Citation Nr: 1343490 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 11-28 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to an initial rating in excess of 10 percent for coronary artery disease (CAD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from November 1968 to August 1970. This appeal to the Board of Veterans' Appeals (Board) arises from a November 2010 rating decision of the Reno, Nevada Regional Office (RO) of the Department of Veterans' Affairs (VA). In March 2013, the case was remanded in order to schedule the Veteran for a Board videoconference hearing. That hearing was held in May 2013 before the undersigned Veteran's Law Judge; a transcript of the hearing is of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran's coronary artery disease is rated under Diagnostic Code 7005, which assigns ratings y on factors including the level of metabolic equivalents (METS) and the ventricular ejection fraction. Review of the record shows that a February 2010 echocardiogram and February 2010 stress testing produced three apparently different readings for the Veteran's ejection fraction: a 58% finding from an echocardiogram; a 42% "rest" finding on an exercise treadmill stress test with radionuclide injection and a 51% "post-stress" finding noted on that same treadmill test. Additionally, a February 2010 VA cardiac consultation report notes the 58% ejection fraction found on the echocardiogram and also notes that the stress test produced perfusion images revealing an ejection fraction of "approximately 50%." Given these discrepancies, the RO requested a medical opinion as to which ejection fraction reading was the most accurate. In a November 2010 opinion, a VA physician concluded that the 51% and 58% findings were the most accurate. However, it is not clear whether this physician reviewed the above mentioned reports. Also, the physician did not provide any explanation as to why the 42% "rest" finding was not thought to be accurate. Additionally, although it appears that the "approximately 50% finding" from the cardiac consultation is simply a reference to the 51% "post-stress" ejection fraction finding, this is not entirely clear. Accordingly, because the ejection fraction measurement can be a critical factor in assignment of the rating for coronary artery disease, a remand is necessary so that a fully informed and explained opinion can be provided concerning which February 2010 ejection fraction finding is considered to be most accurate. The Board also notes that the Veteran last received a VA cardiovascular examination in June 2011. Although he has not specifically alleged that his coronary artery disease has worsened since that time, because approximately 2 1/2 years have passed since June 2011 and because he did report during his May 2013 Board hearing that he had experienced a sharp pain in the middle chest since June 2011 that he had not experienced previously, on remand, the medical professional providing the medical opinion should also examine the Veteran to determine the current severity of his coronary artery disease. Prior to arranging for the examination and medical opinion, the RO/AMC should obtain records of VA treatment and evaluation for cardiovascular disability dated since October 2012. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should obtain records of VA treatment and evaluation the Veteran has received for cardiovascular disability dated since October 2012. 2. Then, the RO/AMC should arrange for a VA examination by an appropriate medical professional to determine the current severity of the Veteran's coronary artery disease. The Veteran's claims file must be reviewed by the examiner in conjunction with the examination. Any indicated tests, including an echocardiogram and stress testing should be performed. The examiner should provide current ejection fraction and METS readings, along with any other pertinent findings. The examiner should also specifically review the February 2010 treadmill test with radionuclide injection report (with 42 percent "rest" ejection fraction and 51 percent "post stress" ejection fraction), the February 2010 VA cardiovascular consultation report (with notation of the 58% ejection fraction on echocardiogram and "approximately 50% ejection fraction" revealed from perfusion images) and the November 2010 VA medical opinion indicating that the 58% and 51% readings were the most accurate. The examiner should then provide an opinion as to which February 2010 ejection fraction reading is likely the most accurate. The examiner should specifically explain the reasoning behind the opinion provided. 3. The RO/AMC should then review the examination report and medical opinion to ensure that they are in full compliance with the remand instructions. If not, remedial action must be taken. 4. The RO/AMC should then readjudicate the claim. If it remains denied, an appropriate supplemental statement of the case should be issued and the Veteran and his representative should be provided the opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. No action is required of the appellant until he is notified. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). _________________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).