Citation Nr: 18155874 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 16-34 641 DATE: December 6, 2018 ORDER Entitlement to an evaluation in excess of 60 percent for service connected ischemic heart disease status post coronary artery bypass graft (CABG) is denied. REMANDED Entitlement to service connection for atrial fibrillation with implantation of a pacemaker as secondary to service connected ischemic heart disease status post coronary artery bypass graft (CABG) is remanded. FINDING OF FACT At no point during the pendency of this appeal has the Veteran’s ischemic heart disease status post coronary artery bypass graft (CABG) manifested with 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 less than 30 percent. CONCLUSION OF LAW The criteria for a rating in excess of 60 percent for service connected ischemic heart disease status post coronary artery bypass graft (CABG) are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.31, 4.104, Diagnostic Code (DC) 7017-7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1963 to June 1968. The Board finds that the RO addressed the issue of whether the Veteran’s atrial fibrillation with implantation of a pacemaker is secondary to his service connected ischemic heart disease status post CABG in the Supplemental Statement of the Case (SSOC). Therefore, the Board will also address the same issue. 1. Entitlement to an evaluation in excess of 60 percent for service connected ischemic heart disease status post coronary artery bypass graft (CABG) In the present case, the Veteran contends that he is entitled to a higher disability rating for his coronary artery disease. Currently, the Veteran’s CAD status post CABG is rated under 38 C.F.R. § 4.104, Diagnostic Code 7017-7005. Pursuant to DC 7017 and 7005, a 60 percent rating is warranted when there is more than one episode of congestive heart failure in the past year; or a workload of 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or there is left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is warranted when there is chronic congestive heart failure; or 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. 38 C.F.R. § 4.104, DC 7005. One MET is defined as 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 determination 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) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). The Veteran was afforded a VA examination in November 2014. The examiner indicated that the Veteran does not have congestive heart failure. The examiner reported that the Veteran does not have a cardiac arrhythmia or a heart valve condition. The examiner noted normal heart sounds and normal pulses. No response was provided for rhythm. No edema was noted. The examiner noted that the Veteran had a stress test in June 2014 and the Veteran achieved a METs level of 9. The Veteran’s left ventricular ejection was 58 percent. The Veteran was afforded a VA examination in March 2017. The Veteran was diagnosed with the following heart conditions: implanted cardiac pacemaker; coronary artery bypass graft; symptomatic tachy-brady syndrome (Holter monitor); and ischemic heart disease. The examination revealed that the Veteran underwent a pacemaker implant in May 2016 followed by a cardioversion in June 2016. The Veteran underwent a nuclear stress test in July 2016 which reported no significant reversible ischemia. The examination revealed that continuous medication is required to control the Veteran’s heart condition. The Veteran has cardiac arrhythmia. The Veteran’s atrial fibrillation was noted to be constant. There is no congestive heart failure, no heart valve condition, or infections cardiac conditions. Heart sounds and pulses are normal and there is no edema. Heart rhythm was noted to be irregular. The echo cardiogram of July 7, 2016 showed a left ventricular ejection fraction of 55 percent. The Veteran’s exercise stress test showed a METs level of 9. The examiner noted that the Veteran’s current atrial fibrillation is not related to the Veteran’s service connected ischemic heart disease. Private treatment records from Dr. K.C., dated July 20, 2017, revealed that the Veteran developed walk-through anginal symptoms in 2014. Medical therapy has been adequate in controlling the Veteran’s anginal symptoms. However, Dr. K.C. expressed that the Veteran developed atrial fibrillation and tachybrady syndrome requiring a pacemaker. Dr. K.C. opined that the Veteran’s atrial fibrillation is at least in part a consequence of the Veteran’s other cardiovascular and coronary artery disease. She stated that at a minimum, the presence of atrial fibrillation complicates decisions regarding the management of the Veteran’s coronary artery disease, including but not limited to medications used to control the Veteran’s heart rate and anticoagulant/antiplatelet medication usage. Based on the foregoing, the preponderance of the evidence is against a rating in excess of 60 percent. Indeed, the competent medical evidence of record, to include the March 2017 VA examination, does not show chronic congestive heart failure; 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. On the contrary, the examination report shows greater than 3 METs with evidence of ejection fraction of 55 percent. A review of VA treatment records does not reveal any evidence to support a higher rating. Accordingly, a higher rating of 100 percent is not warranted. In making its rating determination above, the Board has also carefully considered the Veteran’s contentions with respect to the nature of his service-connected heart disability, and notes that his lay testimony is competent to describe certain symptoms associated with such disability. The Veteran’s history and symptom reports have been considered, including as presented in the medical evidence discussed above, and has been contemplated by the disability rating that has been assigned for his service-connected heart disability. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected heart disability addressed above. As such, while the Board accepts the Veteran’s statements with regard to the matters he is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected heart disability at issue. Accordingly, entitlement to an increased rating for service connected ischemic heart disease status post CABG is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for atrial fibrillation with implantation of a pacemaker as secondary to service connected ischemic heart disease status post coronary artery bypass graft (CABG) is remanded. The evidence shows that most of the Veteran’s cardiac treatment during the period on appeal focused on the Veteran’s cardiac arrhythmia. Here, the record shows that the Veteran had a pacemaker implanted due to tachybrady syndrome on May 4, 2016. The Veteran’s private physician, Dr. K.C., opined that the Veteran’s atrial fibrillation is at least in part a consequence of the Veteran’s other cardiovascular and coronary artery disease. At the March 2017 VA examination, the VA examiner opined that the Veteran had symptomatic tachybrady syndrome as indicated by the Holter monitor dated in April 2016 which subsequently required a pacemaker implant in May 2016. The examiner indicated that atrial fibrillation was a new and separate diagnosis from the Veteran’s cardiac conditions. However, the examiner noted that the Veteran’s current atrial fibrillation is not related to the Veteran’s service connected ischemic heart disease. The Board finds that on remand, the Veteran should be afforded a new VA examination. The VA examiner should reconcile the conflicting medical opinions from the March 2017 VA examiner and the Veteran’s private physician. Then, the VA examiner should provide an opinion as to whether the Veteran’s atrial fibrillation with implementation of a pacemaker was caused or aggravated by his service-connected ischemic heart disease status post coronary artery bypass graft (CABG). The matter is REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s atrial fibrillation with implementation of a pacemaker. The examiner should opine as to whether it at least as likely as not that the Veteran’s atrial fibrillation with implementation of a pacemaker was caused by or was chronically worsened (aggravated beyond its natural progression) by the Veteran’s service-connected ischemic heart disease status post coronary artery bypass graft (CABG) to include any medication used for his heart disability. In providing the above, the examiner is requested to review all pertinent records associated with the claims file. The examiner should reconcile the conflicting medical opinions from the March 2017 VA examiner and the Veteran’s private physician. A clear rationale for all opinions is requested and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.D.