Citation Nr: 1624788 Decision Date: 06/21/16 Archive Date: 07/11/16 DOCKET NO. 13-26 681 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for service-connected coronary artery disease, status-post stent placement. REPRESENTATION Veteran represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran had active service from February 1969 to December 1971, with service in Vietnam. This matter comes before the Board of Veterans Appeals from a January 2011 rating decision in which the RO granted service connection for coronary artery disease, status post stent placement, associated with herbicide exposure, and assigned a 10 percent disability rating, effective February 9, 2010. By September 2013 rating decision, the RO granted a temporary total rating of 100 percent, effective April 4, 2011, based on surgical or other treatment necessitating convalescence, and assigned a 10 percent rating, effective from June 1, 2011. The Veteran continued his appeal for a higher rating. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA electronic claims file. Virtual VA contains documents that are either duplicative of the evidence in the VBMS electronic claims file or not relevant to the issue on appeal. FINDING OF FACT Resolving any reasonable doubt in his favor, the Veteran's coronary artery disease has demonstrated a workload greater than 5 METs but no greater than 7 METs; but has not manifested episodes of acute congestive heart failure, workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. CONCLUSION OF LAW The criteria for a 30 percent rating for service-connected coronary artery disease have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, DC 7005 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). For the issues decided in the instant document, VA provided adequate notice in a letter sent to the Veteran in November 2010. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claim. VA has obtained all identified and available service and post-service treatment records. Further, in December 2010, the Veteran underwent a VA examination which, although it did not include a review of the claims folder, did include a review of all the Veteran's records in the CPRS system, a review of the examination worksheet, and a history obtained from the Veteran. Additionally, examination findings were reported, along with diagnoses/opinions, which were supported in the record and were related to the relevant rating criteria; thus, the December 2010 VA examination report is adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). It appears that all obtainable evidence identified by the Veteran relative to his claim has been obtained and neither he nor his representative has identified any other pertinent evidence which would need to be obtained for a fair disposition of this appeal. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002). The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claim under the VCAA. No useful purpose would be served in remanding this matter for yet more development. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Factual Background On a VA examination in December 2010, the Veteran reported chest pain with light headedness and that he had never taken Nitroglycerin for it, but carried it with him. Objective examination of the heart revealed atypical impulse, 6th left intercostal space, in the midclavicular line, that the heart appeared to be normal in size on percussion, normal Sl/S2 rhythm, and no murmurs or gallops heard. The impression included coronary artery disease/ischemic heart disease, status post PTCA, with 4 stents done in October 2007. The examiner noted that the Veteran's coronary artery disease or ischemic heart disease was first diagnosed in October 2007, and that he had undergone an angiogram with angioplasty with 4 stents placed, followed by having the angiogram redone after 2 stents were found to have collapsed and needed to be replaced. The examiner further noted that since then the Veteran had 5-6 episodes of chest pain with light headedness, but had no cardiac workup since 2007. It was noted that the Veteran had been sent for an ETT with MIBI, an echocardiogram, and a chest x-ray, and MET capacity was estimated at 6-7, limited by non-cardiac symptoms. VA treatment records included a report of an echocardiogram conducted in January 2011, which revealed that the Veteran had a mildly dilated left atrium, normal left ventricular function, and mild mitral valve regurgitation. He also underwent an exercise stress test in January 2011, and it was noted that he exercised on Bruce protocol for 4 minutes and 9 seconds and achieved 5 METs. It was noted that the test was negative for angina, non-diagnostic for ischemia, and terminated due to leg pain. It was also noted that the ischemic ST changes in solitary lead were not diagnostic for a positive treadmill test, that the Veteran needed more aggressive anti-hypertensive and risk factor modification, and most importantly smoking cessation should be emphasized. VA treatment records showed that in April 2011, the Veteran was seen for evaluation of chest pain, palpitations, diaphoresis, and irregular pulse, and was found to be in atrial fibrillation. He was given medicine to improve his heart rate, converted to sinus shortly after, and chest pain resolved. A few days later he was found to have a high-grade proximal LAD stenosis, and developed a new atrial fibrillation. Thereafter, in April 2011, he underwent cardiac stent placement, tolerated the procedure well, and on one month follow-up was found to be asymptomatic. He was to continue Plavix for his coronary artery disease, as well as continue taking the following medications: statin, ACE inhibitor, and beta-blocker. For his atrial fibrillation it was noted that he was taking Metoprolol. VA treatment records showed that in May 2011, it was noted that the Veteran had recently completed an exercise stress test where he achieved 5 METS and the test was stopped because of leg pain. It was also noted that the Veteran could resume his previous occupation/level of activity from the cardiac standpoint. III. Analysis The Veteran essentially contends he should be entitled to a rating in excess of 10 percent (prior to and effective after the temporary total rating) for his service-connected coronary artery disease. He has contended that a 10 percent rating does not reflect his current condition, and reports that although VA has attempted two tests for him on the treadmill, he has never been able to complete a stress test. The Veteran claims that because he has been unable to complete a stress test, this is an indication that his condition is worse than shown by the 10 percent rating assigned. Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's ischemic heart disease has been rated under Diagnostic Code (DC) 7005, which provides that a 10 percent rating is assigned for a workload of greater than 7 METs but not greater than 10, which results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent evaluation is assigned when a workload of 5 METs but not greater than 7 results in dyspnea, fatigue, angina, dizziness, or syncope, or there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is assigned when there is more than one episode of congestive heart failure in the past year, or a workload of 3 METs but not greater than 5 results in dyspnea, fatigue, angina, dizziness, or syncope, or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 38 C.F.R. § 4.104, DC 7005. Whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or x-ray) is present and whether or not there is a need for continuous medication must be ascertained in all cases. Even if the requirement for a 10% (based on the need for continuous medication) or 30% (based on the presence of cardiac hypertrophy or dilatation) evaluation is met, METs testing is required in all cases except: (1) when there is a medical contraindication; (2) when the left ventricular ejection fraction has been measured and is 50% or less; (3) when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year; or (4) when a 100% evaluation can be assigned on another basis. If left ventricular ejection fraction (LVEF) testing is not of record, evaluate based on the alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the veteran's cardiovascular disability. 38 C.F.R. § 4.100. Based on the medical evidence of record, the Board finds that the criteria for the assignment of a 30 percent rating for the Veteran's coronary artery disease have been met for the entire appeal period. In that regard, on VA examination in 2010, the examiner estimated the Veteran's METs capacity at 6-7, limited by non-cardiac symptoms, and on a stress test in January 2011, the Veteran achieved a workload of 5 METs, and the test was terminated due to leg pain. Although it appears that the Veteran's stress tests have been terminated due to non-cardiac symptoms, there has nonetheless been METs workload capacities documented. Thus, the criteria for a 30 percent rating, for the Veteran's coronary artery disease have been met. A rating in excess of 30 percent, however, is not warranted as there has been no showing or report of congestive heart failure in the past year, workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Although the Veteran is competent to report certain symptoms, such as shortness of breath or fatigue, he is not competent to opine as to his specific METs levels or whether left ventricular dysfunction is present at a specific ejection fraction, as confirmation of these symptoms requires precise medical testing. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The current severity of the Veteran's coronary artery disease must be determined based on the medical evidence of record, and prior to April 4, 2011 and effective from June 1, 2011, the medical evidence of record does not support a rating greater than 30 percent. No additional higher or alternative ratings under different diagnostic codes are warranted as the Veteran's service connected disability has consistently been characterized as coronary artery disease. 38 C.F.R. § 4.104, DCs 7000-7123. The Board has also considered whether this case should be referred for extraschedular consideration for rating of the Veteran's coronary artery disease. The governing norm in such exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptoms, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here, the rating criteria contemplate the Veteran's coronary artery disease symptoms as they address taking medication, functional impairment as measured by METS, fatigue, dyspnea, angina, dizziness, and syncope. Furthermore, the rating criteria provide for higher ratings for more severe symptoms. Thus, referral for extraschedular ratings for the disability at issue is not warranted. See Thun, 22 Vet. App. at 115. A Veteran may also be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014). In this case, however, neither the Veteran nor the record has raised this contention. Yancy v. McDonald, No. 14-3390 (Ct. Vet. App. Jan. 12, 2016). The Board therefore concludes that the preponderance of the evidence supports the assignment of a 30 percent rating for coronary artery disease, prior to April 4, 2011 and effective from June 1, 2011. Gilbert v. Derwinski, 1 Vet.App. 49, 55 (1990). ORDER A 30 percent rating for coronary artery disease is granted, subject to the regulations and statutes governing the payment of monetary benefits. ____________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs