92 Decision Citation: BVA 92-01626 Y92 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 91-42 742 ) DATE ) ) ) THE ISSUE Entitlement to an increased evaluation for a heart disorder, currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Nadine W. Benjamin, Associate Counsel INTRODUCTION The matter came before the Board on appeal from a rating decision of May 1990 from the Lincoln, Nebraska, Regional Office. The veteran served on active duty from April 1978 to August 1989. The notice of disagreement was received in June 1990. The statement of the case was issued in October 1990. The substantive appeal was received in November 1990. In December 1990, the veteran appeared at a personal hearing conducted at the regional office, and gave testimony in support of his claim. In March 1991, a supplemental statement of the case was issued. In September 1991, the case was docketed by the Board. The veteran has been represented throughout his appeal by the Disabled American Veterans, and a representative from that organization submitted an informal hearing presentation in October 1991. The case is now ready for appellate review. By a rating decision dated in January 1990, service connection was granted for a heart condition, and a 100 percent evaluation was assigned from August 1989. In May 1990, the regional office reduced the veteran's evaluation from 100 percent to 30 percent disabling, effective from August 1990. This appeal ensued. CONTENTIONS The veteran contends that his service-connected heart condition has not improved, and that therefore, the reduction of his rating was in error. The veteran asserts that his most recent Department of Veterans Affairs (VA) examination was inadequate, lasting only 10 minutes, and that his disorder could not be fairly evaluated by that examination. DECISION OF THE BOARD For the reasons and bases hereinafter set forth, it is the opinion of the Board that the preponderance of the evidence supports the veteran's claim for an increased rating for his service-connected heart disorder. FINDING OF FACT The veteran's service-connected heart disorder is currently manifested by complaints of dizziness, shortness of breath and angina. More than light manual labor is not feasible. CONCLUSION OF LAW A 60 percent for the veteran's service-connected cardiovascular disorder is warranted. 38 U.S.C. 1155, 5107 (formerly 38 U.S.C. 355, 3007); 38 C.F.R. Part 4, Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board notes that we have found that the veteran's claim is "well grounded" within the meaning of 38 U.S.C. 5107(a) (formerly 38 U.S.C. 3007(a)); effective on and after September 1, 1989. That is, we find that he has presented a claim which is not implausible. We are also satisfied that all relevant facts have been properly developed. The evidence of record includes a VA disability evaluation examination report, which includes a history and physical examination, X-rays, and reports of laboratory tests. Also of record are a VA hospitalization report and outpatient treatment records. We are of the opinion that, while the veteran questions the adequacy of his VA examination, the record contains adequate evidence upon which to make a determination, and that therefore no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C. 5107(a). Service connection is in effect for coronary artery disease, status post myocardial infarction with possible left ventricle aneurysm and pulmonary hypertension. The agency of original jurisdiction has assigned a 30 percent evaluation for the veteran's service-connected heart disorder under the provisions of Diagnostic Code 7005 of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. 1155 (formerly 38 U.S.C. 355); 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. 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. A 30 percent evaluation is warranted for arteriosclerotic heart disease after 6 months following acute illness from coronary occlusion or thrombosis, or with a history of substantiated anginal attacks, when ordinary manual labor is feasible. A 60 percent evaluation is warranted following a typical history of acute coronary occlusion or thrombosis, or with a history of substantiated repeated anginal attacks, when more than light manual labor is not feasible. Authentic myocardial insufficiency with arteriosclerosis may be substituted for occlusion in these evaluation criteria. A 100 percent evaluation is also appropriate after this six-month period with chronic residual findings of congestive heart failure or angina on moderate exertion or when more than sedentary employment is precluded. Authentic myocardial insufficiency with arteriosclerosis may be substituted for occlusion in these evaluation criteria. 38 C.F.R. Part 4, Code 7005. The veteran's service medical records show that in June 1989, a Medical Board Evaluation Report was written. It notes that in March 1989, the veteran was treated for progressive dyspnea which had occurred over the prior three months. At that time, cardiomegaly was noted on X-ray, and an EKG showed anteroseptal myocardial infarction. He was subsequently evaluated at the Bethesda Naval Hospital in April 1989, and underwent a cardiac catherization. A hemodynamic analysis showed mild pulmonary hypertension. The veteran was felt to have single vessel coronary artery disease, evidence of a prior anterior apical myocardial infarction, left ventricular dysfunction, elevated left ventricular endiastolic pressure, and pulmonary hypertension. He was placed on limited duty, and Captopril was prescribed. He was referred to the medical board where his current symptoms included shortness of breath and lightheadedness. He was diagnosed as status post myocardial infarction due to fixed obstructive coronary artery disease, congestive heart failure with a functional class of II-C, left ventricular aneurysm with thrombus, and mild pulmonary hypertension. In February 1990, the veteran underwent a VA examination, and he reported regular heart rhythm with no definite chest pain. It was noted that he could walk 30 to 35 minutes at a moderate pace going uphill before experiencing shortness of breath. An electrocardiogram was reported to show changes consistent with a left ventricle aneurysm, and an echocardiogram showed left ventricle and left auricle enlargement with left ventricle dysfunction. Blood pressure was reported to be 106/70. Chest X-rays were normal. The impression was coronary heart disease, pulmonary hypertension, secondary to left ventricle dysfunction, and possible left ventricle aneurysm. The examiner noted that the veteran's functional capacity was Class II and stated that his exercise capacity was markedly and permanently reduced. In July 1990, the veteran was hospitalized at a VA facility after complaining of chest pain lasting 10 to 15 minutes, which took three nitroglycerin tablets to relieve. He was admitted for unstable angina. Examination showed regular rate and rhythm without murmur; there were no S3 or S4 sounds. During hospitalization, myocardial infarction was ruled out and medication was continued. An echocardiogram showed ischemic cardiomyopathy and an ejection fraction of 25 to 30 percent with extensive anteroseptal infarct. The veteran underwent a thallium exercise treadmill test. He exercised 9 minutes and 2 seconds on a modified Bruce protocol. There were no ST-T changes consistent with ischemia on the treadmill and there was no chest pain. The examination was stopped because of fatigue and shortness of breath. Findings showed the anterolateral and anteroseptal wall with relatively fixed ischemia, compatible with infarct. The veteran remained stable over the course of his hospitalization, which lasted for three days. His condition at release was considered good, and it was noted that he was currently capable of returning to full employment which did not involve strenuous physical activity. The VA received a letter dated in July 1990 from David E. Cantral, M.D., a physician at the Omaha, Nebraska, VA Medical Center. It was stated that he first treated the veteran in October 1989 for followup from a previous hospitalization and evaluation performed at the naval hospital in Bethesda, Maryland. Dr. Cantral noted that the veteran had undergone a myocardial infarction in early 1989 and had had subsequent chronic left ventricular dysfunction with evidence of residual coronary disease. It was stated that the veteran remained symptomatic from his left ventricular dysfunction, that he had chronic dyspnea on exertion and occasional episodes of chest pain which were relieved with nitroglycerin. It was Dr. Cantral's opinion that the veteran's heart condition had not improved since he was initially evaluated in Bethesda, Maryland. VA outpatient treatment records beginning in 1989 have been reviewed. In October 1989, an electrocardiogram was abnormal showing left anterior fascicular block and anterolateral infarct. In November 1989, the veteran complained of feelings of double beats starting approximately one week prior. Examination disclosed no murmurs and regular rate and rhythm. In August 1990, he was examined on two occasions. On August 15, 1990, no ankle swelling was noted and the heart had regular rate and rhythm with no murmurs. On August 24, 1990, he complained of lightheadedness, left chest pain, blurry vision and some weakness. In September 1990, he reported occasional angina, and nitroglycerin use 3 to 4 times a week. His blood pressure was recorded as 118/78 and examination showed regular rate and rhythm with no murmurs or gallops. The veteran was assessed as being stable at that time with weekly angina controlled with nitroglycerin; he was to start routine nitroglycerin patches. The veteran was noted to be doing well overall in October 1990, and noted that he had occasional sharp pain in the left chest wall lasting a few seconds. He reported that anginal symptoms had improved significantly with the use of a nitroglycerin patch. His blood pressure was recorded as 108/70, and examination of the heart showed regular rate and rhythm with no murmurs or gallops. It was reported that the veteran walked 3 to 4 times a week on level ground for approximately 20 to 25 minutes. It was further reported that he was willing to try light jogging. In January 1991, he complained of occasional chest pains relieved with the nitroglycerin patch and nitroglycerin. He stated that he became a little lightheaded at times when standing for a while. Blood pressure was recorded as 118/76, and examination of the heart showed regular rate and rhythm with no murmurs or gallops. Occasional angina with occasional lightheadedness and heart palpation were noted. The Board has also considered the veteran's testimony, presented at his December 1990 personal hearing. The veteran testified that he experiences chest pains and shortness of breath 2 to 3 times a week and lightheadedness when standing up. He stated that he becomes fatigued and must take 2 to 3 naps a day and that recently his prescription for Captopril was increased because of angina attacks. He denied that he could walk 30 to 35 minutes uphill before experiencing shortness of breath and testified that his VA examination, was, in his opinion, cursory. The veteran stated that he previously did surveying work, and had been unable to find employment since his separation from service in 1989. He testified that he did yard work and work around the house and experiences shortness of breath, requiring him to stop and rest. A complete transcript is of record. Under the regulatory criteria for Diagnostic Code 7005, an increased rating of 60 percent would require a finding that the veteran experiences repeated anginal attacks and that more than light manual labor is not feasible. The veteran complains of shortness of breath and chest pain 2 to 3 times per week. When performing household chores, he must stop and rest because of shortness of breath. The clinical evidence of record shows that he has been treated for complaints of angina which is relieved with nitroglycerin. The VA examination report notes a functional classification of Class II, which encompasses slight limitation of physical activity and comfortableness at rest but ordinary physical activity resulting in fatigue, palpitation, dyspnea or anginal pain. A physician has opined that the veteran's condition has not improved since his evaluation in 1989. The Board finds that the evidence reasonably supports a finding that the veteran has a history of repeated anginal attacks and that more than light manual labor is not feasible. As such, a 60 percent rating is warranted. We do not find that a 100 percent rating is supported by the evidence. There is no showing that the veteran would be confined to sedentary work only or that there is angina on moderate exertion. (NOTE: The section numbers of title 38, United States Code, were changed in 1991. The new section numbers are given above, followed, in parentheses, by "formerly 38 U.S.C." and the old section numbers in effect prior to the 1991 revisions.) ORDER A 60 percent evaluation for coronary heart disease, status post myocardial infarction with possible left ventricle aneurysm and pulmonary hypertension, is granted, subject to applicable regulations governing monetary awards. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 ANTHONY FAVA CHARLES E. EDWARDS, M.D. 38 U.S.C. § 7102(a)(2)(A) (1989) (formerly § 4002(a)(2)(A), recodified in 1991) permits a Board of Veterans' Appeals Section, upon direction of the Chairman of the Board, to proceed with the transaction of business without awaiting assignment of an additional Member to the Section when the Section is composed of fewer than three Members due to absence of a Member, vacancy on the Board or inability of the Member assigned to the Section to serve on the panel. The Chairman has directed that the Section proceed with the transaction of business, including the issuance of decisions, without awaiting the assignment of a third Member. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C. 7266 (formerly 38 U.S.C. 4066), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988 (see sec. 402 of the Veterans' Judicial Review Act (Pub. L. 100-687)). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.