Citation Nr: 1805252 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 14-10 794A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to a disability rating in excess of 30 percent for coronary artery disease, status-post angioplasty with stent placement (heart condition). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Smith, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Marine Corps from August 1965 to February 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. FINDING OF FACT During the appeal period, the Veteran's heart condition was characterized by a workload between 5 and 7 METs with resulting fatigue and chest pain; the Veteran's left ventricular (LV) dysfunction was also no less than 55 percent CONCLUSION OF LAW During the appeal period, the criteria for a rating in excess of 30 percent for the Veteran's service-connected heart condition have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.7, 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Assist and Notify VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C. §§ 5103, 5103A and 38 C.F.R. § 3.159. For the issue decided herein, VA provided adequate notice in a letter sent to the Veteran in December 2010. The Board finds VA has satisfied its duty to assist the Veteran in the development of the claim as well. VA has obtained all identified and available service and post-service treatment records. The Veteran identified a number of private treatment reports, which have either been obtained by VA or two attempts were made by VA to obtain. The VA examinations for the Veteran's heart condition are also adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). The examiners considered the Veteran's symptoms and history, performed appropriate testing, and addressed all relevant rating criteria. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C. § 5103(a), § 5103A, or 38 C.F.R. § 3.159 and that the Veteran will not be prejudiced as a result of the Board's adjudication of this claim. Increased Rating The Veteran's entire history is reviewed when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will also consider entitlement to staged ratings to compensate for times since the claim was filed when the disability may have been more severe than at other times during the appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In such case, VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. In the instant case, the Veteran filed a claim for service connection for ischemic heart disease (IHD) on September 28, 2010. As the Veteran was already service-connected for coronary artery disease, his claim for service connection was interpreted as a claim for increase. Therefore, the period under consideration for the claim for increase begins on September 28, 2009. The Veteran's coronary artery disease, status post angioplasty with stent placement has been rated under Diagnostic Code 7005. 38 C.F.R. § 4.104. Under Diagnostic Code 7005, 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 dilatation on electrocardiogram, echocardiogram, or x-ray is rated at 30 percent. 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 resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent is rated at 60 percent. Chronic congestive heart failure, or; a 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 is rated a maximum 100 percent. Id. Evidence The Veteran contends that his service-connected heart condition is worse than the 30 percent rating assigned. The relevant medical evidence of record includes VA examination and private treatment reports, which the Board will discuss chronologically. A December 2009 attending note from West LA VA Medical Center (VAMC) referring to the Veteran's coronary artery disease indicates that he denied chest pain, shortness of breath, or dyspnea. The physician also indicted there was no dyspnea on exertion. A January 2011 medical evaluation from Dr. J.T. notes that in 2005, the Veteran had chest pressure, which led to hospitalization and coronary catheterization. Dr. J.T. also noted that the Veteran underwent a coronary stent in June 2005 and had another episode of chest pain in 2008. The report reflects the Veteran's indication that he had occasional twinges of chest pain, which occur about 3-4 times a year and last for a few seconds, including in the previous year. The report indicates that the Veteran denied a history of congestive heart failure and also denied any periods of incapacitation in the past 12 months. Dr. J.T. indicated that the Veteran's heart was normal S1 and S2 and there was no evidence of S3 or S4. The report indicates regular heart rate and rhythm and no evidence of murmur or gallop. The report indicates that the PHI is palpable between the fifth and sixth intercostal space and there are no heaves or thrills. The diagnoses were atherosclerotic heart disease and status post myocardial infarction, status post coronary angioplasty, with coronary stenting. As to diagnostic studies, Dr. J.T. indicated that the Veteran was not a candidate to undergo treadmill exercise testing due to knee pain and an inability to run on the treadmill. An echocardiogram (echo) was suggested. The corresponding January 2011 echo indicates normal left ventricular ejection fraction and normal appearing mitral, aortic, and tricuspid valves with no significant Doppler flow abnormality. The Veteran's ejection fraction was 55 percent. The report indicates that there was no change in the initial METs level of 6.0 and METs activities of walking about two to three city blocks and swimming. The report also indicates that based on these additional results and the doctor's examination, there was no change in the initial diagnosis of atherosclerotic heart disease; status post myocardial infarction, status post coronary angioplasty, with coronary stenting. A January 2011 radiology report from Dr. T.D. refers to two chest views. The report indicates that the Veteran's heart size is within normal limits. The report indicates that the aorta is slightly uncoiled with calcification in the aortic knob and that no acute pulmonary infiltrates were seen. The impression was uncoiled arteriosclerotic aorta and "no acute pathology." A February 2011 nurse practitioner note from East LA Community-Based Outpatient Clinic indicates that as to cardiac issues, there was no chest pain or nocturnal dyspnea and that the Veteran denied syncope. A March 2011 echo from JPMD indicates normal left ventricular ejection fraction and normal appearing mitral, aortic, and tricuspid valves with no significant Doppler flow abnormality. The Veteran's ejection fraction was 55 percent. A February 2012 radiology report from Dr. T.D. refers to two chest views. The report indicates that the Veteran's heart size is normal. The report also indicates that his aorta is slightly uncoiled with calcification in the aortic knob and that no acute pulmonary infiltrates were seen. The impression was "no acute pathology." In February 2012, the Veteran underwent a VA heart examination. The corresponding Disability Benefits Questionnaire (DBQ) indicates a diagnosis of coronary artery disease. As to the Veteran's medical history, the examiner noted a 2005 stent placement following hospitalization for chest pain. The examiner indicated that the Veteran's heart condition qualifies within the generally accepted medical definition of IHD. The examiner indicated that continuous medication is required for the Veteran's heart condition. The DBQ indicates there is no myocardial infarction. The DBQ indicates no congestive heart failure (CHF) or episodes of chronic CHF in the past year. The DBQ indicates no cardiac arrhythmia and that the Veteran does not have a heart valve condition. The DBQ indicates no infectious cardiac conditions, including active valvular infection (including rheumatic heart disease), endocarditis, pericarditis or syphilitic heart disease. The examiner indicated there were no pericardial adhesions. The examiner noted that the Veteran had an angioplasty in 2005 and indicated there were no other hospitalizations for the treatment of a heart condition. Physical examination indicated the following: a regular heart rate; 4th intercostal space for point of maximum impact; normal heart sounds, clear auscultation of the lungs, no jugular-venous distension, normal peripheral pulses; and no peripheral edema. The examiner indicated there were no scars associated with the Veteran's heart condition. The examiner indicated there were no other pertinent physical findings, complications, conditions, signs and/or symptoms. As to diagnostic testing, the DBQ indicates no evidence of cardiac hypertrophy and no evidence of cardiac dilation. The examiner notes that a February 2012 EKG was performed and indicated sinus bradycardia and a normal chest x-ray. The examiner also noted the March 2012 echocardiogram and that it indicated normal wall motion and wall thickness and a left ventricular ejection of 65 percent. As to the interview-based METs test, the examiner noted the February 2012 report. The examiner indicated that the symptoms reported by the Veteran for the lowest level of activity were dyspnea, fatigue, and angina. The examiner indicated results of 5-7 METs. The examiner indicated that the METs level limitation is due solely to the Veteran's heart condition. A March 2012 echocardiogram from JPMD indicates an ejection fraction of 65 percent. The conclusion was normal left ventricular ejection fraction and normal appearing mitral, aortic, and tricuspid valves with no significant Doppler flow abnormality. In July 2017, the Veteran underwent another VA heart examination. The corresponding DBQ indicates a diagnosis of coronary artery disease, status post stent placement, diagnosed in 2002. The examiner indicated that this diagnosis qualifies within the generally accepted medical definition of IHD. The examiner also indicated that the Veteran requires continuous medication for his heart condition. The DBQ indicates that the Veteran has not had CHF, no cardiac arrhythmia, no heart valve condition, and no pericardial adhesions. The examiner noted that the Veteran has had an angioplasty but no other hospitalizations. Physical examination indicated the following: heart rate of 51; regular rhythm; 5th intercostal space for point of maximum impact; normal heart sounds; no jugular-venous distension; clear auscultation of the lungs; normal peripheral pulses; and no peripheral edema. The examiner indicated there were no scars associated with the Veteran's heart condition. The examiner indicated there were no other pertinent physical findings, complications, conditions, signs and/or symptoms. As to diagnostic testing, the examiner indicated there was evidence of cardiac hypertrophy per echocardiogram conducted during this examination. The examiner indicated there was no evidence of cardiac dilation. The corresponding July 2017 EKG indicated results of sinus bradycardia, normal chest x-ray, and normal echo with LV ejection fraction of 58 percent. The examiner indicated that no exercise test was performed. As to the interview-based METs test, the examiner indicated that the symptom reported by the Veteran for the lowest level of activity was fatigue. The examiner indicated METs of 5-7 and indicated that the METs level provided is due solely to the heart condition. As to lay statements, in his February 2012 notice of disagreement, the Veteran indicates that VA never considered a March 2011 echocardiogram report or hospitalization due to chest pains. As to these reports, the Board acknowledges that the Veteran indicated that he was hospitalized for chest pain at Queen of the Valley Medical Center in 2008. While these reports are of record, they fall outside the appeal period. As to the March 2011 echo, the Board notes that it is of record and has been considered. In the notice of disagreement, the Veteran indicated that he experiences dyspnea, fatigue, angina, dizziness, and syncope. He also noted that he has a stent in his heart, has been diagnosed with anemia, and that he once took Actos and currently takes Metoprolol. In the notice of disagreement, the Veteran also provided a number of web article findings to explain that his symptoms, which he indicated also include anemia, lead to congestive heart failure. Merits Having reviewed the evidence, medical and lay, the Board finds that a rating in excess of 30 percent is not warranted for the Veteran's heart condition. Throughout the appeal period, both VA and private treatment reports indicate that the Veteran's METs were 5-7. As the VA and private examiners physically examined the Veteran, performed appropriate testing, and the results are all consistent, the Board finds the METs provided probative. The medical and lay evidence also indicates symptoms of resulting fatigue and angina (chest pain) during the appeal period. See Dr. J.T.'s January 2011 evaluation and the July 2017 DBQ. As noted, the Board finds the medical evidence probative. As to the Veteran's lay reports of his symptoms, he is competent to report physical symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that a lay person is competent to report observable symptoms). The Board also has no reason to doubt the credibility of his assertions and therefore finds his reports probative as well. METs of 5-7 with resulting fatigue and chest pain are commensurate with a 30 percent rating. Additionally, the July 2017 VA examiner indicated that there was evidence of cardiac hypertrophy. Cardiac hypertrophy is also commensurate with a 30 percent rating. Thus in light of the evidence, the Board finds that a 30 percent rating is warranted. A higher rating is not warranted. While the record reflects that the Veteran experiences fatigue and chest pain, a higher rating requires that he also has METs of 3 to 5. 38 C.F.R. § 4.104, Diagnostic Code 7005. However, the probative evidence is consistent that the Veteran's METs during the appeal period were 5-7. Regarding the Veteran's symptoms, the Board acknowledges that the Veteran emphasized in his notice of disagreement that he experiences all of the symptoms listed in Diagnostic Code 7005. To the extent that the Veteran perceives that he must have all of the symptoms listed in Diagnostic Code 7005 in order to receive a higher rating, the Board notes that any one of the symptoms is sufficient to rate the Veteran's heart condition under Diagnostic Code 7005 since the code lists the symptoms disjunctively. Nor do the symptoms alone determine the rating assigned. All of the symptoms are accounted for in each rating under Diagnostic Code 7005, and the determination of the appropriate rating is contingent on the METs associated with those symptoms. Nor is a higher rating warranted when considering the Veteran's LV ejection fraction during the appeal period. A higher rating requires LV ejection fraction of 30 to 50 percent. However, the probative medical evidence in this case indicates that the Veteran's LV ejection fraction during the appeal period was no less than 55 percent. There is also no indication of chronic congestive heart failure during the appeal period. To the contrary, the probative medical evidence consistently indicates that the Veteran has not had congestive heart failure. The Board acknowledges that the Veteran indicated in his notice of disagreement that the symptoms he experiences lead to congestive heart failure. While he is competent to report his physical symptoms, he is not competent to characterize those symptoms as congestive heart failure as the record does not suggest that he has medical training to make such a medical determination, which requires medical experience and training and clinical testing to diagnose. Jandreau v. Nicholson. The Board also acknowledges the web articles submitted by the Veteran pertaining to congestive heart failure. The web articles discuss congestive heart failure in a general sense. However, the probative medical evidence of VA and private treatment reports are based on physical examination and diagnostic testing of the Veteran and qualified physicians' evaluation of his specific heart condition. Thus, the Board finds the VA and private reports more probative, which are consistent that the Veteran does not have congestive heart failure. The Board also acknowledges that the record is inconsistent as to whether the Veteran also has a myocardial infarction. The January 2011 diagnosis from Dr. J.T. indicates status-post myocardial infarction while the February 2012 VA examiner indicated there was no myocardial infarction. Myocardial infarction is covered under Diagnostic Code 7006, which applies the same rating criteria as Diagnostic Code 7005. 38 C.F.R. § 4.104. Thus given the evidence, a higher rating would also not be warranted under Diagnostic Code 7006. Nor may the Veteran be compensated under both Diagnostic Codes 7005 and 7006 as the codes account for the same symptoms. The Veteran cannot be compensated for the same symptomology more than once, as such would constitute pyramiding in violation of 38 C.F.R. § 4.14. Consideration has also been given to assigning staged ratings. However, the Board finds that at no time during the appeal period has the disability warranted a higher schedular rating than assigned. Hart v. Mansfield, 21 Vet. App. at 505. At no point during the appeal period did the Veteran's METs or LV ejection fraction warrant a higher rating. Nor does the record indicate any congestive heart failure. Accordingly, the Board finds that the disorder has not significantly changed, and a uniform rating is warranted. Given the evidence, the Board finds that a rating of 30 percent, but no higher, is warranted for the Veteran's service-connected heart condition. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a disability rating in excess of 30 percent for coronary artery disease, status-post angioplasty with stent placement is denied ___________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs