Citation Nr: 18152287 Decision Date: 11/21/18 Archive Date: 11/21/18 DOCKET NO. 15-37 324 DATE: November 21, 2018 ORDER Entitlement to an initial disability rating higher than 10 percent for coronary artery disease (CAD) status post coronary artery bypass grafting surgery (CABG) prior to January 19, 2016 and higher than 60 percent on and thereafter is denied. FINDINGS OF FACT 1. Prior to January 19, 2016, the Veteran’s CAD status post CABG required continuous medication and was manifested by left ventricular ejection fraction (LVEF) between 55 to 60 percent, consistent with an estimated metabolic equivalent of tasks (METS) level of 7-10 due solely to his cardiac ondition, with no evidence of cardiac hypertrophy, dilatation, or chronic congestive heart failure. 2. On and after January 19, 2016, the Veteran’s CAD has been manifested by a workload of greater than 3 METS but not greater than 5 METS resulting in dyspnea, fatigue, angina, dizziness, or syncope, but no chronic congestive heart failure or LVEF of less than 30 percent. CONCLUSIONS OF LAW 1. Prior to January 19, 2016, the criteria for an initial disability rating higher than 10 percent for CAD status post CABG are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.104, Diagnostic Code (DC) 7017. 2. On and after January 19, 2016, the criteria for an initial disability rating higher than 60 percent for CAD status post CABG are not met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. § 4.104, DC 7017. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service with the United States Army from January 1964 to January 1966. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In an October 2018 rating decision, the Agency of Original Jurisdiction (AOJ) increased the evaluation for the Veteran’s CAD status post CABG to 60 percent, effective January 19, 2016. As the 60 percent rating is less than the maximum evaluation allowable, and the Veteran has not withdrawn his appeal, this issue remains in appellate status. AB v. Brown, 6 Vet. App. 35 (1993) (indicating that a veteran is presumed to be seeking the highest possible rating unless he or she expressly indicates otherwise). The Veteran seeks higher disability ratings for his service-connected CAD status post CABG. Disability ratings are determined by comparing a veteran’s present symptomatology with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4 (2018). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A review of the recorded history of a disability is necessary to make an accurate rating. 38 C.F.R. §§ 4.2, 4.41. The regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran’s service-connected CAD status post CABG is currently rated under DC 7017 as 10 percent disabling prior to January 19, 2016 and as 60 percent disabling on and thereafter. According to this diagnostic code, a rating of 10 percent is assigned for disability manifested by a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A rating of 30 percent is assigned for 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 electrocardiogram, echocardiogram, or X-ray. A rating of 60 percent is assigned for more than one episode of congestive heart failure within the past year, or where a workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A rating of 100 percent is assigned for chronic congestive heart failure, or where a workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or where there is left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104. 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 evaluation, and a laboratory decision 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) resulting in dyspnea, fatigue, angina, dizziness, or syncope may be used. Note 2, 38 C.F.R. § 4.104. In this regard, the pertinent evidence in this case consists almost entirely of clinical findings from VA examinations in April 2014, August 2015, and January 2016. Prior to January 19, 2016 The relevant evidence includes an April 2014 VA examination report, which notes the Veteran’s diagnosis of ischemic heart disease with a history of CABG and cardiac pacemaker implant in August 2013. He was currently taking aspirin and Metoprolol daily, but there was no history of myocardial infarction or congestive heart failure and no evidence of cardiac hypertrophy or dilatation. Exercise stress testing was not conducted and according to interview-based METs testing, the lowest level of activity at which the Veteran reported symptoms of dyspnea, fatigue, angina, and dizziness was 5-7 METs, consistent with activities such as golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). An echocardiogram from October 2013 showed LVEF of 55 percent, which the examiner found indicative of mild functional limitation due to ischemic heart disease that did not impact the Veteran’s ability to work. Subsequent VA treatment records show that despite some dyspnea on exertion, the Veteran reported feeling better. He also had an improvement in his breathing and activity level and denied chest pain. See VA Cardiology Note, dated March 11, 2015. A December 2014 echocardiogram showed LVEF of 55-60 percent. These records also noted the Veteran had other comorbid conditions such as mild restrictive pulmonary impairment from bilateral pleural effusions, rheumatoid arthritis, and deconditioning. See VA Pulmonary Note dated May 21, 2014. When examined by VA in August 2015, the Veteran continued to require medication for his heart disease. He denied any cardiac symptoms, but did report some left shoulder discomfort from the pacemaker and pulling/tightness at the sternotomy site when taking a deep breath. He also reported fatigue with exercise (walks several times a week and takes breaks when cutting his grass), but denied angina and did not require nitroglycerine. There was no history of myocardial infarction or congestive heart failure and no evidence of cardiac hypertrophy or dilatation. The Veteran had not been hospitalized since his bypass surgery in 2013. Chest X-rays were normal and an echocardiogram was also normal with an LVEF of 55-60 percent. An exercise stress test was not required as part of the Veteran’s current treatment plan, and this test was not without significant risk. Instead the examiner conducted an interview-based METs test which showed the lowest level of activity at which the Veteran reported fatigue was 5-7 METS (consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), heavy yard work (digging). However, the examiner noted that the METS level due solely to his heart condition was 7-10 consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, jogging (6 mph). He explained that the Veteran’s LVEF was 55-60 percent and that while he reported fatigue with physical activity, he denied other cardiac symptoms. In addition, the Veteran’s cardiologist indicated that the Veteran’s shortness of breath was not cardiac in nature and pulmonary testing did not indicate a respiratory cause. Rather, the Veteran’s dyspnea was due to a history of anemia. The examiner also noted the Veteran’s other conditions which limit his physical activity, including neck and back symptoms, foot problems, arthritis, diabetes, and general debility related to his age. The examiner concluded that based on this examination, the Veteran’s cardiac condition does not restrict his activity or prevent him from physical activity. Based on this evidence, assignment of a rating higher than 10 percent is not warranted. First, there is no evidence or allegation of even a single episode of congestive heart failure. Second, while the Veteran had METs findings of 5-7, such levels were not solely attributable to his service-connected heart condition. Both VA examiners specifically found that the Veteran’s METs were impacted by his multiple non-cardiac medical conditions and that his CAD was not a limiting factor for physical activity. Further, it appears that his LVEF of 55-60 percent is a more accurate measurement of cardiac functioning as it is based on present objective medical evidence due solely to the Veteran’s CAD. Third, as has been noted, the Veteran’s LVEF has been well over 50 percent during this timeframe. Thus, the Board finds that, prior to January 19, 2016, the Veteran’s impairment due to CAD status post CABG was more consistent with a 10 percent disability rating and that the level of disability necessary to support the assignment of the next higher evaluation of 30 percent is absent. A preponderance of the evidence is against this portion of the claim, and there is no reasonable doubt to be resolved. On and after January 19, 2016 The current 60 percent rating is based on findings from a January 2016 VA examination report. Although the Veteran required continuous medication for control of his heart condition, he was not found to have congestive heart failure and had not had any non-surgical or surgical procedures since his CABG in 2013. An echocardiogram showed LVEF between 60 and 65 percent. The examiner noted that the lowest activity level at which the Veteran reported dyspnea, fatigue angina or dizziness attributable to a cardiac condition was between 3 and 5 METs consistent with activities such as light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph). The examiner noted that the limitation in METs level was due solely to the Veteran’s cardiac condition. The remaining records show continued periodic evaluation and treatment of the Veteran’s CAD status post CABG symptoms since January 19, 2016, but do not otherwise indicate that they are more severe than those recorded in the previous VA examination. In August 2016, he was seen for complaints of chest pain. A cardiology stress was negative and LVEF was 70 percent. See VA Cardiology Inpatient Note, dated August 10, 2016. The most recent entry dated in June 2018 shows that the Veteran reported some fatigue and slower movements along with aches and pains from arthritis, but was staying active and otherwise doing well with no new cardiac symptoms. He specifically denied chest pain, dyspnea, syncope, and dizziness. The clinical assessment was stable CAD. See VA Cardiology Clinic Note, dated June 12, 2018. Thus, the criteria for a rating higher than 60 percent have not been met for any period on and after January 19, 2016. There is no evidence the Veteran experienced chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope or, LVEF of less than 30 percent. Accordingly, the Board finds that during this period his impairment due to CAD stats post CABG is more consistent with a 60 percent disability rating and that the level of disability necessary to support the assignment of the next higher evaluation of 100 percent is absent. A preponderance of the evidence is against this portion of the claim, and there is no reasonable doubt to be resolved. With regard to both timeframes, the Board has also considered whether a separate and/or higher rating may be assigned under a different diagnostic code, but there is no evidence that the Veteran’s CAD stats post CABG would be better classified under a different diagnostic code. The remaining cardiovascular codes all have the same criteria as DC 7017, for which the Veteran has already been assigned the current 10 percent and 60 percent evaluations. See e.g., DCs 7000-7008, 7011-7020. 38 C.F.R. § 4.104. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J.R. Bryant