Citation Nr: 0029481 Decision Date: 11/08/00 Archive Date: 11/16/00 DOCKET NO. 91-17 814 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for heart disease. 2. Entitlement to an increased rating for paroxysmal supraventricular tachycardia, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL Appellant and his mother ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The veteran served on active duty from July 1955 to May 1957. These matters arise before the Board of Veterans' Appeals (Board) on appeal from a January 1990 rating decision from the Atlanta, Georgia, Regional Office (RO), which, in pertinent part, denied service connection for heart disease with supraventricular tachycardia. The veteran perfected a timely appeal to that decision. This case was previously before the Board in October 1991, September 1994, and February 1999; on each occasion the case was remanded for additional development. By a rating action dated in January 1997, the RO, in pertinent part, granted service connection for paroxysmal supraventricular tachycardia and assigned a schedular 10 percent evaluation for that disability. Additionally, the RO denied service connection for heart disease, claimed as secondary to the service-connected paroxysmal supraventricular tachycardia. Review of the record shows that hearings were held at the RO before a local hearing officer in November 1990 and before a member of the Board in September 1991. The veteran was also afforded a videoconference hearing at the RO before a member of the Board in Washington, D.C. in September 1998. The member of the Board who held the videoconference hearing is making the decision in this case and is the signatory to this decision. In March 1999 the veteran appears to be raising the issue of entitlement to an earlier effective date for the grant of service connection for paroxysmal supraventricular tachycardia. This issue has not been adjudicated by the RO and is referred to the RO for appropriate action. FINDINGS OF FACT 1. Service connection is in effect for paroxysmal supraventricular tachycardia. 2. The veteran has been diagnosed with heart disease, to include arteriosclerotic, coronary, and ischemic types. 3. The veteran's heart disease is not of service origin and is not related to his service-connected paroxysmal supraventricular tachycardia. 4. The veteran's service-connected paroxysmal supraventricular tachycardia is severe with frequent attacks. CONCLUSIONS OF LAW 1. The veteran's heart disease (other than paroxysmal supraventricular tachycardia) was not incurred in nor may it be presumed to have been incurred in active service, nor is it being proximately due to or the result of a service- connected disease or injury. 38 U.S.C.A. §§ 1101, 1112, 1113, 1131, 1137, 5107 (West 1991 & Supp. 2000); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (1999). 2. The criteria for a 30 percent rating for paroxysmal supraventricular tachycardia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. § 4.7, Diagnostic Code 7013 (effective prior January 12, 1998). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Factual Background The veteran's service medical records reveal that at the time of examination for enlistment into active military service, July 1955, his vascular system was within normal limits and that his blood pressure was 118 systolic and 58 diastolic (118/58). In August 1955, the veteran was hospitalized because of irregular heart action and shortness of breath. The diagnosis was observation, medical, for heart disease, because of tachycardia and palpitations, no disease found. The veteran was hospitalized in January 1956 for palpitations, chest pain and shortness of breath. He was discharged in February 1956 with a diagnosis of anxiety reaction, chronic, moderate, in a passive aggressive personality. In November 1956 the veteran was hospitalized for paroxysmal tachycardia. He was transferred to another facility later in November 1956 with a transfer diagnosis of paroxysmal tachycardia and suspect rheumatic fever, systolic gallop and precardial pain. He was discharged in December 1956 with a final diagnosis was paroxysmal tachycardia, cause undetermined. At the time of physical examination for separation from service in May 1957 the veteran's heart and vascular systems were clinically evaluated as normal. His blood pressure was 122/70. A chest x-ray was negative. On file are private treatment records covering a period from 1972 to 1977. During this time he was evaluated for several disorders including palpitations. Several elevated blood pressure readings were also recorded. The veteran was hospitalized at a private facility in December 1980. The discharge diagnoses were arteriosclerotic heart disease; atrial fibrillation; and early congestive heart failure. In January 1985 the veteran was hospitalized at a private facility with a rapid and irregular pulse. An electrocardiogram revealed atrial fibrillation with a rapid ventricular response. He was admitted for cardiac telemetry monitoring and further treatment of his tachyarrhythmia. The veteran was discharged that day with an assessment of paroxysmal atrial fibrillation with a rapid uncontrolled ventricular rate. In February 1985 the veteran was hospitalized at a private facility. The record indicates that he had been followed in the past for years by a number of different cardiologists. The diagnoses were: Atrial flutter with ventricular rate around 160; tendinitis, left shoulder; and right lung base pneumonia. He was hospitalized in February 1985 for pneumonitis and atrial flutter. He reported that his skipping was getting worse. He had no chest pains suggesting ischemic heart disease. The physician indicated that the fact that he had arrhythmia since childhood suggested a congenital basis. An examination of the heart revealed no clicks, murmurs or gallops. Chest X-rays revealed right pneumonia in the lower base which was noted by the physician to be probably the cause of the atrial flutter. Subsequently he received treatment at VA and private facilities for various disorders, including heart disease. On private examination in July 1985 the veteran stated that when he was 18 years of age in Korea he began noticing tachycardia. He stated that he passed out one time after a long run in the Army. He had no further syncopal episodes. He had skipping for several years but this had not bothered him particularly. The veteran was hospitalized by at a private facility in January 1988 because of tachycardia at home. EKGs showed a heart rate of 104. The diagnosis was ventricular tachycardia, by history. He was seen at private and VA facilities during 1998 for palpitations. He was hospitalized at a private facility in August 188 for, paroxysmal supraventricular tachycardia. In April 1990 the veteran was hospitalized at a private facility with a 30-year history of intermittent tachycardia with a recent history of progressively severe angina. The veteran indicated that he had a long history of tachyarrhythmia dating back over 30 years when he was in the Army. The veteran's past medical history included diabetes and hypertension. In May 1990 he underwent triple-vessel coronary bypass. Postoperatively, he developed transient atrial flutter. The veteran was re-hospitalized from late December 1990 to early January 1991, with an eight-hour history of severe palpitations. The diagnoses during the hospitalization were: Coronary atherosclerotic heart disease; history of supraventricular tachycardia (SVT) with proximal atrial fibrillation for greater than 30 years; diabetes mellitus, insulin dependent; history of hypercholesterolemia; scarlet fever as a child; history of Bright's disease; previous back surgery with recent fall last week with injury to back and right foot; and SVT this admission with shortness of breath. The veteran received intermittent treatment at a private facility from 1990 to 1992 for palpitations. Received apparently in 1992 was an undated private medical certificate which indicates that the veteran had severe, recurrent paroxysmal supraventricular tachycardia. A hearing was held at the RO in November 1990. At that time the veteran testified that during his basic training he had a flare-up of heart trouble after taking five injections. He indicated that he had a fever and was hospitalized for approximately one week. After basic training, while stationed in Korea in January 1956, he was rehospitalized with a rapid heart beat. He indicated his second hospitalization was for 20 or 21 days. He also indicated he had been last employed in 1972. Both he and his mother testified that he had never suffered from rheumatic fever. He further testified that no one in his family had ever had a heart problem and that he had been to numerous doctors for his heart disorder both in and after service. A hearing was also conducted before the Board sitting at Washington, D. C. in September 1991. The veteran testified that he had scarlet fever at age 4, but denied suffering from rheumatic fever. He also indicated that at age 14 or 15 he suffered a kidney infection. He testified that he has been on medication for his heart problem. He stated that he experienced tachycardia continuously since service. He stated that the first time he was given "heart pills" was in the 1950's. The veteran's representative contended that the veteran's heart condition may be a result of injections given to him in boot camp which precipitated his heart condition. A VA cardiovascular examination was conducted in March 1995. The veteran complained of chest pain with episodes of anginal-type palpitation at rest. An EKG showed a sinus rhythm rate of 76. Episodes of paroxysmal atrial tachycardia and ischemic heart disease (IHD) were diagnosed. The veteran's cardiac status was noted by the examiner to be moderately compromised. AVA examination was conducted in December 1995. History of tachycardia, paroxysmal atrial supraventricular type, and IHD were diagnosed. The veteran was again noted to be moderately compromised. The examiner added that while the veteran had a documented history of inservice physiologic manifestations of heart disease it was impossible to opine as to when and where the onset of the specific symptoms of coronary artery disease had occurred. The examiner added that the veteran's current arteriosclerotic heart disease should be considered "adjunct" to the supraventricular tachycardia experienced by the veteran while in the military. The veteran's adjudication claims folder was reviewed by a VA fee basis cardiologist. In an undated opinion, following a review of the records, the examiner rendered an opinion that the veteran's supraventricular tachycardia pre-existed his service entrance and appeared to have significantly worsened beyond its natural progression during the time he was in the service. It was stated that the veteran's past history of supraventricular tachycardia was not likely to be related to his current history of atherosclerotic heart disease. It was added that while chronic supraventricular tachycardia could result in some long term cardiac problems, e.g., LV [left ventricle] systolic dysfunction, this did not appear to have been the case in the present case. The physician further opined that the veteran's IHD, which required 4 vessel bypass in 1990, was more likely related to the other exhibited cardiac risk factors. A VA cardiovascular examination was conducted in June 1997. Following the examination of the veteran, the physician indicated that the veteran did not then have supraventricular tachycardia. The veteran was noted to have labile hypertension. It was noted that the medical history implied that the veteran had insulin-dependent diabetes mellitus. The physician further noted that the most likely cause for the veteran's coronary artery disease was the diabetic condition and the history of smoking. It was reported that he smoked one to two packs a day for many years. He quit in 1990 following a heart attack. It was added that there was no evidence that the veteran ever had rheumatic heart disease. No murmurs or clicks were noted to be manifested, and there was no indication of the presence of congestive heart failure at the time of the examination. The diagnoses included Atherosclerotic heart disease, prior history of myocardial infarction, postoperative status coronary artery by-pass, intermittent supraventricular tachycardia presently compensated stable angina, insulin-dependent diabetes mellitus, and labile hypertension. The veteran was hospitalized at a VA facility in June 1997 for a Holter monitor due to complaints of a rapid heartbeat and skipping. The findings showed supraventricular beats every 10.7 SVEs per hour. The interpretation was predominant rhythm was normal sinus. The veteran was hospitalized at a private facility in September and October 1997 for tachycardia, and atrial flutter. The discharge diagnoses were tachyarrhythmia, supraventricular tachycardia, atrial flutter, and atrial fibrillation. Of record is a January 1998 opinion from VA cardiologist. The examiner following a review of the veteran's records noted that it appeared that the veteran's history of supraventricular tachycardia pre-dated his service enlistment and that it was unlikely that this condition was related to his later development of clinical manifestations relating to coronary atherosclerotic heart disease. The examiner stated that the veteran's coronary disease was far more likely to be related to his multiple risk factors, which were noted to include hypercholesterolemia, diabetes, hypertension, and tobacco use. During the veteran's videoconference hearing in September 1998, he testified that he received treatment for heart disease at Villa Rica Hospital in Villa Rica, Georgia in 1957. The veteran was furnished appropriate release of information forms in March 1999 so that VA could attempt to obtain pertinent medical evidence, such as those 1957 records from Villa Rica Hospital. The veteran is not shown to have returned the release forms to VA. He also testified that he has received treatment for his heart disease from a VA cardiologist and that he was told by a nurse that the VA cardiologist concurred with her opinion that the veteran's heart disease, to include paroxysmal atrial fibrillation was related to his service-connected paroxysmal supraventricular tachycardia. He further testified that he was scheduled for a Holter monitor examination on September 24, 1998. The veteran testified that he experienced the tachycardia and flutter daily. An undated letter was submitted in conjunction with the September 1998 hearing from a VA RNCS [Registered Nurse Certified Specialist]. The nurse indicated that the veteran had been under her care since May 1996 for paroxysmal atrial fibrillation. The nurse stated that she and the veteran's cardiologist were of the opinion that the veteran's paroxysmal atrial fibrillation could very well be related to the service-connected supraventricular tachycardia. The nurse also pointed out that cardiology had been asked to put the veteran on an event monitor in order so that her and the veteran's physician could get a better idea as to what was occurring. The letter was signed by both the nurse and the VA cardiologist. Also submitted at the time of the September 1998 hearing was notification from the VA that the veteran was scheduled for a Holter monitor later in September 1998. A VA progress note, dated in September 1998, written by the above-mentioned VA RNCS, indicates that a VA physician had agreed that the veteran should have an event monitor. The note also indicated that the physician had co-signed a letter for the veteran stating that "we" feel that his paroxysmal atrial fibrillation could very well be related to the tachycardia which he had in service. A VA fee-basis cardiology examination was conducted in July 1999. The veteran reported a history of tachycardia since 1955. The examiner noted that supporting rhythm strip documentation was not of record. The veteran was currently asymptomatic and it was noted that the record had been reviewed in its entirety, as was the veteran both interviewed and examined. There was a history of open-heart surgery in 1991. In 1997 the veteran had EKGs documenting supra ventricular tachycardia and atrial fibrillation. It was reported that he was currently in sinus rhythm. EKG was noted to indicate a sinus mechanism and the examiner noted that in comparison with previous EKG's, there had been no significant changes. The examiner noted that it could not be determined exactly what happened concerning the veteran's described tachycardia in 1955 and 1956. Pre-excitation syndrome, rheumatic fever, and alcohol were noted as possible causative factors at a younger age to explain the veteran's inservice tachycardia. The examiner rendered an opinion that as concerning the atrial fibrillation, atrial flutter, and supraventricular tachycardia at a later stage of the veteran's life and after open heart surgery, the most likely cause is attributable to his underlying organic heart disease. The assessment included palpitations in "1995" which the veteran associated with immunization shots in the army. There were no rhythm strips to judge if it was supraventricular tachycardia or sinus tachycardia and atrial flutter as evidenced by the EKGs on admission in 1997. An addendum to the July 1999 examination report, dated in August 1999, shows that the physician opined that the paroxysmal atrial fibrillation is aggravated by the IHD, but did not opine as to the possibility of the reverse being true. The examiner noted that the veteran subjectively described feeling tachycardia and palpitations. According to the examiner the only documentation in the records was that mentioned before or during the veteran's open-heart surgery admission. The examiner also noted that the paroxysmal atrial fibrillation occurred at the time of the veteran's coronary artery bypass graft (CABG) surgery and was most likely due to his underlying IHD. As to the tachycardia in 1955 and 1956, the examiner again noted that it may just have been anxiety or it may have been sinus tachycardia or PSVT [paroxysmal supraventricular tachycardia]. Documentation by either EKG or rhythm strips were noted to not have been provided. Review of the record also contains evidence of a November 1999 email communication between VA personnel concerning the inadequacy of the above-mentioned July 1999 examination report as well as the August 1999 addendum. A printout of a subsequently dated email, dated later in November 1999, shows that a VA employee had spoken with the fee-basis physician who conducted the July 1999 examination. It was reported that the physician indicated that the heart disease was the underlying cause of the veteran's currently complained of tachycardia but could not state the reverse was true, i.e., that the tachycardias are the cause of the veteran's currently diagnosed heart disease. It was further stated that the physician indicated that the veteran was currently asymptomatic and that the only documentation he had to go on was the 3 EKG reports from 1997 which documented supraventricular tachycardia and atrial fibrillation and atrial flutter, but that currently the veteran was shown to be in sinus rhythm. The physician also noted that the rhythm strips in the record happened at the time of the veteran's coronary artery bypass graft surgery and most likely was due to underlying IHD. It was stated that the physician noted that the veteran had complaints of tachycardia, but that recent EKG testing showed sinus mechanism, and in comparison with previous EKG's, there was no significant changes. It was also mentioned that the physician could not comment on anything from 1955-56 because there was no documentation of EKG or rhythm strips available. Service Connection Initially, the Board finds that the veteran's claim is well grounded pursuant to 38 U.S.C.A. § 5107(a) (West 1991) in that the claim is plausible or capable of substantiation. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). This finding is based on the service medical records in opinions from VA physicians. Service connection may be established for disability resulting from personal injury or disease incurred in or aggravated by service. 38 U.S.C.A. § 1131 (West 1991). In the absence of chronicity at onset, a grant of service connection requires evidence of continuity of symptomatology demonstrating that a current disability was incurred in service. 38 C.F.R. § 3.303(b) (1999). Certain chronic diseases, including cardiovascular diseases to include arteriosclerosis, may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active military service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Regulations also provide that service connection may be established where all the evidence of record, including that pertinent to service, demonstrates that the veteran's currently disability was incurred in service. 38 C.F.R. § 3.303(d) (1999). In addition, service connection may be established for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that a claimant is entitled to service connection on a secondary basis when it is shown that the claimant's service-connected disability aggravates a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Court stated that, pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. 3.310(a), when aggravation of a veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. The lay statements and testimony describing the symptoms of heart disease are considered to be competent evidence. However, a diagnosis and an analysis of the etiology regarding such symptoms requires competent medical evidence and cannot be evidenced by lay testimony and statements. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In this regard the service medical records do not contain a definitive diagnosis of heart disease, other than his service-connected disorder. Additionally, the first clinical evidence of the coronary artery disease or hypertension was in the early 1970s, many years after service. There is no medical evidence which related his cardiovascular disease to his period of service. A VA physician in December 1995 stated that it was almost impossible to state when the veteran had the initial onset of the coronary artery disease and, therefore, that the veteran's current arteriosclerotic heart disease should be considered "adjunct" to the supraventricular tachycardia experienced by the veteran while in the military. However, subsequently two cardiologists, rendered medical opinions which essentially indicated that the veteran's service- connected paroxysmal supraventricular tachycardia was not related to the coronary artery disease. Also, there is no competent medical evidence which relates the heart disease to any reported inservice inoculations. The Board finds that in view of the two VA opinions, the preponderance of the evidence is against the veteran's claim for service connection for heart disease. The Board notes that a VA registered nurse and a VA treating physician indicated that the paroxysmal atrial fibrillation could very well be related to the service-connected supraventricular tachycardia. However, as indicated in the May 1998 supplemental statement of the case, the paroxysmal atrial fibrillation is included in the evaluation for the supraventricular tachycardia under Diagnostic 7010. Increased Rating Initially, the Board finds that the veteran's claim is well grounded, in that he has presented a plausible claim. 38 U.S.C.A. § 5107(a) (West 1991). See also Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Pursuant to 38 U.S.C.A. § 5107(a) (West 1991), the Board is obligated to assist the veteran in the development of his claims. Upon a review of the record, the Board finds that all of relevant evidence necessary for adjudication of his claim has been obtained. Therefore, the duty to assist the veteran in the development of fact pertinent to his increased rating claim, as mandated by 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. Disability ratings are based on schedular requirements, which reflect the average impairment of earning capacity occasioned by the state of a disorder. 38 U.S.C.A. § 1155 (West 1991). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (1999). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. § 4.10 (1999). Also, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). The veteran's appeal stems from an original rating decision grant of service connection for the disability at issue wherein the current 10 percent rating was assigned, effective October 31, 1988. Therefore, separate ratings can be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (1999). Effective prior to January 12, 1998, the veteran's service- connected paroxysmal supraventricular tachycardia may have been evaluated under 38 C.F.R. § 4.104, Diagnostic Code 7013. Under that diagnostic code, paroxysmal tachycardia, where there are infrequent attacks, the rating is 10 percent. When severe, with frequent attacks, an assignment of a 30 percent rating was warranted. By regulatory amendment effective January 12, 1998, however, substantive changes were made to the schedular criteria for evaluating diseases of the heart, as set forth in 38 C.F.R. § 4.104, Diagnostic Codes 7000-7017. See 62 Fed. Reg. 65207- 65244 (1997). Where the law or regulations governing a claim change while the claim is pending, the version most favorable to the claimant applies, absent congressional intent to the contrary. See Karnas v Derwinski, 1 Vet. App. 308, 312-313 (1991). The Board notes that the RO has properly considered both the current and former regulations in evaluating the veteran's service-connected paroxysmal supraventricular tachycardia disability. The revised regulations do not contain a diagnostic code specifically for paroxysmal supraventricular tachycardia. Rather, Diagnostic Code 7010 concerns supraventricular arrhythmias. Diagnostic Code 7010 provides that permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia, documented by ECG or Holter monitor, warrants a 10 percent evaluation. Paroxysmal atrial fibrillation or other supraventricular tachycardia with more than four episodes per year, documented by ECG or Holter monitor, warrants a 30 percent evaluation. To summarize, the clinical records reflect that the veteran's paroxysmal supraventricular tachycardia has required medical treatment and evaluation, to include several hospitalizations between 1988 and most recently in October 1997. Additionally, the veteran has provided competent testimony that the heart irregularities now occur on a daily basis. Additionally, on one occasion his paroxysmal supraventricular tachycardia was described as severe and recurrent. The current 10 percent rating contemplates infrequent attacks. After reviewing the medical evidence in conjunction with the veteran's statements, it is the Board's judgment that the degree of impairment resulting from the paroxysmal supraventricular tachycardia more nearly approximates the criteria for the next higher evaluation under the old diagnostic criteria. 38 C.F.R. § 4.7, Diagnostic Code 7013. Accordingly, a 30 percent rating is warranted for severe paroxysmal supraventricular tachycardia, with frequent attacks. This 30 percent represents the highest schedular rating authorized under both the old and revised rating criteria. The evidence does not provide a basis which demonstrates that a rating in excess of 30 percent is warranted. The 30 percent rating is the highest rating warranted throughout the appeal period. Fenderson v. West, 12 Vet. App. 119 (1999) ORDER Service connection for heart disease is denied. Entitlement to an evaluation of 30 percent for paroxysmal supraventricular tachycardia is granted subject to the law and regulations governing the payment of monetary benefits. ROBERT P. REGAN Member, Board of Veterans' Appeals - 16 - - 1 -