38 CFR 4.104: METs, Ejection Fraction, and Heart Rating Tiers

The VA rates heart conditions at 10%, 30%, 60%, or 100% under 38 CFR 4.104, using standardized measurements of how your heart performs under stress. Two numbers do most of the work: the metabolic equivalents (METs) of exertion that trigger cardiac symptoms, and your left ventricular ejection fraction (LVEF). Chronic congestive heart failure and continuous cardiac medication also carry weight. At the top of the schedule, a single veteran with no dependents receives $3,938.58 per month; even the 10% tier pays $180.42.¹

The Two Measurements That Decide the Rating

One MET equals the energy your body burns standing quietly at rest, defined as 3.5 milliliters of oxygen per kilogram of body weight per minute.² At a Compensation and Pension exam, you’ll usually walk a treadmill with rising speed and incline. The examiner logs the MET level where symptoms appear — shortness of breath, chest pain, dizziness, fainting, or extreme fatigue. Lower MET tolerance means a higher rating.

LVEF is the percentage of blood your left ventricle pumps out with each beat, measured by echocardiogram. A healthy heart ejects roughly 55% to 70%. Lower percentages mean the muscle is weakened. The VA treats LVEF as an independent pathway, so a poor ejection fraction can lift your rating even if your treadmill numbers look mild.

The third factor is congestive heart failure, where the heart can’t move blood efficiently and fluid backs up into the lungs, legs, or abdomen. Chronic CHF alone supports a 100% rating; a documented acute episode in the past year matters at 60%.

The Rating Tiers

Most conditions in the schedule share one General Rating Formula. Within each tier, the criteria are joined by “or” — you only need to meet one.²

100% ($3,938.58/month): Chronic congestive heart failure; or symptoms at a workload of 3 METs or less; or LVEF below 30%.
60% ($1,435.02/month): More than one episode of acute congestive heart failure in the past year; or symptoms at 3.1 to 5 METs; or LVEF between 30% and 50%.
30% ($552.47/month): Symptoms at 5.1 to 7 METs; or cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent imaging.
10% ($180.42/month): Symptoms at 7.1 to 10 METs; or continuous medication required to control the heart condition.

These are 2026 rates for a single veteran with no dependents; compensation rises with qualifying dependents.¹ Because each tier uses “or” between its criteria, a veteran whose stress test lands at 6 METs (normally 30%) but whose echocardiogram shows an LVEF of 45% qualifies for 60%.

The continuous-medication rule at 10% matters more than many veterans realize. Taking daily heart medication establishes a minimum 10% rating even if you can hit 10 METs on a treadmill without symptoms.² The regulation doesn’t limit which drugs count; any continuous cardiac medication prescribed to control the condition qualifies.

One caution about the 30% tier: it requires echocardiogram or equivalent imaging such as a MUGA scan or MRI. A standard electrocardiogram (ECG) alone doesn’t satisfy the hypertrophy or dilatation criterion. If you’re relying on that pathway, check that the right imaging study is in your file.

When a Treadmill Test Isn’t Safe

Some veterans can’t safely perform a stress test because of unstable angina, advanced heart block, uncontrolled blood pressure, or similar risks. The regulation allows the examiner to estimate your MET level from a clinical interview instead. The estimate must be expressed in METs and supported by specific real-world examples of activities that trigger symptoms — slow stair climbing, shoveling snow, and the like.²

Your own descriptions matter here. “I get winded going up half a flight of stairs” gives the examiner something concrete; “I can’t do much” doesn’t. Precise examples make the MET estimate defensible on review or appeal.

Diagnostic Codes for Common Heart Conditions

The General Rating Formula applies to most conditions in the schedule, but each diagnosis carries its own diagnostic code and some codes have special rules.²

DC 7000 — Valvular heart disease, including mitral or aortic stenosis.
DC 7001 — Endocarditis.
DC 7002 — Pericarditis.
DC 7005 — Coronary artery disease, one of the most commonly claimed heart diagnoses.
DC 7006 — Myocardial infarction. A heart attack triggers a temporary 100% rating for three months, then the residual is rated under the General Rating Formula.
DC 7010 — Supraventricular arrhythmias.
DC 7011 — Ventricular arrhythmias. This code also governs implantable defibrillators.
DC 7020 — Cardiomyopathy, including hypertrophic and dilated forms.

A confirmed clinical diagnosis has to be in your records before the VA can rate a claim. Vague language like “possible cardiac condition” stalls the claim; a definitive diagnosis tied to a specific code is the starting point.

Implanted Devices: Defibrillator vs. Pacemaker

The gap between the two devices is large. An automatic implantable cardioverter-defibrillator (AICD) earns a 100% rating for as long as the device is in place under DC 7011.² Since AICDs are rarely removed, that generally functions as a permanent 100% rating.

A pacemaker (DC 7018) is different. It receives a temporary 100% rating for one month after hospital discharge following implantation or reimplantation. After that month, the underlying arrhythmia is rated under DC 7010, DC 7011, or DC 7015 for heart block, with a guaranteed minimum of 10%.² Make sure your records accurately reflect which device you have.

Hypertension Is Rated Separately

Hypertension has its own diagnostic code (DC 7101) and uses blood pressure readings rather than METs or LVEF.³

60% — Diastolic pressure predominantly 130 or higher.
40% — Diastolic pressure predominantly 120 or higher.
20% — Diastolic pressure predominantly 110 or higher, or systolic predominantly 200 or higher.
10% — Diastolic predominantly 100 or higher, or systolic predominantly 160 or higher, or a history of diastolic pressure predominantly 100 or more with continuous medication required for control.

The VA wants readings taken on at least three different days. “Predominantly” means most readings, not a single spike at an appointment. Home logs with dates can supplement the clinical readings in your VA file.

If you have both hypertension and coronary artery disease and both are service-connected, they should be rated as separate disabilities because the measurement criteria are entirely different.

Temporary 100% After Surgery or a Cardiac Event

Certain procedures and events trigger a temporary 100% rating during recovery. The window depends on the procedure:²

Heart valve replacement (DC 7016): 100% for an indefinite period following hospital admission, until a re-evaluation sets the permanent rating.
Coronary bypass surgery (DC 7017): 100% for three months following hospital admission.
Cardiac transplant (DC 7019): 100% for a minimum of one year from hospital admission, with a guaranteed minimum of 30% after re-evaluation.
Myocardial infarction (DC 7006): 100% during and for three months following the heart attack, confirmed by lab tests.

Once the temporary period ends, the VA re-evaluates and rates the residual under the General Rating Formula. Transplant is the only one of these that guarantees a minimum 30% permanent rating. The temporary clock runs from the date of hospital admission (or the date of the heart attack for DC 7006), not from the date the VA processes your claim, so back pay covers that window if adjudication drags.

Getting Service Connection When It Wasn’t Diagnosed in Service

You don’t always have to prove the condition started during service. Two pathways matter most for heart claims: presumptive service connection and secondary service connection.

Presumptive Connection for Ischemic Heart Disease

Veterans exposed to Agent Orange or other tactical herbicides get ischemic heart disease as a presumptive condition, meaning a qualifying diagnosis plus qualifying service is enough.⁴ The definition is broad: coronary artery disease, coronary artery spasm, bypass surgery history, all forms of angina (stable, unstable, and Prinzmetal’s), and acute, subacute, and old myocardial infarction all fall within it.

Hypertension, peripheral vascular disease, and stroke are explicitly excluded from the ischemic heart disease definition for herbicide-exposure purposes. Hypertension has its own separate presumptive pathway for Agent Orange exposure.⁵ The PACT Act’s added presumptives for Gulf War and post-9/11 veterans focused mainly on cancers and respiratory disease rather than heart conditions.⁶

Secondary Connection

Under 38 CFR 3.310, a disability is service-connected if it was caused or permanently worsened by an already service-connected condition.⁷ This works both directions for heart claims. A heart condition can be secondary to another service-connected disability, and other conditions (erectile dysfunction, depression, anxiety) can be secondary to service-connected heart disease. Each secondary condition gets its own rating, combined with your heart rating under the VA’s combined ratings math.

Proving secondary connection takes three things: a current diagnosis of the secondary condition, an existing service-connected disability, and a medical opinion linking the two.

TDIU If Your Heart Condition Keeps You from Working

If your rating is below 100% but your heart condition prevents steady employment, Total Disability Based on Individual Unemployability pays at the 100% rate — $3,938.58 for a single veteran with no dependents.⁸ You generally need one service-connected disability rated 60% or more, or two or more service-connected disabilities combined at 70% or more with at least one at 40%, plus evidence you can’t maintain substantially gainful employment because of service-connected conditions. Marginal or occasional work doesn’t disqualify you.

The VA itself uses a heart case as an example: a veteran with a 60% heart rating whose chest pain during activity led a doctor to recommend retirement qualified for TDIU. The medical evidence in a TDIU claim should say specifically why the heart condition prevents work, not just repeat the diagnosis. Severe fatigue that makes a full day unreliable, restrictions on sitting or lifting, and cognitive problems tied to reduced cardiac output all matter, and can make even sedentary work impractical.

Benefit of the Doubt

When the evidence for and against a claim is roughly balanced, the VA is required by statute to decide in the veteran’s favor. The law states that where there is “an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.”⁹

In heart claims this rule tends to matter when your functional capacity falls between two tiers, or when medical opinions disagree about whether a secondary condition is linked to heart disease. If the evidence tips even slightly toward the higher rating or toward service connection, the VA should resolve the ambiguity your way. Citing the rule expressly in a Notice of Disagreement or appeal forces the adjudicator to address it on the record.

1
U.S. Department of Veterans Affairs. Current Veterans Disability Compensation Rates
2
eCFR. 38 CFR 4.104 – Schedule of Ratings, Cardiovascular System
3
eCFR. 38 CFR 4.104 – Cardiovascular System
4
eCFR. 38 CFR 3.309 – Disease Subject to Presumptive Service Connection
5
U.S. Department of Veterans Affairs. Agent Orange Exposure and Disability Compensation
6
U.S. Department of Veterans Affairs. The PACT Act and Your VA Benefits
7
eCFR. 38 CFR 3.310 – Disabilities That Are Proximately Due To, or Aggravated By, Service-Connected Disease or Injury
8
U.S. Department of Veterans Affairs. Individual Unemployability if You Cannot Work
9
Office of the Law Revision Counsel. 38 USC 5107 – Claimants Responsibility; Benefit of the Doubt