Citation Nr: 1800479 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 12-34 981 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to an initial rating in excess of 10 percent for coronary artery disease (CAD) status post myocardial infarction prior to November 22, 2010 and entitlement to a rating in excess of 60 percent for coronary artery disease status post myocardial infarction from November 22, 2010. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Freeman, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The case is currently under the jurisdiction of the Oakland, California RO. In April 2016, the Veteran participated in a hearing with the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. The Board most recently remanded this claim in May 2016 for additional development. Here, the Veteran was assigned a 10 percent rating for coronary artery disease (CAD) in April 2011, effective June 3, 1998, and a 60 percent rating for CAD from November 22, 2010. FINDINGS OF FACT 1. Prior to November 22, 2010, the Veteran did not have arteriosclerotic heart disease resulting in a workload of greater than 5 METs but not greater than 7 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. 2. From November 22, 2010, the Veteran's coronary artery disease required the use of medication and had an estimated METs of greater than 3 but not greater than 5 that resulted in dyspnea and fatigue, but was not productive of 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. CONCLUSIONS OF LAW 1. For the appeal period prior to November 22, 2010, the criteria for an initial rating higher than 10 percent for coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7005 (2017). 2. For the appeal period beginning on November 22, 2010, the criteria for a rating higher than 60 percent rating for coronary artery disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record includes service treatment records, VA treatment records, and lay statement in support of the claim. In addition, the Veteran was afforded a VA examination in connection with his claim on appeal in November 2010 and March 2017. 38 U.S.C.A. § 5103A (d); 38 C.F.R. § 3.159; see McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). The Board has found that the November 2010 and March 2017 medical examinations and opinions obtained by VA were adequate, and were based upon a complete review of the evidence of record as well as consideration of the Veteran's lay assertions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. The Board also finds that there has been substantial compliance with its remand directives in May 2016. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, outstanding VA treatment records were obtained and associated with the evidence of record before the Board, and the Veteran was afforded adequate VA examination in March 2017 and his claim was readjudicated by the RO in a September 2017 Supplemental Statement of the Case. In a November 2016 correspondence, the Social Security Administration (SSA) stated that they no longer have the Veteran's records as they have been destroyed. Legal Criteria Service connection for CAD was granted in an April 2011 rating decision with an initial 10 percent evaluation assigned effective June 3, 1998, and 60 percent effective November 22, 2010. The Veteran contends that an increased rating is warranted for his service-connected CAD in excess of 10 percent as of the initial grant, and in excess of 60 percent thereafter. Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 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. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Under Diagnostic Code 7005, a 10 percent rating is warranted for arteriosclerotic heart disease (coronary artery disease) resulting in a workload of greater than 7 METs but not greater than 10 METs causing in dyspnea, fatigue, angina, dizziness, or syncope, or when continuous medication is required. Id. A 30 percent rating is warranted for arteriosclerotic heart disease resulting in a workload of greater than 5 METs but not greater than 7 METs causing 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. A 60 percent rating is warranted for arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or a workload of greater than 3 METs but not greater than 5 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. Finally, a 100 percent rating is warranted for arteriosclerotic heart 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. If non-service-connected arteriosclerotic heart disease is superimposed on service-connected valvular or other non-arteriosclerotic heart disease, the adjudicator is to request a medical opinion as to which condition is causing the current signs and symptoms. 38 C.F.R. § 4.104, Diagnostic Code 7005, Note. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. Analysis The Veteran contends he is entitled to an increased rating in excess of 10 percent for his service-connected CAD prior to November 22, 2010 and in excess of 60 percent from November 22, 2010. Based on the medical evidence of record, the Board finds that the preponderance of the evidence is against ratings in excess of 10 and 60 percent for the Veteran's CAD. The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical and lay evidence for the issue on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. CAD prior to November 22, 2010 Private treatment record in January 1998 showed that the Veteran underwent a coronary arteriography. No coronary anomaly was reported. He was treated for coronary artery disease and quintuple vessel disease, and had four stents placed. On evaluation, the left main coronary artery was of moderate length, intermediate sized vessel and unstable agina. It trifurcates into the LAD, LCX and Ramus coronary arteries and the left main coronary artery was normal. The left anterior descending artery indicated a large vessel, which reaches the apex of the heart and gave origin to two moderate sized diagonal arteries. The Veteran's physician concluded that the endoluminal stenting (ACS Multilink 3.Ox 15mm) of the Mid LAD was successful. Pre stenosis was 70 percent and post stenosis was 0 percent. The endeluminal stenting (ACS Multilink 3.5 x 25mm) of the Mid LAD was successful. Pre stenosis was 80 percent and post stenosis was 0 percent. The endoluminal stenting (ACS Multilink 3.5 x 15mm) of the Proximal LAD was Successful. Pre stenosis was 50 percent and post stenosis was 0%. See Medical treatment record dated in April 2014. Private treatment record in January 1998 showed coronary artery disease status post myocardial infarction. The Veteran was also shown to have had a workload of 12.9 METs in August 1999. No evidence of cardiac hypertrophy or dilatation per ECG findings was indicated at that time. See treatment record from Community Hospital of Monterey Peninsula, received in July 2001. At a July 2000 private evaluation, the Veteran reported working very hard and felt somewhat fatigue. He reported chest pain which "comes and goes" with a tightness-like sensation and a feeling that his left arm was cold. He stated that it seemed to get worsened with deep breathing activities, and felt like the heart attack that he had in the past. Medical records show he was previously admitted for atypical sounding chest discomfort. He underwent treadmill testing which was negative for ischemia after myocardial infarction was ruled out, he was subsequently discharged. The Veteran was afforded a VA examination in November 2010. He described being diagnosed with hypertension around 1999. The Veteran reported that he was diagnosed with coronary artery disease in 1998, and treated with stents and angioplasty. He reported that he had another heart scare in 1999, however, treadmill test was okay, and he was treated medically. The examiner reported that the Veteran has cardiac disease resulting in slight limitation of physical activity. It was indicated that the Veteran is comfortable at rest, but ordinary activity results in fatigue, palpitation, dyspnea, or angina. The Veteran workload (METs) level was indicated as 4. The examiner reported that the January 1998 treatment record showed a diagnosis of CAD, stenting and angioplasty with evidence of mild heart enlargement without evidence of microalbuminuria, or renal failure insufficiency. As discussed above, a 30 percent rating is warranted for arteriosclerotic heart disease resulting in a workload of greater than 5 METs but not greater than 7 METs causing dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. In this regard, before November 22, 2010, the probative evidence, as discussed in detail above, shows that the Veteran's coronary artery disease resulted in mild heart enlargement, with no evidence of myocardial infarction or EKG changes documented. Also, as detailed above, prior to November 2, 2010, the probative evidence of record fails to show that the Veteran's coronary artery disease was manifested by coronary artery disease resulting in a workload of greater than 5 METs, but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilation on electrocardiogram, echocardiogram or x-ray. In January 1998, METs was estimated as 12.9. It was not until November 2010 (the date the RO granted 60 percent), that METs were estimated at between 3-5 but not greater than 5. Having reviewed the complete record, the Board finds that the evidence does not support the criteria for an initial rating in excess of 10 percent prior to November 22, 2010, for coronary artery disease under Diagnostic Code 7005. CAD beginning November 22, 2010 Beginning November 22, 2010, the Veteran has been in receipt of a 60 percent disability rating under Diagnostic Code 7005 for his coronary artery disease. The November 2010 VA examination is summarized above. A VA treatment record dated in February 2013 showed that the Veteran was transferred for further evaluation of chest pain. The Veteran reported that he was awoken due to chest pain that lasted for 3 to 4 hours until relieved by NTG and morphine. The VA physician reported that the Veteran had extensive CAD hx s/p PI-stent of mid LAD in 1998, with increasing chest pain on minimal exertion. Dr. J.M. Li reported that although the Veteran's chest pain was somewhat typical, the negative trop made it less likely to be cardiac in origin. The Veteran underwent a cardiac catheterization procedure in February 2013 and was given morphine 30mg for pain. VA treatment record in November 2016, showed the left ventricular systolic function was grossly normal as-seen. Assessment of the diastolic parameters indicates a relaxation abnormality of the left ventricle. No ischemic ECG changes or chest pain to workload was achieved. The Veteran was also afforded a VA examination in March 2017. The examiner indicated that continuous medication is required to control the Veteran's heart condition. The examiner also reported that the Veteran has not had a myocardial infarction. No congestive heart failure was indicated. No cardiac arrhythmia or heart valve condition was indicated. The Veteran has not had any infectious cardiac condition, including active valvular infection, endocarditis, pericarditis or syphilitic heart disease. The Veteran has had percutaneous coronary intervention. It was also reported that the Veteran has not had any other complications, conditions, signs or symptoms related to his heart problem. There is no evidence of cardiac hypertrophy or evidence of cardiac dilatation. The March 2017 EKG showed unusual P axis, possible ectopic atrial bradycardia, which is unchanged from the 2010 study. In addition, there is no evidence of transient ischemic dilatation of the left ventricle. No evidence of significant regional myocardial ischemia or of an old myocardial infarct. Normal left ventricular ejection fraction of 59% was indicated. There was hypokinesis of the inferior septum and periapical area on beating heart images. METs level ranged from 3-5, but not higher than 5. The examiner noted that the ischemic abnormality that was noted on the prior examination was not noted on the March 2017 examination. The VA examiner further noted that the note that indicated a NSTEMI in 1998 does not appear accurate in reviewing the earlier records. The examiner also stated that cardiac admission excluded myocardial infarction in following EKGs and chemical tests. The VA examiner also reported that repeat catheterization in February 2013 demonstrated two-vessel coronary artery disease in a right dominant system (PDA and apical LAD). The examiner reported that prior stents were patent, both new lesions were in small vessels and medical management was suggested. In conclusion, the examiner opined, coronary artery disease and angina symptoms were first documented in 1998, and opined that there has been no documented myocardial infarction in review of the available record. Further, the examiner opined that ejection fraction remains normal without demonstrated wall motion abnormality by echocardiogram; 2016 MPI suggested that there was no regional wall motion abnormality consistent with prior infarct. Neither biochemical nor EKG changes suggested infarction in 1998, 2000, 2013 or 2016 admissions. The Board finds that a review of the evidence of record shows that a higher rating is not warranted. The persuasive evidence of record shows no evidence of chronic congestive heart failure, a work-load of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Thus, a 100 percent rating is not warranted for the period from November 22, 2010, as there is no showing of a left ventricular ejection fraction that is less than 30 percent or findings of chronic congestive heart failure. The Board also finds that the Veteran's description of symptoms and limitations are credible and consistent with the evidentiary record. However, as it pertains as to whether he manifests the particular symptoms and limitations entitling him to a higher rating, the Board places greater probative weight to the findings of the VA examiners' opinions, as to the actual clinical extent of the coronary artery disease, as these physicians have greater expertise and training to more accurately identify and measure aspects of disability such as METs levels. There is no doubt of material fact to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107 (b). ORDER A disability rating in excess of 10 percent for coronary artery disease prior to November 22, 2010, and in excess of 60 percent effective November 22, 2010, is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs