Citation Nr: 1801543 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 14-12 134A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to a rating in excess of 30 percent for coronary artery disease (CAD) associated with herbicide exposure. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD T. Joseph, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from April 1965 to January 1967. During his period of service, the Veteran earned the National Defense Service Medal, Vietnam Service Medal, and Vietnam Campaign Medal. This matter comes before the Board of Veterans' Appeals (Board) from a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which, in pertinent part, granted service connection for coronary artery disease associated with herbicide exposure, with an evaluation of 30 percent, effective June 7, 2001. In April 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. FINDING OF FACT Throughout the appellate period, the Veteran's CAD was not manifested by congestive heart failure, a workload of less than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 50 percent or less. CONCLUSION OF LAW The criteria for an evaluation in excess of 30 percent for CAD have not been met. 38 U.S.C.A. §§ 1155, 5103 (2012); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has reviewed all of the evidence in the record. Although the Board has an obligation to provide adequate reasons or bases supporting its decision, there is no requirement that each item of evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board will summarize the evidence as deemed appropriate, and the analysis below will focus specifically on what the evidence shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Disability ratings are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's entire history is reviewed when assigning disability ratings. See generally 38 C.F.R. § 4.1. 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). 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). In this case, the Veteran's service-connected CAD is currently assigned a 30 percent evaluation pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides that a 10 percent rating is warranted for documented CAD resulting in workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or a requirement of continuous medication. 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent rating is warranted for documented CAD resulting in 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 dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating is warranted for documented CAD resulting in more than one episode of congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is warranted for documented CAD resulting in chronic congestive heart failure, or workload 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. Id. Private treatment records show that the Veteran underwent a stress echocardiogram in February 2003. The Veteran achieved a maximum workload of 13.3 METs. The Veteran experienced mild to moderate exertional dyspnea. Resting echocardiographic images reveal normal resting left ventricular contractility and immediate post stress echocardiographic images reveal normal compensatory increase in left ventricular ejection fraction (LVEF). The Veteran underwent a stress dual isotope imaging study in August 2005. No ischemic electrocardiogram (EKG) changes were noted. The Veteran had a normal heart rate and a mildly hypertensive blood pressure response to exercise. Gated single-photon emission computed tomography (SPECT) showed an LVEF of 50%. Another stress echocardiogram was performed on the Veteran in March 2007. The Veteran achieved a maximum workload of 11.2 METs. He did experience mild exertional dyspnea. His resting echocardiographic images revealed normal resting left ventricular contractility. A Doppler evaluation of the left ventricular filling revealed A-wave dominance, which suggested the presence of possible decreased left ventricular compliance. This finding was consistent with mild diastolic left ventricular dysfunction. Immediate post stress echocardiographic images revealed normal left ventricular contractility. In October 2007, the Veteran underwent stent angioplasty. The procedure required direct stenting of the proximal left anterior descending artery and a percutaneous transluminal coronary angioplasty (PTCA) of the ostium of the large first diagonal branch. The Veteran appeared for a VA examination in April 2008. The examiner noted that the Veteran was doing well. The Veteran's cardiac MET workload was over 10, and there was no evidence of ischemic heart disease following the intracoronary stenting. The Veteran underwent an adenosine dual isotope imaging study in November 2008. Gated SPECT imaging revealed LVEF of 55%. No transient ischemic dilatation was noted. The Veteran underwent an echocardiogram in December 2009. Results showed that the left ventricle had normal cavity size and normal systolic function. The estimated LVEF was 65%. Results also showed evidence of diastolic dysfunction. The Veteran appeared for another VA examination in July 2010. In November 2010, an addendum opinion was requested. Based on the July 2010 physical examination findings and the Veteran's history, the examiner opined that the Veteran's METs score was approximately 6-7. A January 2011 VA cardiology note reflected a positive diagnosis of non-radiating angina in the lower substernal area, palpitations with exertion, leg edema, and occasional dizziness. Moreover, a January 2011 VA echocardiogram report reflected mild concentric left ventricular hypertrophy and normal left ventricular function. Myocardial perfusion imaging conducted in March 2011 showed that the Veteran's left ventricle was large in size. The LVEF on the post dipyridamole study was 50%, and 53% at rest. Upon review of the record in April 2011, a VA examiner determined that Veteran's estimated METs would be at least 7. The Veteran appeared for a VA examination in September 2016. The examiner noted no showing of congestive heart failure. Upon interview-based METs testing, the examiner opined that the Veteran's METs were greater than 7 to 10 METs, which have been found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging at 6 mph. The Veteran testified at a hearing in April 2017. At that time, he reported ongoing symptoms such as pain, dizziness, lightheadedness, and fatigue. Myocardial perfusion imaging conducted in June 2017 showed no myocardial ischemia or infarct. Left ventricular cavity size was normal at rest, with absence of transient ischemic dilation at stress. Left ventricular systolic function was normal without regional wall motion abnormalities. The Veteran's LVEF was 66% Based on the evidence described above, the Board finds that the Veteran's CAD does not warrant an initial evaluation higher than 30 percent. Over the course of the appellate period, the evidence does not show congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 50 percent or less. The Board notes that myocardial perfusion imaging conducted in March 2011 showed an ejection fraction of 50% and 53% at rest; however, a range between 50 and 53 percent is more consistent with a finding of ejection fraction greater than 50 percent than it is with a finding of 30 to 50 percent. Moreover, as shown above, the objective medical evidence of record has been relatively consistent throughout the appeal period; taken as a whole, the evidence most closely approximates that required for a 30 percent disability rating. The Board has also considered the Veteran's assertions regarding his cardiac symptoms, which he is competent to provide. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Although laypersons are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a layperson, as it generally involves the outcomes of clinical testing and knowledge of cardiology. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran can certainly describe what he experiences, such as pain, dizziness, lightheadedness, and fatigue; however, the record does not show that the Veteran possesses the training or experience needed to evaluate his CAD. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also 38 C.F.R. § 3.159 (a)(1) (2017). As such, an initial rating in excess of 30 percent is not warranted. As the preponderance of the evidence is against an increased schedular rating, the benefit of the doubt rule does not apply. 38 U.S.C.A. § 5107(b); see Gilbert, supra. The Board is grateful for the Veteran's honorable service, and this decision is not meant to detract from that service. However, given the record before it, the Board finds that evidence in this case does not reach the level of equipoise. Unfortunately, the Board concludes that an increased rating is not warranted at this time. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a rating in excess of 30 percent for coronary artery disease associated with herbicide exposure is denied. ____________________________________________ A. S. CARACCIOLO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs