93 Decision Citation: BVA 93-18264 Y93 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 91-47 633 ) DATE ) ) ) THE ISSUE Entitlement to an increased evaluation for arteriosclerotic heart disease with hypertension, currently evaluated as 60 disabling. REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD J.T. Hutcheson, Associate Counsel INTRODUCTION This matter came before the Board of Veterans' Appeals (hereinafter "the Board") on appeal from a July 1991 rating decision of the Albuquerque, New Mexico Regional Office (hereinafter "the RO") which denied service connection for myelofibrosis and an increased evaluation for arteriosclerotic heart disease with hypertension. The veteran had active military service from March 1936 to October 1962. The notice of disagreement was received in July 1991. The statement of the case was issued in August 1991. The substantive appeal was received in September 1991. The veteran has been represented throughout this appeal by the Paralyzed Veterans of America, Inc. That organization submitted written argument in October 1991. This case was received and docketed at the Board in November 1991. A written presentation from the accredited representative was submitted in November 1991. In March 1992, the Board remanded this case to the RO so that additional clinical documentation could be obtained for incorporation into the record and so that the issue of secondary service connection for myelofibrosis could be formally considered. Written argument was received in March 1992. Additional treatment records were incorporated into the record. In October 1992, the RO increased the disability evaluation for the veteran's heart disorder from 30 to 60 percent and denied service connection for myelofibrosis as secondary to his service-connected arteriosclerotic heart disease with hypertension. A supplement statement of the case was issued in November 1992. In a November 1992 statement, the veteran expressly withdrew his appeal as to the issue of service connection for myelofibrosis. This case was again received and docketed at the Board in March 1993. A second written presentation from the accredited representative was submitted in April 1993. CONTENTIONS OF APPELLANT ON APPEAL The veteran asserts on appeal that the RO erred in failing to grant an evaluation in excess of 60 percent for his service-connected cardiovascular disorder as that disability is productive of chronic congestive heart failure and renders him unable to perform any activity. He contends that although his congestive heart failure may arise from either his service-connected arteriosclerotic heart disease and hypertension, his nonservice-connected myelofibrosis or a combination thereof, he merits the award of a 100 percent disability evaluation upon resolution of reasonable doubt in his favor. The accredited representative requests that, if the Board is unable to grant the benefit sought on appeal, this case be again remanded to the RO so that an additional cardiovascular examination may be conducted. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claim file, it is the decision of the Board that the record supports the allowance of a 100 percent disability evaluation for arteriosclerotic heart disease with hypertension. FINDING OF FACT The veteran's arteriosclerotic heart disease with hypertension may be presumed to significantly contribute to chronic congestive heart failure and subsequent preclusion from more than sedentary employment. CONCLUSION OF LAW The schedular criteria for a 100 percent rating for arteriosclerotic heart disease with hypertension have been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, including § 4.3 and Diagnostic Codes 7005, 7007 (1992). REASONS AND BASES FOR FINDING AND CONCLUSION Initially, it is necessary to determine if the veteran has submitted a well-grounded claim within the meaning of 38 U.S.C.A. § 5107(a) (West 1991), and if so, whether the Department of Veterans Affairs (hereinafter "VA") has properly assisted him in the development of his claim. A "well-grounded" claim is one which is not implausible. Our review of the record indicates that the veteran's claim is plausible. In addressing the accredited representative's request that the veteran be afforded an additional VA cardiovascular examination, we observe that the veteran's claims file contains several detailed cardiovascular evaluations conducted during his almost monthly hospitalizations. Therefore, we conclude that further VA examination would merely duplicate clinical findings already of record. Accordingly, an additional remand in order to allow for further development of the record is not appropriate. I. Historical Review The veteran's service medical records indicate that he suffered from hypertension associated with shortness of breath, chest pain and a pounding heart. In May 1980, service connection was established for arteriosclerotic heart disease with hypertension. II. Increased Evaluation The veteran advances on appeal that his service-connected cardiovascular disorder is manifested by severe cardiovascular symptoms including chronic congestive heart failure and therefore warrants the assignment of a 100 percent evaluation under the provisions of 38 C.F.R. Part 4, Diagnostic Code 7005 (1992). The Board observes that disability evaluations are determined by comparing the veteran's present symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1992). A 60 percent evaluation is warranted for arteriosclerotic heart disease 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. A 100 percent evaluation is warranted during, and for six months following, acute illness from coronary occlusion or thrombosis with circulatory shock. A 100 percent evaluation is also appropriate after this six month period with chronic residual findings of congestive heart failure; angina on moderate exertion or where 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, Diagnostic Code 7005 (1992). A 60 percent evaluation is warranted for hypertensive heart disease with marked enlargement of the heart (confirmed by roentgenogram or an apex beat beyond the mid-clavicular line), sustained diastolic pressure of 120 or more (which may have later been reduced), dyspnea on exertion and the preclusion of more than light manual labor. A 100 percent evaluation requires definite signs of congestive heart failure and the preclusion of more than sedentary employment. 38 C.F.R. Part 4, Diagnostic Code 7007 (1992). An August 1989 statement from Richard D. Lueker, M.D., notes that the veteran reported suffering from a blood disease and denied experiencing any symptoms of angina, congestive failure, arrhythmia or syncope. Dr. Lueker found that the veteran suffered from blood dyscrasia and exhibited significant overall cardiomegaly and mildly elevated blood pressure. An August 1989 statement from Armin E. Rembe, M.D., indicates that the veteran suffered from myelofibrosis with secondary anemia. A May 1990 hospital summary and associated treatment records from Chandler Regional Hospital convey that the veteran was admitted in obvious congestive heart failure with myelofibrosis and a thyroid nodule. After a period of treatment which included the prescription of Lasix (a medication prescribed to control hypertension and edema), the veteran's condition improved. At discharge from the hospital, the veteran was diagnosed with myelofibrosis with secondary anemia, congestive heart failure secondary to anemia, possible restrictive cardiomyopathy, occult hyperthyroidism and hypertension by history. A December 1990 statement from Dr. Lueker notes that the veteran exhibited a blood pressure of 140/64; a heart rate of between 96 and 102; a point of maximum impulse in the sixth intercostal space; and no significantly distended neck veins or significant murmur. The doctor reported that a March 1990 echocardiogram showed significantly increased thickness of the septum free wall and enlargement of the left ventricle. Dr. Lueker diagnosed the veteran as suffering from "myofibrosis and congestive [heart] failure" and presumed that "his failure is secondary to high output state produced in part by the anemia and also in part because of the increased wall thickness of the left ventricle. A December 1990 Air Force treatment record notes that the veteran discontinued taking his Lasix due to the presence of normal blood pressure and lack of congestive heart failure symptoms. Air Force medical personnel diagnosed the veteran as suffering from congestive heart failure secondary to discontinuance of Lasix. An April 1991 Air Force medical summary conveys that the veteran complained of shortness of breath with mild exertion and extreme fatigue and that he suffered from myelofibrosis, hypertension, congestive heart failure secondary to high cardiac output and thrombocytosis. The veteran's Air Force physician concluded that he was 100 percent disabled and unable to work secondary to extreme fatigue and shortness of breath due to congestive heart failure and chronic anemia. At the May 1991 VA examination for compensation purposes, the veteran's history of myelofibrosis and associated blood dyscrasia, extremely low hematocrit, frequent blood transfusions, shortness of breath on slight exertion and periods of high output congestive heart failure was noted. The veteran denied experiencing true angina or severe chest pain. The VA examiner diagnosed the veteran as suffering from myelofibrosis with marked anemia and extremely low hematocrit; "some" arteriosclerotic heart disease and mild hypertension controlled by medication. The examiner concluded that the veteran's cardiac failure was secondary to his blood disorder. Air Force treatment records dated in September 1991 note that the veteran was suffering from anemia and high output congestive heart failure. A November 1991 hospital summary from Beaumont Army Medical Center conveys that the veteran was diagnosed with myelofibrosis; portal hypertension and ascites secondary to myelofibrosis; rectal varices and hypertension. A cardiovascular examination conducted during the hospitalization found a regular heart rate and rhythm; blood pressure of 116/50 and a faint Grade II/IV systolic ejection murmur. A February 1992 hospital summary from Cannon Air Force Base Hospital relates that the veteran was admitted for hypotension possibly due to septic shock and that he was immediately transferred to the University Hospital Center. A March 1992 hospital summary from the University Hospital Center reports that the veteran was admitted due to fever and a marked drop in systolic blood pressure to 60. At discharge, he was diagnosed as suffering from resolved septic shock, myelofibrosis, Klebsiella septicemia, gastrointestinal bleeding, left lower lobe pneumonia, cirrhosis, congestive heart failure, anemia and portal hypertension. Air Force hospital summaries and treatment records dated between March and July 1992 report that the veteran was hospitalized almost monthly due to myelofibrosis, associated anemia and his need for blood transfusions. The Board has weighed the probative evidence and the veteran's argument on appeal. We observe that the veteran suffers from periods of congestive heart failure and is clearly precluded from performing any form of employment. The veteran is service connected for arteriosclerotic heart disease, which can itself lead to congestive heart failure. His non-service condition, myelofibrosis, has resulted in severe anemia requiring at times blood transfusions. Anemia can also result in congestive heart failure. It has been noted by one of the veteran's attending physicians that the heart failure was the result of the veteran's anemia due to myelofibrosis. However, in the Board's judgment, such a fine line cannot be drawn as to the cause of the heart failure, since both anemia and arteriosclerotic heart disease can result in heart failure. In other words, arteriosclerotic heart cannot be easily disassociated from the veteran's chronic heart failure. Under Code 7005, arteriosclerotic heart disease, a 100 percent rating is allowed with chronic residual findings of congestive heart failure and more than sedentary employment precluded. The veteran falls within these guidelines. Given this fact and upon resolution of reasonable doubt in the veteran's favor, we conclude that a 100 percent disability evaluation is warranted for arteriosclerotic heart disease with hypertension. ORDER A 100 percent disability evaluation is granted for the veteran's arteriosclerotic heart disease with hypertension subject to the laws and regulations governing the award of monetary benefits. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 * IRVIN H. PEISER, M.D. JEFF MARTIN *38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board 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.A. § 7266 (West 1991), a decision of the Board 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. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). 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.