Citation Nr: 18153220 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 09-36 175 DATE: November 27, 2018 ORDER An initial rating of 30 percent, and no higher, for coronary artery disease prior to September 15, 2010, is granted. A rating in excess of 30 percent for coronary artery disease, from September 15, 2010 is denied. FINDINGS OF FACT Since the grant of service connection, the Veteran’s coronary artery disease has manifested with a workload of greater than 5-7 metabolic equivalents (METs) resulting in dyspnea and fatigue; cardiac hypertrophy shown by echocardiogram; and left ventricular dysfunction with an ejection fraction greater than 50 percent. CONCLUSIONS OF LAW 1. The criteria for an initial 30 percent rating, and no higher, for coronary artery disease prior to September 15, 2010, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.104, Diagnostic Code (DC) 7005. 2. The criteria for a rating in excess of 30 percent for coronary artery disease from September 15, 2010, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.104, DC 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1982 to December 2007. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) which granted service connection for coronary artery disease and assigned an initial 10 percent rating effective January 1, 2008. In an August 2015 rating decision, the RO granted an increase to 30 percent, effective September 15, 2010. As this rating did not constitute a full grant of the benefits sought, the claim remains on appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). In February 2017, the Board referred the matter to the Veterans Health Administration (VHA) for an advisory opinion. The Veteran, along with his representative, did not provide any response within the 60-day response period. In October 2017, the Board remanded this matter for further development, which has since been completed. Higher Ratings Disability ratings are determined by applying a schedule of reductions in earning capacity from specific injuries or a combination of injuries that is based upon the average impairment of earning capacities. 38 U.S.C. § 1155. Each disability must be viewed in relation to its entire history, with emphasis upon the limitations proportionate to the severity of the disabling condition. 38 C.F.R. § 4.1. When rating the Veteran’s service-connected disability, the entire medical history must be reviewed. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of the two disability evaluations is 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. After careful consideration of the evidence of record, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of “staged rating” is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Staged ratings apply to both initial and increased rating claims. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran’s coronary heart disease is currently rated under 38 C.F.R. §4.104, DC 7005. Under DC 7005, a 10 percent rating is warranted if a workload of between 7 and 10 metabolic equivalent of tasks (METs) results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. 38 C.F.R. § 4.104. A 30 percent rating is warranted if a workload between 5 and 7 METs result in dyspnea, fatigue, angina, dizziness, or syncope; or if there is evidence of cardiac hypertrophy or dilatation. Id. A 60 percent rating is warranted if there had been more than one episode of acute congestive heart failure in the past year; or if a workload between 3 and 5 METs result in dyspnea, fatigue, angina, dizziness, or syncope; or if there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. Entitlement to an initial rating in excess of 10 percent prior to September 15, 2010 The Veteran asserts that he was entitled to an initial rating in excess of 10 percent because his coronary artery disease manifested with a symptom of left ventricular hypertrophy prior to September 15, 2010. The Board agrees. In an April 2017 VHA advisory opinion, a cardiologist opined that the Veteran had left ventricular hypertrophy on or before October 2005 based on the measurements of the thickness and size of the left ventricle in the 2005 report, which, after medical calculations, were consistent with a finding of concentric left ventricular hypertrophy. Considering this favorable and competent evidence, a 30 percent rating is warranted. An even higher rating, however, is not warranted for this appeal period. A higher rating of 60 percent rating requires more than one episode of acute congestive heart failure in the past year; or a workload between 3 and 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. At an initial January 2008 VA examination, the Veteran was found to have a workload of 8 METs. His history, physical, and testing results were negative for congestive heart failure. Private treatment records showed that an April 2009 exercise echocardiogram (ECG) revealed a workload of 13.5 METs. At a November 2009 VA examination, an examiner noted that the Veteran had a workload of 8 METs and a normal electrocardiogram (EKG). In an addendum, the examiner noted that there a recent evaluation showed some concern for congestive heart failure, noting dyspnea on exertion and orthopnea as was noted during the VA examination. LVEF was not reported. At an April 2010 VA examination, the Veteran reported no changes in his cardiac condition or any treatment since the last examination. The examiner estimated his workload to be at 8 METs. The examiner noted that the cardiac ultrasound and cardia consult was scheduled after the November 2009 evaluation, but the Veteran cancelled them. An addendum opinion provided later that same month had no additions or changes to the prior examination report. VA treatment records in 2010 indicate no changes in the coronary artery disease symptoms and showed a normal ECG study; an X-ray report showed a normal cardiac silhouette. A June 2010 CG showed left ventricular ejection fraction (LVEF) was normal and estimated to be between 60-65 percent. Based on the evidence, a higher rating is not warranted for this period. The next highest rating of 60 percent requires a workload between 3 and 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation, or more than one episode of acute congestive heart failure within the past year; or LVEF of 30-50 percent. The medical evidence has not shown such findings at any time throughout the appeal period. The VA and private medical evidence, as well as the November 2009 and April 2010 VA examination reports all show a workload of greater than 7 METs. LVEF was between 60 and 65 percent, which is greater than that required for a higher rating. There is also no evidence of a confirmed diagnosis of congestive heart failure during this period. Entitlement to a rating in excess of 30 percent from September 15, 2010 The Veteran is in receipt of a 30 percent rating effective from September 15, 2010. A September 15, 2010 private ECG report showed mild to moderate concentric left ventricular hypertrophy and a LVEF of 72 percent. The Veteran underwent another VA examination in July 2015. The examiner found no signs of congestive heart failure and found no evidence of cardiac dilatation. The ECG showed a normal study. The examiner noted that an exercise stress test was not performed, as the Veteran became short of breath during testing. The examiner estimated that he had a workload of greater than 3 and 5 METs before resulting in fatigue. However, the examiner also noted that if the estimated METs level was based solely on his coronary artery disease, the Veteran would have a workload of between 5 and 7 METs (i.e., walking 1 flight of stairs, golfing, mowing lawn, etc.) before resulting in fatigue. The examiner explained that the Veteran had a significant smoking history that is a co-morbid condition that limited his endurance and overall METs attainment. VA treatment records in 2015 to 2017 indicated that he was seen for complaints of shortness of breath, lightheadedness, and palpitations in July 2015. An exercise tolerance test was performed that same month which showed that the Veteran had a workload of 10.1 METs before exhibiting fatigue. An August 2015 myocardial perfusion study showed normal left ventricular systolic function with a LVEF of 70 percent. In December 2016, when he was seen for a dry cough, he denied shortness of breath or dyspnea on exertion. There were no coronary artery disease symptoms noted at the December visit. At a December 2017 VA contract examination, the Veteran reported walking for about 1.5 miles for 3 times per week and could perform housework and/or yard work. He did not have a history of congestive heart failure or any hospitalizations. The examiner found no evidence of cardiac hypertrophy or dilatation and therefore, did not perform LVEF testing. The examiner also noted that the Veteran failed to report to Echo and EKG testing scheduled in conjunction with the examination. The Veteran had an estimated (interview-based) workload between 7 and 10 METs before exhibiting fatigue and dyspnea. The examiner explained that exercise stress testing was contraindicated. The examiner noted the METs level was due solely to the coronary artery disease. Given the above, the Board finds that a rating in excess of 30 percent from September 15, 2010 is not warranted. The medical evidence has not shown the Veteran’s coronary artery disease to manifest with a workload between 3 and 5 METs that results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation, or more than one episode of acute congestive heart failure within the past year; or LVEF of 30-50 percent. Rather, the evidence shows a much greater workload based solely on the Veteran’s coronary artery disease. The July 2015 examiner opined that the Veteran had a workload of between 5 and 7 METs based solely on his coronary artery disease, which falls within the 30 percent rating criteria. An exercise tolerance test performed in July 2015 during an outpatient evaluation showed that the Veteran had a workload of 10.1 METs before exhibiting fatigue. While he submitted evidence showing a stress test in August 2015 had to be stopped due to protocol, this does not warrant a 60 percent rating. The report does not sufficiently explain the reason the test was stopped, nor reflect estimated METs. What is known is that VA examiners have already indicated that a stress test is contraindicated in the Veteran’s case due to factors other than his service-connected coronary artery disease. All of the probative estimated METs findings based solely on the coronary artery disease are consistent with a 30 percent rating. Finally, during the period on appeal, the LVEF readings were at all times greater than 50 percent, which is not consistent with a 60 percent rating under DC 7005. The Board acknowledges that in advancing this appeal, the Veteran believes that his disability is more severe than the assigned disability rating reflects; however, the competent medical evidence, which consists of diagnostic test results pertinent to the rating criteria, are the most probative evidence in this case. As such, resolving doubt in favor of the Veteran, a 30 percent rating, and no higher, is warranted since the grant of service connection. The evidence does not support additional staged ratings for any time on appeal. There are no additional expressly raised or reasonably raised issues on the record. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Tang, Associate Counsel