55	As above.	Either deep or widespread ulcer or surgery.
60	Rest pain/unable to exercise.	not applicable

1.6 Raynaud's Disease

Functional class (determined according to Figure 1-C) is the primary criterion for assessment. Signs of vasospastic disease and therapy (see Table 1.6) are secondary criteria for assessment.

Figure 1-C: Definitions of Functional Class

See note to Figure 1-C immediately following Figure.

Functional Class	Symptoms
I	No limitation of physical activity.
II	Slight limitation of physical activity. Comfortable at rest and with ordinary, light Activities of Daily Living. Greater activity causes symptoms.
III	Marked limitation of physical activity. Comfortable at rest. Ordinary activity causes symptoms.
IV	Inability to carry out any physical activity without discomfort.

Note to Figure 1-C

1. Figure 1-C also appears in Section 1.3 - Arrhythmias. It is repeated here for ease of reference.

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Table 1.6: Raynaud's Disease

See note immediately following Table 1.6.

% WPI	Functional Class	Signs	Therapy
5	I	Nil.	Nil.
10	I	Nil.	Drug(s).
15	I	Nil.	Surgery.
20	II	Neither ulceration nor trophic changes.	Drug(s).
25	II	Either ulceration or trophic changes.	Drug(s).
30	II	not applicable	Surgery.
35	III	Neither ulceration nor trophic changes.	Drug(s).
40	III	Either ulceration or trophic changes.	Drug(s).
45	III	not applicable	Surgery.
50	IV	not applicable	not applicable

Note to Table 1.6

1. Therapy - final column of Table 1.6:

Surgery includes sympathectomy and local debridement;

Drug(s) means continuous therapy with one or more drugs.

Division 1 - Chapter 1

Chapter 1 - The Cardiovascular System

1.0 Introduction

Figure 1-A: Activities of Daily Living

1.1 Coronary Artery Disease

Figure 1-B: Symptomatic Level of Activity in METS According to Age and Gender

Table 1.1: Coronary Artery Disease

1.2 Hypertension

1.2.1 Diastolic Hypertension

Table 1.2.1: Diastolic Hypertension

1.2.2 Systolic Hypertension

Table 1.2.2: Systolic Hypertension

1.3 Arrhythmias

Figure 1-C: Definitions of Functional Class

Table 1.3: Arrhythmias

1.4 Peripheral Vascular Disease of the Lower Extremities

Table 1.4: Peripheral Vascular Disease of the Lower Extremities

1.5 Peripheral Vascular Disease of the Upper Extremities

Table 1.5 Peripheral Vascular Disease of the Upper Extremities

1.6 Raynaud's Disease

Figure 1-C: Definitions of Functional Class

Table 1.6: Raynaud's Disease

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