Citation Nr: 0110260 Decision Date: 04/06/01 Archive Date: 04/11/01 DOCKET NO. 94-26 154 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to an increased rating for coronary artery disease, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. C. Graham, Counsel INTRODUCTION The veteran served on active duty from May 1965 to January 1971, from July 15, 1972, to July 29, 1972, and from January 1973 to October 1989. The instant appeal arose from a July 1993 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), in Montgomery, Alabama, which denied a claim for an increased rating, above 10 percent, for coronary artery disease with hypertension and angina pectoris. An October 1994 hearing officer decision and subsequent rating decision granted an increased rating, to 30 percent. The 30 percent rating was made effective from the date of the claim for increase in an August 1998 rating decision. This case was remanded by the Board of Veterans' Appeals (Board) in January 1997, April 1999, and March 2000 for further development. FINDING OF FACT The appellant's service-connected heart disorder is currently manifested by noncardiac chest pain; no significant coronary artery disease; a workload of 7 METs (metabolic equivalent); diastolic blood pressure predominantly 100 or less, with medication; no left ventricular dysfunction; and no history of congestive heart failure or myocardial infarction. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for the veteran's service-connected heart disorder have not been met. Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000); 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7007, 7101 (2000); 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7007, 7101 (1997). REASONS AND BASES FOR FINDINGS AND CONCLUSION On November 9, 2000, the President signed into law the Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). The new law applies to all claims, as here, filed before the date of the law's enactment, and not yet finally adjudicated as of that date. See Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, § 7(a), 114 Stat. 2096, 2099-2100 (2000). The new law contains revised notice provisions, and additional requirements pertaining to the VA's duty to assist. See Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, §§ 3-4, 114 Stat. 2096 (2000) (to be codified as amended at 38 U.S.C. §§ 5102, 5103, 5103A, and 5107). As an initial matter, it is the conclusion of the Board that the new law has no impact on the issue in this case. This is true because the VA has already fulfilled the notice and duty to assist requirements of the Veterans Claims Assistance Act. All relevant facts have been properly developed to the extent possible. The record includes the veteran's service medical records; post-service VA, private, and military medical treatment records; a transcript of the veteran's July 1994 hearing before RO personnel; and written statements prepared by the veteran and his representative. Also, over the pendency of this appeal, he has been examined no less than four times by the VA. As noted above, this case has previously been remanded three times by the Board in order to comply with the duty to assist. The veteran has not made the VA aware of any records relevant to the present claim that have not been associated with the claims folder. Thus, as sufficient data exists to address the merits of the claim, the Board concludes that the VA has adequately fulfilled its statutory duty to assist the veteran in the development of his claim. See Veterans Claims Assistance Act of 2000, Pub. L. No. 106-475, 114 Stat. 2096 (2000). See also, Murphy v. Derwinski, 1 Vet. App. 78 (1990) and Littke v. Derwinski, 1 Vet. App. 90 (1990). In addition, the appellant has been notified of the information necessary to substantiate his claim for a disability evaluation in excess of 30 percent. In this regard, the Board notes that the pertinent regulations governing evaluations for diseases of the heart were amended during the pendency of this appeal, effective January 12, 1998. See Schedule for Rating Disabilities; The Cardiovascular System, 62 Fed. Reg. 65207 et seq. (Dec. 11, 1997). He was advised in the August 1998 supplemental statement of the case of the amended requirements necessary to establish entitlement to the benefits sought as he was provided the pertinent regulation, 38 C.F.R. § 4.104, Diagnostic Code 7005 (1998). The April 1999 Board remand provided the pre-amendment version of 38 C.F.R. § 4.104, Diagnostic Code 7005 as regards the next higher, 60 percent, evaluation. Under these circumstances, the Board finds that adjudication of the issue on appeal, without referral to the RO for initial consideration under the new law, poses no risk of prejudice to the veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92 (published at 57 Fed. Reg. 49,747 (1992)). In evaluating the veteran's request for an increased rating, the Board considers the medical evidence of record. The medical findings are compared to the criteria in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2000). In so doing, it is the Board's responsibility to weigh the evidence before it. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In evaluating service-connected disabilities, the Board looks to functional impairment. The Board attempts to determine the extent to which a service-connected disability adversely affects the ability of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. §§ 4.2, 4.10 (2000). 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 (2000). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The veteran was granted service connection for a history of atypical angina in a March 1990 rating decision, and a noncompensable disability evaluation was assigned. That decision was based on a review of service medical records and VA examinations performed in late 1989 and early 1990. The service medical records showed a long history of complaints of chest pain; numerous chest X-rays which revealed no abnormality of the heart; electrocardiographic reports which showed normal variant, nonspecific T wave abnormality, without changes; and normal thallium stress tests without evidence of ischemia. He was hospitalized at St. Anthony Hospital in Oklahoma City for evaluation of chest pain in October 1987, and the only finding was slow flow in the right coronary artery of unknown significance. During service his medications included Procardia, Cardrogen, Ecotrin, and Persantine. His August 1989 retirement examination noted treated high blood pressure and normal blood pressure on examination. The November 1989 VA examination diagnosed a history of atypical angina. A January 1990 thallium stress test gave an impression of findings consistent with near and/or prolonged ischemia of the basal septum and superolateral segment and partially of the posterolateral segment. VA treatment records associated with the file after the March 1990 rating decision included a November 1989 holter report which revealed normal results. However, as the veteran reported three episodes of pain and two episodes of dizziness, it was noted that ischemia could not be ruled out. A December 1989 stress test was negative for ischemia with good exercise tolerance. The veteran requested an increased rating in January 1993. The Board has reviewed treatment records from the United States Army Medical Department Activity in Fort McClellan, Alabama, dated from 1989 to 1992. These records included a November 1989 electrocardiographic report which revealed sinus bradycardia and nonspecific T wave changes. An October 1989 record assessed hypertension without control secondary to omission of medication. A December 1989 stress test from Noble Army Community Hospital was negative for ischemia as was a January 1990 holter report. Blood pressure was normal at that time. A February 1990 record gave an assessment of coronary artery disease. Around June 1990, the veteran was seen by a private cardiologist in Huntsville, Alabama, who noted the pertinent history. The veteran denied hypertension, and it was not found on examination. Physical examination was essentially normal, and he noted more prominent T wave changes on electrocardiogram (EKG). Due to the veteran's complaints of chest pain and treadmill tests reported as normal and abnormal, the cardiologist recommended cardiac catheterization. A June 1990 discharge summary from Huntsville Hospital revealed that cardiac catheterization with coronary arteriography showed no significant coronary artery disease. A left ventriculogram was noted to reveal no regional wall abnormalities. Left ventricular function may have been depressed, but that finding was hard to interpret due to the fact that the veteran was taking Corgard and Cardizem. It was recommended that all heart medication except Procardia be discontinued. An April 1992 outpatient treatment record from the Redstone Arsenal in Alabama, assessed possible hypertension. In April 1993 the veteran was hospitalized at the VA Medical Center (MC) in Birmingham, Alabama, for cardiac catheterization. That record referred to the January 1990 thallium stress test findings, consistent with near and/or prolonged ischemia of the basal septum and superolateral segment and partially of the posterolateral segment, as "clinically positive and electively nondiagnostic." The veteran reported chest pain worsening over the last two months which radiated to his left arm and elbow and increased consistently when he walked up stairs. He stated that recently the chest pain occurred at rest and was associated with shortness of breath and nausea. Chest X-ray showed increased heart size, and EKG showed normal sinus rhythm and no changes since 1989. Cardiac catheterization revealed normal coronary angiogram, normal left ventriculogram, and systemic arterial hypertension. He was noted to have mild diastolic hypertension, and blood pressure control was recommended. It was believed that his pain was due to gastroesophageal reflux disease (GERD). A May 1993 rating decision recharacterized the veteran's service-connected heart disability, formerly rated as history of atypical angina, as coronary artery disease with hypertension and angina pectoris, and increased the disability evaluation to 10 percent based on the post-service military treatment records. An October 1993 chest X-ray was normal. In August 1994 the veteran underwent a VA heart examination. He reported chest pain with headache, sweating, and tingling in the hands; shortness of breath, sometimes at rest; and severe dyspnea with exertion. He also reported a history of three angioplasties. The diagnosis was severe coronary artery disease, status postoperative angioplasty times three. An August 1994 thallium stress test gave an impression of ischemia in the interior wall extending into the lateral wall, anterior wall, and basal septum. That month, the veteran also underwent a VA hypertension examination. He reported no symptoms in connection with hypertension. Sitting blood pressure was 130/80 and 135/85; standing was 150/90; and lying was 130/84. Medications included aspirin, Cardizem, Isosorbide, Benazepril, and Nitroglycerine. The left border of the heart was located at the left anterior axillary line by percussion. The apical beat was not visible or palpable. The diagnosis was "essential hypertension (borderline control)." The veteran was hospitalized from November 14, 1994, to November 16, 1994, at the Birmingham VAMC. He was admitted for left heart catheterization. However, the cardiology department declined to perform the procedure after reviewing the 1993 catheterization which had revealed normal results as well as reportedly finding a normal thallium test within the last six months. The veteran was hospitalized from April 29, 1996, to May 1, 1996, at the Birmingham VAMC. The diagnoses included "atypical chest pain, not coronary artery disease" and hypertension. A left heart catheterization was performed which revealed normal coronary arteries. The veteran reported having angioplasties in 1987 and in 1992. It was noted that an April 1996 thallium stress test was positive for ischemia. A review of that record shows a normal EKG that month. The report concluded "as the patient now has two left heart catheterizations revealing normal coronary arteries, another source of his atypical chest pain should be researched as it is almost definitely not coronary in origin." VA treatment records include a January 1998 record of a blood pressure check. Blood pressure readings were 118/70 on the right and 110/78 on the left. His hypertension was noted to be stable. A March 1998 blood pressure check revealed readings of 110/70 on the right and 110/80 on the left. Again, his hypertension was noted to be stable. In May 1998 the veteran underwent another VA examination. He reported shortness of breath, irregular heartbeats, and chest pain. It was reported that he had "four times angiopathy, right" with the last procedure performed in 1990. Blood pressure was 130/85. The diagnoses were essential hypertension and generalized arteriosclerosis with coronary insufficiency and status post four times angiopathy. The Board has reviewed recent VA treatment records dated through April 2000. These records consistently show that the veteran had essentially good control of his hypertension and that his complaints of chest pain were believed by the physicians in charge of his care to be due to noncardiac causes. An October 1999 record noted excellent hypertension control. A January 1999 treatment record noted, as regards the veteran's complaints of chest pain, that normal results of cardiac testing "makes me think that this is not cardiac." Later that month, the veteran's chest pain had improved and that the physician "still doubt[ed] a cardiac etiology." His blood pressure was 155/90. An April 1999 cardiology consultation report concluded "atypical chest pain with no epicardial coronary artery disease." It was suspected that the chest pain was nonischemic. A June 1999 EKG was normal. In June 1999, the veteran underwent another VA examination. The examiner noted that the claims folder had been reviewed in detail. The examiner noted a disparity between the veteran's understanding of his heart problems and the chart records. The examiner noted "a longstanding history of chest pain with features very typical for coronary disease, however, with repeated normal cardiac catheterizations." The examiner noted that the main source of disparity was that the veteran believed he had a percutaneous transluminal coronary angioplasty in 1987 in a Texas hospital. The examiner found the report in the service medical records of cardiac catheterization at St. Anthony Hospital in 1987 and that discharge notes revealed normal arteriography. The examiner noted that the veteran reported continued chest pain, at times severe. The examiner noted the normal results of the 1993 and 1996 cardiac catheterizations. The veteran described dyspnea at one block and that he was recently found to have an aortic murmur consistent with aortic valve disease. His estimated level of metabolic equivalents (METs) was 7. The examiner noted that an EKG from April 1999 showed sinus rhythm, left axis deviation and nonspecific ST-T wave abnormality. Medications included Diltiazem, aspirin, Isosorbide, Hydrochlorothiazide, Lisinopril, and Lansoprazole. The impressions included hypertension, aortic valvular murmur with probable hemodynamic insignificant aortic stenosis, and atypical chest pain. The examiner concluded that the veteran's "chest pain, in the setting of normal epicardial arteries as well as normal left ventricular function, places him in a category atypical for coronary disease." The examiner suggested that the chest pain might be due to microvascular flow limitation. The examiner indicated that if microvascular coronary artery disease could be excluded with certainty, then he would tend to conclude that the abnormal findings on the thallium stress tests were false positives. The June 1999 examiner provided a supplemental report in June 2000 in response to the Board's April 2000 remand. The examiner noted that he had reviewed a June 1999 echocardiogram taken shortly before the June 1999 VA examination. He noted that the echocardiogram showed no evidence of aortic stenosis; no evidence of concentric left ventricular hypertrophy; and evidence of normal left ventricular function. He also noted that he had reviewed an October 1998 sestamibi stress test which showed a normal study, including normal thickness and normal size of the left ventricular and normal profusion. The examiner concluded that "[i]n view of his previously normal coronary arteriographies or coronary catheterizations as well as the normal profusion study, in my opinion the [veteran] has no significant coronary artery disease." He also found no evidence of myocardial infarction or coronary occlusion. He stated that there was no evidence of congestive heart failure in the past year, and he stated that the veteran's exertional chest pain "most likely is noncardiac in origin." The veteran's service-connected heart disorder is presently evaluated as 30 percent disabling under Diagnostic Code 7005 for coronary artery disease. Prior to January 12, 1998, coronary artery disease was evaluated in accordance with the criteria set forth at 38 C.F.R. § 4.104, Diagnostic Code 7005 (1997). Under the old regulations, a 30 percent rating is assigned following typical coronary occlusion or thrombosis or with a history of substantiated anginal attack, ordinary manual labor feasible. Id. A 60 percent evaluation is for application when there is arteriosclerotic heart disease following typical history of acute coronary occlusion or thrombosis, as above, or with history of substantiated repeated anginal attacks, more than light manual labor is not feasible. Id. A 100 percent evaluation is warranted for arteriosclerotic heart disease during and for six months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc. Id. A 100 percent evaluation is also warranted for arteriosclerotic heart disease after six months following acute illness, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded. Id. Under the new regulations, a 30 percent evaluation is assigned when documented coronary artery disease resulting in a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2000). A 60 percent evaluation is assigned for documented coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent evaluation is assigned for documented coronary artery disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. Id. The Court has stated that where the law or regulation changes during the pendency of a case, the version most favorable to the veteran will generally be applied. Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). The VA General Counsel has addressed the retroactive applicability of revised Rating Schedule criteria to increased rating claims and has determined that in such circumstances as those presented here, the Board should first determine whether the amended regulation is more favorable to the claimant. VAOPGCPREC 3- 2000. The Board has separately applied the new and the old versions of the regulation to the facts of the case, discussed in further detail below, and has determined that the new and old provisions are equally favorable to the veteran as, under either version, he is entitled to no more than a 30 percent schedular rating. This is so because the preponderance of the evidence reveals that the veteran does not have coronary artery disease with symptoms which satisfy the 60 percent or higher ratings under either the old or the new rating criteria. As regards the old criteria, which requires either a history of acute coronary occlusion or thrombosis or substantiated repeated anginal attacks, more than light manual labor is not feasible, for a 60 percent rating, the Board notes that the medical records do not demonstrate that the veteran's heart problems satisfy any of these criteria. First, the medical records do not show a history of acute coronary occlusion or thrombosis. Second, the medical records do not show "substantiated repeated anginal attacks." As regards the second point, the Board is aware that the medical record is replete with the veteran's subjective complaints of chest pain, and that, on occasion, medical professionals have suggested that this chest pain is angina, related to coronary artery disease. The evidence which supports the claim includes outpatient treatment records dated in 1989 and 990, provided by Fort McClellan, which diagnosed angina and coronary artery disease; an August 1994 VA examination report which diagnosed severe coronary artery disease, status postoperative angioplasty times three; a May 1998 VA examination which diagnosed "generalized arteriosclerosis with coronary insufficiency and status post four times angiopathy"; and several thallium stress tests positive for ischemia. The evidence which does not support the claim includes the June 1990 discharge summary from Huntsville Hospital which revealed no significant coronary artery disease after cardiac catheterization with coronary arteriography was performed; the April 1993 VAMC Birmingham discharge summary which attributed the veteran's complaints of chest pain to GERD after normal findings on cardiac catheterization; the April/May 1996 VAMC Birmingham hospitalization report which diagnosed "atypical chest pain, not coronary artery disease" after yet another normal left heart catheterization; VA outpatient treatment records in 1999 which repeatedly assessed the chest pain as noncardiac and that there was no coronary artery disease; and the June 1999 VA examination report with the June 2000 addendum which found no significant coronary artery disease. The preponderance of the evidence shows that the veteran's chest pain is non-cardiac; therefore, he does not have a history of substantiated repeated anginal attacks. The Board is highly persuaded by the conclusions of the VA physician who examined the veteran in 1999 and prepared a supplemental report in 2000. This examiner concluded that the veteran's chest pain was "most likely non cardiac in origin" and that he had "no significant coronary artery disease." His findings are particularly probative because he clearly reviewed the evidence of record, including the service medical records and post-service treatment records in reaching his conclusion. None of the medical evidence which supports the claim indicates that the medical record had been reviewed. The Board weighs more heavily the medical evidence which does not support a finding of coronary artery disease and angina than the evidence which supports the veteran's contentions because the medical evidence which does not support the claim was, in general, made after more significant diagnostic testing than that performed in connection with the medical evidence which supports the claim. The non-supportive findings are more probative because they were frequently made after a period of inpatient treatment when the veteran had undergone invasive diagnostic testing as well as noninvasive diagnostic testing. None of the findings in the medical evidence which supports the veteran's contentions, on the other hand, were made after a period of inpatient treatment or in connection with cardiac catheterization. Lastly, some of the supportive medical evidence, like the diagnoses at the time of the August 1994 and May 1998 VA examinations, were apparently based solely on the medical history provided by the veteran. As such, that medical evidence is less probative. The 1994 examiner reported the veteran had undergone three angioplasties, and the 1998 examiner reported that the veteran had undergone four angioplasties, all between 1985 and 1990. The veteran was apparently the source of the examiners' findings that he had undergone numerous angioplasties, when, in fact, the medical evidence does not show that the veteran had ever undergone a single angioplasty. The June 1999 examiner, who did have the benefit of the record to review, noted this disparity in that the veteran reported a history of angioplasty, yet the medical records only revealed evidence of negative cardiac catheterizations. The 1994 and 1998 examiners apparently did not review the medical record, and there is no indication that the examiners ordered any diagnostic testing in connection with the examination. Thus, it appears that his diagnoses of severe coronary artery disease, status postoperative angioplasty times three, and generalized arteriosclerosis with coronary insufficiency and status post four times angiopathy, were based solely on misinformed statements made by the veteran. LeShore v. Brown, 8 Vet. App. 406 (1995). As such, they do not carry significant probative weight. As regards the thallium stress tests that were indicative of ischemia, the Board does not find these test results to be persuasive evidence of significant coronary artery disease. The June 1999 VA examiner noted that he would tend to conclude that the abnormal findings on the thallium stress tests were false positives if coronary artery disease could be excluded with certainty. As his statements in the June 2000 addendum to his report appear to reveal that he excluded coronary artery disease with certainty after reviewing the normal perfusion study, it would seem that one could conclude, based on his June 1999 findings, that the thallium stress tests were false positives. As regards the supporting evidence in the form of the outpatient treatment records dated in 1989 and early 1990, provided by Fort McClellan, which diagnosed angina and coronary artery disease, the Board finds that these records are not persuasive evidence that the veteran actually has angina and coronary artery disease, let alone manifested to the levels of a 60 percent disability evaluation. This is so because after the veteran's cardiac system was fully evaluated in early June 1990, records provided by Fort McClellan no longer show these diagnoses of coronary artery disease and angina. Instead, a late June 1990 record, noting the normal results of the testing in early June, shows acknowledgment that the veteran had normal coronary arteries. For these reasons, the Board does not find that a higher rating is warranted under the old criteria. The Board also does not find that a higher rating is warranted under the new rating criteria for Diagnostic Code 7005. The medical evidence does not show that the veteran's service-connected heart disorder has resulted in documented coronary artery disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. First, as noted above, the preponderance of the medical evidence does not reveal that the veteran has documented coronary artery disease. However, even assuming he does, his heart disorder does not satisfy any of the criteria necessary for a 60 percent rating under Diagnostic Code 7005. First, the medical evidence does not show any episodes of congestive heart failure in the past year. The June 2000 addendum to the 1999 VA examination report concluded, after a review of the record, that there was no evidence of congestive heart failure in the past year. Second, the medical evidence does not show that a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope. The June 1999 examiner estimated that the veteran had a workload of 7 METs. Third, the medical evidence does not show left ventricular dysfunction with an ejection fraction of 30 to 50 percent. After reviewing the record and a June 1999 echocardiogram, the June 2000 VA examination report addendum found normal left ventricular function. For these reasons, the Board does not find that a higher rating is warranted under the new criteria. The Board has also considered the application of other Diagnostic Codes. Because the veteran has hypertension, the Board has considered the application of Diagnostic Code 7007 for hypertensive heart disease. The old criteria for a 60 percent rating under that Diagnostic Code required marked enlargement of the heart, confirmed by roentgenogram, or an apex beat beyond the midclavicular line, sustained diastolic hypertension with diastolic blood pressure readings of 120 or more, which may later have been reduced, dyspnea on exertion, more than light manual labor is precluded. 38 C.F.R. § 4.104, Diagnostic Code 7007 (1997). The Board does not find that a 60 percent rating is warranted under the old Diagnostic Code 7007 criteria as the medical evidence does not reveal marked enlargement of the heart. An October 1998 sestamibi stress test was noted in the June 2000 VA addendum to show normal size of the left ventricular. While the April 1993 VA hospitalization record noted increased heart size on X-ray, the Board does not find that this finding alone warrants a 60 percent rating under Diagnostic Code 7007 because later diagnostic testing did not reveal heart enlargement and because the veteran does not satisfy any of the other criteria for a 60 percent rating. The medical evidence does not show an apex beat beyond the midclavicular line or sustained diastolic hypertension with diastolic blood pressure readings of 120 or more at any time. While the veteran has reported dyspnea on exertion, the preponderance of the medical evidence, detailed above, reveals that his symptoms are not due to heart disease. The Board also does not find that a 60 percent rating is warranted under the new Diagnostic Code 7007 criteria. The Diagnostic Code 7007 criteria for a 60 percent rating are identical to the criteria for a 60 percent rating under Diagnostic Code 7005. 38 C.F.R. § 4.104, Diagnostic Code 7007 (2000). Thus, for the same reasons that a higher, 60 percent, rating was denied under Diagnostic Code 7005, above, a higher, 60 percent, rating is denied under Diagnostic Code 7007. Lastly, the Board has considered the application of Diagnostic Code 7101 for hypertensive vascular disease as the veteran is service-connected for hypertension. Under both the old and the new criteria, a 60 percent rating is warranted where the diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101 (2000); 38 C.F.R. § 4.104, Diagnostic Code 7101 (1997). A review of the evidence of record does not reveal that the veteran's diastolic pressure has ever been predominantly 130 or more. The medical evidence shows that the veteran's hypertension is currently well controlled, and that his diastolic pressure is predominantly less than 100. For example, a January 2000 VA treatment record shows a diastolic pressure reading of 86. The Board notes that the veteran had requested separate evaluations for coronary artery disease and hypertension. 38 C.F.R. § 4.14 states that evaluation of the same disability under various diagnoses is to be avoided. The Court in Esteban v. Brown, 6 Vet. App. 259 (1994), held that conditions are to be rated separately unless they constitute the "same disability" or the "same manifestation" under 38 C.F.R. § 4.14. Esteban, 6 Vet. App. at 261. The Board notes that when the RO addressed this issue, it determined, in the September 1999 supplemental statement of the case, that a separate rating for hypertension was not warranted as hypertension is considered a precursor of the arteriosclerotic process and was therefore included in the overall evaluation of the disease. The Board notes that separate evaluations under Diagnostic Code 7005 for coronary artery disease and 7101 for hypertensive heart disease are not warranted since Diagnostic Code 7005 contemplates such impairment. To separately service connect hypertension and coronary artery disease would be a matter of evaluating the same manifestations under different diagnoses. No distinct disability is shown to warrant a separate evaluation. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an increased rating for the veteran's service-connected heart disorder. ORDER A claim for an increased rating for coronary artery disease, currently evaluated as 30 percent disabling, is denied. C. P. RUSSELL Member, Board of Veterans' Appeals