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In other than paired organs, conditions may co-exist which through interaction may give also rise to the need for consideration under the greater disablement principle. One of the simplest example is, the pensioner with entitlement for bronchitis who also suffers from coronary atherosclerosis and as a consequence of acute bouts of coughing claims increasing frequency of attacks of angina. In such cases it is a matter of clinical judgement as to the extent to which the assessment for bronchitis should be increased to cover the greater disablement arising from the interaction between that condition and the coronary atherosclerosis. The pensioner is not entitled to the total assessment of disablement for the coronary atherosclerosis which might well be in the regions of 30 to 40%, but only to that portion of that assessment which it is reasonable to add to cover greater disablement. Depending on the increased frequency in the 27 attacks of angina due to severe bouts of coughing a greater disablement addition in the less than 20% range might well be appropriate.

"43. Hypertension - The first consideration should be to determine whether the· hypertension is primary or secondary. If secondary, entitlement considerations should be directed to the underlying disease process (e.g. Nephritis), and it is unnecessary to notify hypertension separately. As in the case of atherosclerosis, entitlement of attributability is never appropriate, but where disablement for essential hypertension appears to have WP(C) No.3173/2023 along with connected matters arisen or become worse in service, the question whether service compulsions have caused aggravation must be considered. However, in certain cases the disease has been reported after long and frequent spells of service in field/HAA/active operational area. Such cases can be explained by variable response exhibited by different individuals to stressful situations. Primary hypertension will be considered aggravated if it occurs while serving in Field areas, HAA, CIOPS areas or prolonged afloat service."

"47. Ischaemic Heart Disease (IHD). IHD is a spectrum of clinical disorders which includes asymptomatic IHD, chronic stable angina, unstable angina, acute myocardial infarction and sudden cardiac death (SCD) occurring as a result of the process of atherosclerosis. Plaque fissuring and rupture is followed by deposition of thrombus on the atheromatous plaque and a variable degree of occlusion of the coronary artery. A total occlusion results in myocardial infarction in the territory of the artery occluded.

Prolonged stress and strain hastens atherosclerosis by triggering of neurohormonal mechanism and autonomic storms. It is now well established that autonomic nervous system disturbances precipitated by emotions, stress and strain, through the agency of catecholamines affect the lipid response, blood pressure, increased platelet aggregation, heart rate and produce ECG abnormality and arrhythmias.