Citation Nr: 1802942 Decision Date: 01/12/18 Archive Date: 01/23/18 DOCKET NO. 13-04 785 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to an initial compensable rating for valvular insufficiency. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Sangster, Counsel INTRODUCTION The Veteran served on active duty from September 1985 to January 1991, from February 1991 to August 1991, from March 1995 to July 1995, from September 1995 to January 1996, from May 2006 to August 2006, from January 2008 to December 2009, and from January 2010 to January 2011. This case comes before the Board of Veterans' Appeals (Board) on appeal of a May 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, which, in pertinent part, granted service connection for valvular insufficiency, assigning an initial evaluation of 0 percent effective January 9, 2011. The previously remanded this issue for additional development in April 2015 and April 2017. FINDING OF FACT Throughout the period on appeal, the Veteran's valvular insufficiency disability is manifested by a workload greater than 12 METs and requires the need for continuous medication. CONCLUSION OF LAW The criteria for an initial disability rating of 10 percent, but no higher, for a valvular insufficiency disability are met. 38 U.S.C. §§ 1155, 5103(a), 5103A (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code 7000 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran seeks a compensable initial rating for his service-connected valvular insufficiency disability. At the outset, the Board notes that disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet.App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet.App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's valvular insufficiency disability has been rated under Diagnostic Code ("DC") 7000, for valvular heart disease. Under Diagnostic Code 7000, a 10 percent rating is assigned when valvular heart disease, documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization, results in a workload of greater than 7 METs (metabolic equivalents) but not greater than 10 METs; results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is assigned when the disability results in a workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on ECG, echocardiogram, or x-ray. A rating of 60 percent is assigned when the disability results in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs, but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent is assigned when the disability results 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. A 100 percent rating can also be assigned during active infection with valvular heart damage and for three months following cessation of therapy for the active infection. 38 C.F.R. § 4.104, DC 7000. Based on the probative evidence of record in light of the legal criteria, an initial 10 percent, but no higher, is warranted for the Veteran's service-connected valvular insufficiency disability throughout the period on appeal. The relevant evidence of record includes a January 2011 VA examination. While this examination primarily focused on his other service-connected heart disability (chronic costochondritis), the examiner also diagnosed the Veteran with valvular insufficiency involving the mitral, tricuspid, pulmonic and aortic valves. At that examination, the Veteran complained of chest pain. On physical examination, the examiner observed that there was tenderness of the left chest wall up into the axillary region with palpation of the affected area. She also noted that the Veteran had a stress test in January 2011, which revealed a normal echocardiographic response to exercise. In addition, the examiner observed that the Veteran was able to achieve a METs of 13.70 after exercising according to the BRUCE protocol and that he reached 90 percent of the maximal age-predicted heart rate. She also stated that the exercise test was stopped due to knee pain. While she did note that the Veteran had a larger than normal heart size, the Veteran's LV dysfunction ejection fraction was greater than 50 percent. The examiner also observed that an October 2010 imaging study of the Veteran's chest was otherwise normal. The record also includes an April 2013 VA examination. At that time, the Veteran reported continued intermittent mild chest pain. He denied associated diaphoresis, shortness of breath or nausea/vomiting. He also reported that his chest pain on the left side rib area increased with intensity with upper body activity. Moreover, the Veteran indicated that he was not receiving any treatment for the condition, and denied any side effects from any treatment. The examiner noted that there was no ischemic heart disease, no evidence of a myocardial infarction, no congestive heart failure, no cardiac arrhythmia, and no infectious heart conditions. On physical examination, heart rate was 63; rhythm was regular; heart sounds were normal; there was no jugular-venous distension; auscultation of the lungs was clear; peripheral pulses were normal; and there was no peripheral edema. EKG, chest X-ray and echocardiogram were normal. The examiner further indicated that the Veteran did not take continuous medication for his heart condition. METs testing was not done. In accordance with the Board's April 2015 remand, which found the April 2013 VA examination incomplete, the Veteran was afforded another VA examination in July 2015. Neither the July 2015 examination nor a December 2015 addendum to the examination included METs testing, as directed in the April 2015 remand. However, the July 2015 examiner noted that METs test was terminated at the most recent exercise stress test in 2011 due to symptoms not related to the cardiac condition. Additionally, the examiner noted that the Veteran did not take continuous medication to control his heart condition. The record also indicated that the Veteran underwent dobutamine stress echocardiogram testing in August 2015, which was reportedly normal. The complete test results, however, were not associated with the claims file. Consequently, the Board remanded the claim once again for a new VA examination and to obtain the Veteran's medical treatment records. To this end, the agency of jurisdiction (AOJ), obtained outstanding VA medical treatment records, including a copy of the August 2015 dobutamine stress echocardiogram testing and associated them with the claims file. Additionally, the Veteran had another VA examination in September 2017. The examiner commented that the Veteran had previously been diagnosed with valvular heart disease based on an echo report. He observed that while the Veteran had trivial valvular heart disease, he did not have ischemic heart disease or coronary artery disease based on a normal cardiac catheterization done in June 2007 and a normal heart stress test in August 2015. The examiner, however, indicated that the Veteran did take continuous medication required for control of the Veteran's heart condition. He stated that the Veteran took aspirin on a daily basis to prevent a heart attack. Additionally, examination of the Veteran showed no evidence of myocardial infarction, congestive heart failure or a cardiac arrhythmia. His heart rate was 55 and his rhythm was regular. The point of maximal impact was not palpable and the Veteran's heart sounds were normal. His lungs were clear and there was no evidence of jugular-venous distension. Also, his peripheral pulses were normal and no peripheral edema of the lower extremities was found on examination. His blood pressure was normal evidenced by a reading of 128/84. Further, diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. Regarding the August 2015 cardiac stress test, the examiner commented that the Veteran had exercised for ten minutes without chest pain and his heart rate maxed at 166 (target heart rate was 146). He stated that the Veteran achieved a METs of 12. He also conducted an interview-based METs test, and the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. Additionally, the relevant evidence of record includes the Veteran's medical treatment records. While the September 2017 VA examiner was the only examiner that indicated that the Veteran took continuous medicine (aspirin) to control his valvular insufficiency disability, his VA medical treatment records reflect that he was prescribed aspirin as early as September 2011. See VA medical treatment record dated September 2011. Therefore, based on a review of the clinical evidence, the Board determines that the Veteran's service-connected valvular insufficiency disability is manifested by the requirement to take continuous medication. A higher rating is not warranted because a workload of 5 but less than 7 METs, with symptoms of dyspnea, fatigue, angina, dizziness or syncope, or cardiac hypertrophy or dilation upon electrocardiogram, echocardiogram or X-ray, has not been shown. Thus, a rating higher than 10 percent is not warranted on this basis. In reaching this conclusion, the Board has also given consideration to the Veteran's statements. To the extent, however, the Veteran is asserting that his heart condition warrants a higher rating, the Board finds that he is not competent to identify a specific level of impairment imposed by his cardiovascular condition according to the appropriate diagnostic codes. Instead, the Board places greater probative weight on the competent medical evidence concerning the nature and extent of the Veteran's cardiovascular disability provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which this disability is evaluated. ORDER Entitlement to an initial rating of 10 percent, but no higher, for valvular insufficiency is granted. ____________________________________________ JENNIFER HWA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs