Citation Nr: 18144037 Decision Date: 10/23/18 Archive Date: 10/22/18 DOCKET NO. 16-19 430A DATE: October 23, 2018 ORDER Entitlement to an initial rating in excess of 10 percent for service connected ischemic heart disease is denied. FINDING OF FACT Throughout the rating period on appeal, the Veteran’s ischemic heart disease was productive of a workload greater than 7 metabolic equivalents testing (METs). CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for ischemic heart disease have not been met. 38 U.S.C § 1155; 38 C.F.R § 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDING AND CONCLUSION This case comes to the Board on appeal from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran served in the Army from August 1968 to August 1971, during which time he served boots on ground in Vietnam. The Veteran participated in a video conference hearing before the undersigned Veterans Law Judge on July 9, 2018. 1. Entitlement to an initial rating in excess of 10 percent for ischemic heart disease. The Veteran was granted service connection for ischemic heart disease and assigned an initial rating of 10 percent. The Veteran appealed, arguing that his overall MET score of 1-3 entitles him to a higher rating. Specifically, during the hearing, the Veteran reported symptoms of regular shortness of breath and dizziness. The Veteran also noted his use of an oxygen machine, and ongoing chest pain. He says his shortness of breath and need for the oxygen machine are “related” to his ischemic heart disease. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1, 4.7 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole recorded history is necessary so that a rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2018); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). In this case, the Veteran claims entitlement to an initial rating in excess of 10 percent for ischemic heart disease. Ischemic heart disease is rated using the General Rating Formula for Diseases of the Heart found in 38 C.F.R. § 4.104, Diagnostic Code 7005 (2018). Under the General Rating Formula, a 10 percent rating is warranted when there is a workload of greater than 7 METs but not greater than 10 resulting in dyspnea, fatigue, angina, dizziness, or syncope; or requiring continuous medication. A 30 percent rating is warranted when a workload of greater than 5 METs but not greater than 7 METs 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 rating is warranted when there has been 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 results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricle dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is evidence of chronic congestive heart failure; or a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricle dysfunction with an ejection fraction of less than 30 percent. Post-service treatment records reflect a 2006 surgery, at which time the Veteran had stents placed. The records reflect no congestive heart failure, no cardiac hypertrophy, and no ejection fraction under 50 percent. The Veteran has undergone several Disability Benefits Questionnaire (DBQ) examinations. The first of these was in April 2014, at which time the examiner noted he had recently had a normal stress test and echocardiogram, and that his fatigue and shortness of breath were primarily related to his diagnosed COPD, and stated that the Veteran’s MET score based solely on his cardiac condition was likely greater than 10. The examiner did note that he did not have access to some records at that time, including records of the 2006 surgery and recent stress test. In a follow-up C&P Note dated May 1, 2014, the examiner further explained that, in reviewing the conflicting medical evidence, the Veteran’s symptoms of fatigue and shortness of breath were more likely related to his non-service connected COPD. He again estimated the METs related strictly to the Veteran’s cardiac status to be greater than 10. The Veteran underwent a second DBQ examination in May 2015. At that time the examiner conducted an interview-based stress test, and determined that the Veteran had a METs score of 1-3. The examiner indicated by checking the box that this was all due to his cardiac status; however, she provided no further notes or rationale. In April 2016, the Veteran underwent yet another DBQ examination. The examiner indicated that the Veteran had an overall METs score of 1-3, but opined that his METs score related solely to his cardiac status was at least 7-10. He noted that the Veteran was unable to distinguish between his lung and cardiac symptoms. He noted there was no evidence the Veteran’s coronary artery disease had worsened, and that the Veteran’s non-service connected lung issues (including COPD and asthma) were his “significant and ongoing problem” and were the most likely causes of his METs score. In May 2016, a final DBQ was requested to take into consideration all of these conflicting reports. The examiner was asked to provide an opinion specifically as to which disability the METs score reflects. The examiner reviewed the claims file, including the May 2015 DBQ examination. The examiner noted a May 2015 echocardiogram showed a “grossly normal” left ventricle, with an ejection fraction of 55 to 60 percent. The examiner also noted the reports of significant obstructive airways disease. Based on this information, the examiner stated that the METs due solely to the service connected heart condition was 7-10. Following a thorough review of the record, the Board finds that the Veteran’s symptoms were similar in severity throughout the period at issue. The evidence shows that the Veteran’s METs level due only to his service-connected ischemic heart disease is 7-10, and his left ventricular ejection fraction is 55-60 percent, all of which warrant a 10 percent rating. Here, although acknowledging the May 2015 examination report, the Board finds that the majority of the evidence of record, including in particular the May 2016 report of examination in which the examiner specifically discussed the May 2015 findings, supports a finding that the Veteran’s METs relating to his cardiac status is 7-10. The preponderance of the evidence supports a finding that the Veteran is entitled to no higher than the 10 percent rating initially assigned for his ischemic heart disease. The Veteran has consistently presented with a METs score between 7 to 10 related to his ischemic heart disease. He also shows symptoms of dyspnea and fatigue and is on continuous medication. The Veteran is not entitled to the next higher rating of 30 percent. The most probative evidence does not establish that he has an MET score of greater than 5 but less than 7. There is also no evidence of cardiac hypertrophy or dilation on the echocardiograms. Thus, the Board finds the Veteran is not entitled to a 30 percent rating based on the diagnostic criteria. The Veteran is further not entitled to a 60 percent rating for his ischemic heart disease. Again, the Veteran’s METs score due solely to his ischemic heart disease is not greater than 3 but less than 5. Additionally, the Veteran’s ejection fraction of 55 to 60 percent is higher than the 30 to 50 percent required for a 60 percent rating under Diagnostic Code 7005. Thus, the Board finds the Veteran is not entitled to a 60 percent rating based on the diagnostic criteria. The Veteran is also not entitled to a 100 percent rating. Notwithstanding the May 2015 examiner’s findings, discussed above, the weight of the evidence does not show chronic congestive heart failure, a METs score of below 3, nor an ejection fraction of less than 30 percent. Thus, the Board finds that the preponderance of the evidence of record does not support a finding that the Veteran is entitled to a 100 percent rating. In sum, the evidence of record shows that an initial disability rating in excess of 10 percent is not warranted for the Veteran’s ischemic heart disease. As such, the Veteran’s claim for an initial rating in excess of 10 percent for ischemic heart disease must be denied. 38 C.F.R. § 4.104, Diagnostic Code 7005. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Stuedemann, Associate Counsel