Heart Disease

Heart disease at the VA is rated on a framework that surprises most veterans the first time they see it. The rating doesn't turn on which artery is blocked or how many stents you have. It turns on three things: how much physical work you can do before symptoms start, what your heart's pumping fraction is, and whether you've had episodes of congestive heart failure. The anchor code is 38 CFR § 4.104, DC 7005, for arteriosclerotic heart disease, the regulatory name for coronary artery disease. The same evaluation table runs across most of the cardiac family, so the analysis below applies whether the file calls it coronary artery disease, a heart attack, hypertensive heart disease, or valvular disease.

The single most important number in a heart claim is the workload measured in metabolic equivalents, or METs. One MET is the energy you burn sitting still. The rating tiers are built around how many METs you can sustain before you get short of breath, fatigued, dizzy, faint, or have chest pain. A workload of 3.0 METs or less puts you at 100 percent. A workload of 7.1 to 10.0 METs puts you at 10 percent. Until November 2021 ejection fraction and congestive heart failure history were alternative routes to the same percentages, and a rater picked whichever paid more. Both were deleted. Above 30 percent the METs figure is now the only path.

For Vietnam-era veterans there is a second story that often matters more than the rating math: ischemic heart disease is an Agent Orange presumptive condition under 38 CFR § 3.309(e). That changes the service-connection question from "prove your heart disease came from service" to "prove you set foot where you were presumed exposed." This page walks through DC 7005 and the rest of the § 4.104 cardiac codes, the current General Rating Formula quoted in full, what the 2021 rewrite removed and what that means if you were counting on an echocardiogram, what a C&P exam has to measure, the Agent Orange presumptive pathway, and the secondary chains from diabetes, hypertension, and sleep apnea.

TL;DR

• Heart disease is rated under 38 CFR § 4.104. The anchor code is DC 7005 (arteriosclerotic heart disease / coronary artery disease). The cardiovascular family also includes DC 7006 (myocardial infarction), DC 7007 (hypertensive heart disease), and DC 7000 (valvular heart disease).
• Most cardiac codes share one evaluation framework, the General Rating Formula for Diseases of the Heart, built on metabolic equivalents (METs). VA rewrote it effective 2021-11-14.
• The current tiers: 100% for a workload of 3.0 METs or less producing heart failure symptoms; 60% for 3.1 to 5.0 METs; 30% for 5.1 to 7.0 METs, or imaging-confirmed cardiac hypertrophy or dilatation; 10% for 7.1 to 10.0 METs, or continuous medication required for control.
• Ejection fraction was deleted. The phrase appears nowhere in 38 CFR Part 4. The old routes to 100% (EF under 30%) and 60% (EF of 30 to 50%) no longer exist.
• Congestive heart failure was deleted as a standalone criterion. Chronic CHF at 100% and more than one acute episode per year at 60% are both gone; heart failure now enters only through the symptom list attached to a METs level.
• Above 30 percent there is now exactly one path, so the METs figure carries the claim.
• Ischemic heart disease is an Agent Orange presumptive under 38 CFR § 3.309(e). For exposed Vietnam-era veterans, that is often the fastest service-connection path.
• Heart disease is commonly a secondary condition under 38 CFR § 3.310, claimed secondary to diabetes, to hypertension, and to sleep apnea.
• The exam is the rating engine, and more so than before. METs can come from an exercise (stress) test or, when testing is medically contraindicated, from an examiner estimate supported by specific activity examples. With the ejection fraction route gone, an echocardiogram alone no longer reaches the higher tiers.
• In Claim Raven's analysis of 323 BVA heart disease cases, 31.0% were granted, 33.4% were remanded, and 35.6% were denied. Of the 254 cases with a C&P adequacy determination, 57.1% had the exam flagged as inadequate. The dataset codes overall outcome rather than a per-diagnostic-code breakdown, so I can't read the DC 7005 versus DC 7007 split directly from it.

The Cardiovascular Codes and What Each One Pays

The heart section of 38 CFR § 4.104 covers several diagnostic codes. The ones that come up most in claims sit in the arteriosclerotic and hypertensive group and share a common evaluation table.

DC 7005, Arteriosclerotic heart disease (coronary artery disease). This is the anchor code and the one most heart claims land under. Since the 2021 rewrite the code itself carries no criteria beyond a note about superimposed non-service-connected disease; the rating runs on the General Rating Formula below.

DC 7006, Myocardial infarction (heart attack). During and for three months following the infarction, confirmed by laboratory tests, the condition carries a 100 percent rating. The code then directs "thereafter, use the General Rating Formula," the same one that governs DC 7005. A heart attack is an event; the long-term rating reflects the residual cardiac function, not the fact that an attack occurred.

DC 7007, Hypertensive heart disease. This is heart disease caused by long-standing high blood pressure, rated on the same shared table. It is distinct from hypertension itself, which is rated separately under DC 7101 by blood pressure readings. A veteran can carry a rating for hypertension and a separate rating for the hypertensive heart disease it produced, because they address different impairments.

DC 7000, Valvular heart disease (including rheumatic heart disease). Disease of the heart valves, also rated on the General Rating Formula once documented by findings such as an echocardiogram.

The reason these codes matter less than veterans expect is that, past the acute windows, they nearly all funnel into the same evaluation criteria. The fight is rarely over which code applies. Since the 2021 rewrite it is over one thing: what your METs are.

The Shared Rating Framework Is Now METs Alone

This is the core of every heart claim, and it changed substantially. VA rewrote the cardiovascular section effective November 14, 2021. Most cardiac codes under 38 CFR § 4.104, including DC 7005, no longer carry their own criteria and instead point to the General Rating Formula for Diseases of the Heart. Here it is in full:

Workload of 3.0 METs or less results in heart failure symptoms, 100%

Workload of 3.1-5.0 METs results in heart failure symptoms, 60%

Workload of 5.1-7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multigated acquisition scan or magnetic resonance imaging), 30%

Workload of 7.1-10.0 METs results in heart failure symptoms; or continuous medication required for control, 10%

A note to the formula defines the symptom set: heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope.

Two criteria that used to reach the top tiers are gone, and this is the single most important thing on this page.

Ejection fraction was deleted. The pre-2021 formula awarded 100 percent for left ventricular dysfunction with an ejection fraction below 30 percent, and 60 percent for an ejection fraction of 30 to 50 percent. The phrase "ejection fraction" now appears nowhere in 38 CFR Part 4. A veteran whose claim rests on a low ejection fraction and who never completed exercise testing has, under the current formula, no route to 100 or 60 percent through that number alone. If you have been told an echo showing a reduced ejection fraction is worth 100 percent, that advice is four years out of date.

Congestive heart failure was deleted as a standalone criterion. The old formula gave 100 percent for chronic congestive heart failure and 60 percent for more than one episode of acute congestive heart failure in the past year. Neither phrase survives. Heart failure now enters the analysis only through the symptom list attached to a METs level.

What is left is a single ladder built on one measurement, with two supplementary routes: cardiac hypertrophy or dilatation confirmed by imaging at 30 percent, and continuous medication for control at 10 percent.

Two consequences follow.

First, the METs figure now carries almost the whole claim. Under the old formula a veteran had three independent shots at each tier and a rater was supposed to pick the most favorable. Now, above 30 percent, there is exactly one path. That makes how the METs number gets produced the decisive question, and it is the subject of the next section.

Second, the bands are narrow and they are stated to one decimal place. The line between 60 and 100 percent is 3.0 versus 3.1 METs. The line between 30 and 60 is 5.0 versus 5.1. An estimate recorded as "about 4 METs" sits in the middle of the 60 percent band, but an estimate recorded as "3 to 5 METs" straddles two tiers and invites the lower one. Precision in the examiner's wording is worth real money here.

If your claim spans November 14, 2021, the old criteria apply to the period before that date and the current formula from that date forward, with staged ratings where the evidence supports different levels in different periods. A veteran who held a 100 percent rating awarded on ejection fraction before the change does not lose it automatically; protected-rating rules and the § 3.105(e) reduction procedures apply to any proposed reduction.

Third, the 10 percent "continuous medication required" criterion is a floor that catches a lot of veterans whose exercise capacity still tests above 7 METs. If you are on a daily cardiac medication for your service-connected heart disease, that alone supports a 10 percent rating even when your stress test looks reassuring.

C&P Exam Mechanics: How Your METs Figure Gets Set

The heart C&P exam follows the DBQ for ischemic and non-ischemic heart conditions, and it is the rating engine. Since 2021 one number decides the rating above 30 percent, and it is produced here.

An echocardiogram still matters, but its role narrowed sharply. It can establish cardiac hypertrophy or dilatation, which is an independent route to 30 percent. It can no longer carry a claim to 60 or 100 percent, because the ejection fraction criteria that used to do that were deleted. If you are relying on a reduced ejection fraction to reach a high rating, that route closed on 2021-11-14.

METs are more complicated, and this is where claims go wrong. The cleanest source is an exercise stress test, where you actually walk a treadmill and the test measures the workload at which symptoms appear. But for many cardiac patients an exercise test is medically unsafe. The regulation accounts for this: when exercise testing cannot be done for medical reasons, the examiner provides an interview-based METs estimate, asking what level of activity brings on dyspnea, fatigue, angina, dizziness, or syncope. Climbing a flight of stairs, walking on level ground, light yard work, and similar activities each map to a rough METs value.

The interview-based estimate is legitimate and the regulation authorizes it, but it is softer than a measured test, and it is where inadequate exams cluster. The examiner who writes "patient reports getting short of breath with exertion" without translating that into a METs figure has produced a report the rater cannot rate cleanly. The examiner who estimates METs but does not say whether the limitation comes from the heart or from a separate condition (a bad knee, obesity, a lung problem) leaves an opening for the rater to discount the figure.

When the exam is complete, with a METs figure (measured or estimated with a stated reason and supporting activity examples), a clear statement of which heart failure symptoms appear at which workload, and imaging addressing hypertrophy or dilatation, the rater has what they need. When components are missing, the case is a candidate for a remand. The C&P-inadequate share in the heart subset, discussed below, tracks closely with these gaps.

The Agent Orange Presumptive: Ischemic Heart Disease

For a large group of veterans, the service-connection question is settled before the rating math even starts. Ischemic heart disease is an Agent Orange presumptive condition under 38 CFR § 3.309(e). Ischemic heart disease is the umbrella that includes coronary artery disease, the condition rated under DC 7005, along with conditions like stable, unstable, and Prinzmetal's angina and old myocardial infarction.

Here is why the presumptive matters. The normal path to service connection requires you to prove three things: a current diagnosis, an in-service event or exposure, and a medical nexus linking them. Heart disease is common in the general population, so the nexus step is hard. A VA examiner can usually point to age, smoking history, diet, and family history as alternative causes, and a generic claim stalls there.

The presumptive collapses that. If you served in a location and time period for which herbicide exposure is presumed, and you have ischemic heart disease, VA presumes the connection. You do not have to produce a nexus opinion tying the heart disease to the exposure. The covered exposure populations have expanded over time and now reach beyond boots-on-ground Vietnam service to include certain Blue Water Navy service, service in Thailand at specified bases, the Korean Demilitarized Zone, and other locations. The specifics of who qualifies turn on dates and places, so the threshold question for a Vietnam-era veteran with coronary artery disease is always whether the service falls inside a recognized exposure category.

Two cautions. First, the presumptive covers ischemic heart disease specifically. Hypertensive heart disease (DC 7007) and valvular disease (DC 7000) are not ischemic heart disease, so they do not ride the same presumptive even though they share the rating table. Second, the presumptive establishes service connection, not the rating level. Once connected, the heart disease is still rated on the METs formula like any other. A presumptive grant at 10 percent is common when exercise capacity is preserved and the only criterion met is continuous medication.

Secondary Chains: Heart Disease Caused by Another Condition

Heart disease is frequently a secondary condition rather than a primary one. Under 38 CFR § 3.310, secondary service connection is available for a condition caused by a service-connected condition or aggravated by one (Allen v. Brown). Three chains dominate the heart-disease secondary claims I see.

Diabetes to heart disease. This is the most common and best-supported cardiac secondary. Type 2 diabetes is itself an Agent Orange presumptive, and diabetes is a well-established medical cause of coronary artery disease. A veteran service-connected for diabetes who later develops heart disease has a strong secondary claim, because the medical literature linking diabetes to accelerated coronary disease is not seriously contested. The nexus opinion still has to articulate the mechanism, but the underlying biology is on the veteran's side.

Hypertension to heart disease. Long-standing high blood pressure causes the heart muscle to thicken and the heart to enlarge, which is exactly what DC 7007 (hypertensive heart disease) describes. A veteran service-connected for hypertension who develops cardiac hypertrophy or reduced function has a direct secondary pathway. The evidence to look for is an echocardiogram showing left ventricular hypertrophy or dilatation, which doubles as both the nexus and the basis for a 30 percent rating under the "cardiac hypertrophy or dilatation" criterion.

Sleep apnea to heart disease. This chain is well-litigated and increasingly recognized. Untreated obstructive sleep apnea stresses the cardiovascular system through repeated overnight oxygen drops and blood pressure surges, and it is medically associated with hypertension, arrhythmia, and heart disease. A veteran service-connected for sleep apnea can pursue heart disease as a secondary, though the nexus opinion carries more weight here than in the diabetes chain because the causal link, while real, is more contested in any individual case.

For all three, the standard is the same one that governs any nexus opinion. The opinion has to identify the mechanism, address the time course, and rule out other causes. "Heart disease is secondary to diabetes" with no reasoning is not probative. A factually accurate, fully articulated opinion based on sound medical reasoning carries the case.

Pyramiding and Stacking in Cardiac Claims

The pyramiding rule, 38 CFR § 4.14, blocks rating the same impairment twice. In heart claims it shows up in a specific way: you generally cannot stack two cardiac codes that both measure the same cardiac function. If your coronary artery disease (DC 7005) and your hypertensive heart disease (DC 7007) both reduce the same METs capacity, the rater assigns a single evaluation under the predominant code rather than two ratings off the same impaired function. The regulation directs a single rating where the same cardiac dysfunction would otherwise be evaluated twice.

What does stack is hypertension separate from heart disease. Hypertension is rated under DC 7101 on blood pressure readings, which is a different impairment from the pumping-function deficit measured under the cardiac codes. A veteran can carry a rating for hypertension and a separate rating for the heart disease, because high blood pressure readings and reduced cardiac workload are different things. The same logic supports a separate rating for a condition like heart arrhythmia, which is evaluated on its own criteria for the rhythm disturbance rather than on the METs table.

The practical point is to make sure each genuinely distinct cardiovascular impairment is identified and rated under its own code, while not expecting two ratings for one impaired function dressed up under two diagnostic labels.

Common Evidence Gaps in Heart Disease Claims

A few patterns I've noticed across BVA decisions involving heart disease.

No METs figure in the record. The single most common gap. The notes document chest pain, shortness of breath, and a cardiac diagnosis, but nobody translated the functional limitation into a METs number. Without a METs figure, measured or interview-based, the rater has no clean way to place the condition on the table and often defaults to the lowest supportable tier. The Board sends a lot of these back specifically for a METs estimate.

A claim built on ejection fraction. This is now the most expensive mistake available on a heart claim. Ejection fraction was a route to 60 and 100 percent until 2021-11-14 and is no longer a criterion anywhere in Part 4. A file organized around a low ejection fraction, with no METs testing and no imaging finding of hypertrophy or dilatation, can support a diagnosis and still produce a low rating. Get the METs figure.

METs limitation not attributed to the heart. The examiner records that the veteran gets winded at 4 METs but does not say whether the heart, the lungs, the weight, or a joint problem is the cause. When exercise capacity is limited by multiple conditions, the regulation expects the examiner to estimate the portion attributable to the cardiac condition, or explain why that cannot be done. A report that leaves the attribution open invites the rater to discount the figure.

CHF episodes not documented as such. A history of acute congestive heart failure episodes drives the 60 percent and 100 percent tiers, but only when the episodes are documented as CHF in the medical record. Hospitalizations described vaguely, without the CHF finding, may not be counted. The number and dating of acute CHF episodes in the past year is a specific factual question the record needs to answer.

Presumptive eligibility not pinned down. For Vietnam-era veterans with ischemic heart disease, the claim can rise or fall on whether the service falls inside a recognized herbicide-exposure category. Files that assert exposure without the service dates, locations, and unit records to support a presumptive finding force the harder direct-connection analysis instead.

I don't know exactly what percentage of heart disease claims have one or more of these gaps. What I can say from Claim Raven's analysis of 323 BVA heart disease cases is that, of the 254 cases with a C&P adequacy determination, 57.1 percent had the examination flagged as inadequate. Overall outcomes in the heart subset ran 35.6 percent denied, 33.4 percent remanded, and 31.0 percent granted, a near three-way split with denials narrowly leading. That pattern is consistent with the evidence dynamics in this post: when the exam does not produce a clean METs figure, the Board either sends the case back for development or the claim is denied for want of the number the formula requires. Note that these decisions were made largely under the pre-2021 criteria, when three alternative routes existed; with two of them now deleted, a missing METs figure is more damaging than this sample reflects.

What to Push For in a Heart Claim

The cardiac rating is a numbers game, and the numbers come from the exam and the imaging. A few things to make sure the record contains.

A current echocardiogram, read for cardiac hypertrophy or dilatation. That finding is an independent route to 30 percent. Note that the ejection fraction it reports is no longer a rating criterion, so an echocardiogram alone cannot carry the claim above 30 percent the way it could before 2021-11-14.

A METs figure that is either measured by stress test or, if exercise testing is unsafe, an interview-based estimate with the reason stated and the limiting symptom identified. When other conditions also limit your exercise capacity, ask that the examiner estimate the cardiac portion or explain why that is not feasible.

A documented count and dating of any acute congestive heart failure episodes in the past year, because that is what separates the 60 percent and 100 percent tiers from the rest.

For a Vietnam-era veteran with coronary artery disease, the service records that establish presence in a recognized herbicide-exposure location and time period, which can convert a hard nexus fight into a presumptive grant.

An evidence checklist for heart claims should treat the METs figure, the imaging finding on hypertrophy or dilatation, and the presumptive eligibility as three separate proof lanes, because each one independently affects either service connection or the rating tier. Ejection fraction and CHF history are no longer among them; both were deleted from the criteria in 2021.

What to Ask the C&P Examiner to Test

The heart exam should produce, at minimum, a METs figure tied to the heart failure symptom that limits you, plus imaging read for cardiac hypertrophy or dilatation. If a stress test is unsafe, the examiner should say so and provide an interview-based METs estimate rather than leaving the figure blank. The exam should also state which heart failure symptoms appear (the formula lists breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope) and at what workload.

The exam is the rating engine. If the examiner does not produce a METs figure, the rater has no clean tier to assign. If the examiner does not attribute the exercise limitation to the heart when other conditions are also present, the cardiac figure can be discounted. And if the file is organized around an ejection fraction, it is organized around a number that is no longer a rating criterion at all.

Use C&P exam prep for the heart DBQ and track cardiac symptoms and exertion limits before the exam. A log of what activities bring on symptoms, how far you can walk before stopping, how many stairs you can climb, and any episodes of fainting or fluid overload gives an interview-based METs estimate real facts to rest on.

Bottom Line

Heart disease at the VA is rated on a single framework, and since 2021-11-14 it rests on one measurement: workload in METs. The ejection fraction and congestive heart failure criteria that used to offer alternative routes to 60 and 100 percent were deleted outright, and neither phrase survives anywhere in 38 CFR Part 4. The diagnostic code (DC 7005 for coronary artery disease, DC 7006 for a heart attack, DC 7007 for hypertensive heart disease, DC 7000 for valvular disease) mostly funnels into that same table once the acute windows pass. The cases that get the right rating tend to have a clean METs figure attributed to the heart, stated precisely enough to land inside one band rather than straddling two. For Vietnam-era veterans, ischemic heart disease is an Agent Orange presumptive, which can settle service connection without a nexus fight, though the rating still rides the same numbers. And heart disease is often a secondary condition: claimed off diabetes, off hypertension, or off sleep apnea. Same heart, different paper trail, different outcome.

Related Conditions

Heart disease connects most often to hypertension, which is both a separately rated condition and a cause of hypertensive heart disease, and to heart arrhythmia, which is rated on its own rhythm criteria. The secondary chains run through diabetes and sleep apnea, and the downstream circulatory effects connect to peripheral vascular disease. Veterans with more than one cardiovascular condition should review the secondary conditions tool before assuming a single rating tells the whole story.

Methodology and Limitations

• Data source: Rating criteria quoted verbatim from the current 38 CFR § 4.104 General Rating Formula for Diseases of the Heart, as amended effective 2021-11-14, with the related cardiac codes DC 7005, DC 7006, DC 7007, and DC 7000. The Agent Orange presumptive for ischemic heart disease is from 38 CFR § 3.309(e). Secondary service connection is from 38 CFR § 3.310. Pyramiding is from 38 CFR § 4.14. Case law on secondary aggravation from Allen v. Brown.
• Sample size: Patterns in this post are drawn from Claim Raven's analysis of 101,518 condition records drawn from the analyzed subset of Claim Raven's 501,000+ Board-decision library, including 323 heart disease cases. Within that subset, outcomes ran 31.0% granted, 33.4% remanded, and 35.6% denied. Of the 254 cases with a C&P adequacy determination, 57.1% had the examination flagged as inadequate. The dataset predates the criteria on this page: these cases were decided largely under the pre-2021 formula, when ejection fraction and CHF history were independent routes to the higher tiers. Their outcome and exam-adequacy rates describe that framework. The dataset also captures overall outcome rather than a per-code breakdown.
• Classification approach: Diagnostic code definitions and the current METs tiers are drawn from the regulatory text as amended 2021-11-14. The ejection fraction and congestive heart failure criteria described in older sources were deleted by that amendment. The presumptive analysis follows § 3.309(e). Secondary analysis follows § 3.310 and the standard for probative nexus opinions.
• Limitations:
• The 323 decisions predate the criteria on this page. They were decided largely under the pre-2021 formula, where ejection fraction and CHF history were independent routes to the higher tiers. Their outcome and exam-adequacy rates describe that framework.
• The METs tiers are quoted from the current regulation, but application varies with how the exam is documented. The bands are stated to one decimal place, and the regulation does not say how to resolve an estimate recorded as a range that straddles two bands. Two veterans with the same underlying disease can land in different tiers depending on whether the exam produced a clean METs figure.
• Agent Orange presumptive eligibility turns on specific service dates and locations that have changed over time. Whether a given veteran's service falls inside a recognized exposure category is a fact-specific question this page does not resolve.
• The presumptive establishes service connection, not the rating level. The rating is still set on the current METs formula.
• Selection bias: BVA-level patterns reflect cases that appealed. Most heart claims resolve at the RO level and aren't in any BVA dataset.
• Interview-based METs estimates are authorized by the regulation but are inherently softer than measured exercise testing, and their use is uneven across examiners.
• These observations reflect patterns from the regulatory text, case law, and BVA decisions. They are not predictions of individual outcomes.