Citation Nr: 1809166 Decision Date: 02/12/18 Archive Date: 02/23/18 DOCKET NO. 10-09 009 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an initial compensable rating for supraventricular arrhythmia with chest pain. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran had active service from May 1970 to March 1972. This matter comes before the Board of Veterans' Appeals (Board) from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, which, enacting a July 2008 Board decision, granted service connection for supraventricular arrhythmia with chest pain, and assigned an initial noncompensable disability rating, effective from April 2, 2001. In July 2017, the Board remanded this matter in order to obtain the transcript from the Veteran's November 1, 2012, DRO Hearing; obtain all pertinent VA outpatient treatment records from the Central Texas VAMC dated since June 2007; and schedule the Veteran for a VA examination to determine the current severity of his service-connected supraventricular arrhythmia with chest pain. Review of the record shows that there has been substantial compliance with July 2017 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Prior to March 2, 2012, the Veteran's supraventricular arrhythmia with chest pain was manifested by intermittent episodes of supraventricular tachycardia documented by a Holter monitor; at no point did the record that these episodes of supraventricular tachycardia occurred more than 4 times per year. 2. Effective from March 2, 2012, the Veteran's supraventricular arrhythmia with chest pain was manifested by intermittent (paroxysmal) supraventricular tachycardia, 1 to 4 episodes in the past 12 months, documented by his statements, and also contributed to a workload of greater than 5 METs but not greater than 7 METs, resulting in dyspnea, fatigue, angina, dizziness, and syncope; at no time was there any finding of a workload of greater than 3 METs but not greater than 5 METs, resulting in symptoms, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. 3. Effective from August 25, 2017, the Veteran's supraventricular arrhythmia with chest pain, most recently characterized as ventricular arrhythmia, was productive of a workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea and fatigue; at no time was there any finding of congestive heart failure, workload of 3 METs or less resulting in symptoms, or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. Prior to March 2, 2012, the criteria for an initial 10 percent rating for the Veteran's supraventricular arrhythmia with chest pain, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 ( 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Codes 7010, 7011 (2017). 2. Effective from March 2, 2102 thru August 24, 2017, the criteria for a 30 percent rating for the Veteran's supraventricular arrhythmia with chest pain, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 ( 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Codes 7010, 7011 (2017). 3. Effective from August 25, 2017, the criteria for a 60 percent, for the Veteran's supraventricular arrhythmia with chest pain, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 ( 2012); 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.104, Diagnostic Codes 7010, 7011 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran, nor his representative, has alleged prejudice with regard to notice. see Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). II. Factual Background and Analysis Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has been established and a higher initial disability rating is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of the veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran contends that he should be entitled to a compensable rating for the service-connected supraventricular arrhythmia with chest pain. The record reflects that the Veteran's service-connected supraventricular arrhythmia with chest pain has been rated under Diagnostic Code (DC) 7010, which provides for a 10 percent rating for supraventricular arrhythmia manifested by permanent atrial fibrillation (lone atrial fibrillation), or 1 to 4 episodes per year of paroxysmal atrial fibrillation, or other supraventricular tachycardia documented by ECG or Holter monitor. A maximum 30 percent rating is assigned for supraventricular arrhythmia manifested by paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than 4 episodes per year documented by ECG or Holter monitor. 38 C.F.R. § 4.104, DC 7010. Review of the medical evidence of record shows that on a VA examination in May 2002, the Veteran reported that approximately once per month he developed a rapid heart rate that lasted usually less than 5 minutes, which he described as palpitations. He reported that his wife checked his pulse and noted it was a rapid, irregular beat, usually 98 to 110 beats per minute. It was noted that the attacks had not been confirmed by EKG or Holter monitor. On examination, no cardiac arrhythmia was noted. The diagnosis was history of tachyarrhythmia, normal examination. VA treatment records showed that in December 2002, the Veteran was seen to evaluate occasional episodes of angina and palpitations, and a 24 hour Holter monitor reflected he had occasional episodes of sinus tachycardia and occasional premature atrial contractions, and premature ventricular contractions, but no significant SVT (supraventricular tachycardia). It was noted that the Veteran did not have any significant cardiac arrhythmia at the present time, since taking Verapamil, which was noted to control the SVT very well. In April 2004, the Veteran's main concern was listed as chest pain, and it was noted that cardiac arrhythmia was not a major concern at that time. On a VA examination in August 2005, the Veteran complained of atypical chest pain with significant near syncope, documented in 1972, as well as supraventricular tachycardia, but no further delineation of cardiac irregularity. Since then, he had frequent episodic chest pain with occasional borderline increased hypertension with significant hyperlipidemia. He was referred for cardiac catheter, and until then the conclusion was stable angina, paroxysmal, supraventricular tachycardia based on the history and 24 hour Holter monitor, and occasional sinus tachycardia. By RO rating decision in August 2008, service connection was established for the Veteran's supraventricular arrhythmia. On a VA examination in January 2010, the diagnosis was supraventricular arrhythmia, currently no episodes. On a VA examination on March 2, 2012, the diagnoses included atherosclerotic cardiovascular disease, stable angina, and supraventricular arrhythmia. An interview-based METs test revealed that a workload of greater than 5 METs but not greater than 7 METs, resulted in dyspnea, fatigue, angina, dizziness, and syncope. The examiner opined that the Veteran's METs level limitation was not solely due to the heart condition, estimating that 50 percent was due to his heart condition, and 50 percent was due to his bilateral knee DJD (degenerative joint disease). The Veteran reported he had arrhythmia every 90 days or so with the last one occurring the week prior and lasting about 15 minutes with sharp pain. He also reported that 6 to 8 months prior he was having a bad episode and went to the emergency, but it resolved as these come and go. With these episodes he reported he was at rest and felt he could not breathe, felt his heart racing, and a metallic taste in his mouth. He reported he had worn a Holter monitor but it did not capture the event and he was told the monitor was faulty. He reported he did not take any current medication for arrhythmia, blood pressure, or hyperlipidemia. It was noted that the Veteran had intermittent (paroxysmal) supraventricular tachycardia, 1 to 4 episodes in the past 12 months, that were documented by his statements. Testing for left ventricular dysfunction revealed an ejection fraction of less than 50 percent. The diagnosis was listed as recurrent episodes of PSVT (paroxysmal supraventricular arrhythmia). In the July 2017 remand, the Board directed that in scheduling the Veteran for a VA examination to determine the current severity of his service-connected disability, all appropriate testing should be conducted and all clinical manifestations of the service-connected supraventricular arrhythmia with chest pain should be reported in detail. The VA examiner was also asked to determine whether the Veteran's service-connected supraventricular arrhythmia with chest pain was manifested by any of the following: permanent atrial fibrillation (lone atrial fibrillation), 1-4 episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor, or paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than 4 episodes per year documented by ECG or Holter monitor. On the VA DBQ (disability benefits questionnaire) examination in August 2017, the diagnosis was listed as supraventricular arrhythmia with chest pain, diagnosed in 1972. The examiner responded "yes" to whether the Veteran had a cardiac arrhythmia, and indicated he had ventricular arrhythmia (sustained). The examiner indicated that an EKG revealed first degree AV block, left axis deviation; a chest x-ray was normal; an echocardiogram revealed left ventricular ejection fraction (LVEF) of 60 percent, wall motion was normal, and wall thickness abnormal with trace mitral regurgitation. An interview-based METs test revealed that a workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea and fatigue. The examiner indicated that the METs level was due solely to the heart condition that the Veteran was claiming in the diagnosis section. The examiner was asked to review the chest x-ray performed in August 2017 and the echocardiogram performed in August 2017 with an ejection fraction of 60 percent, and indicate if there were any clinically significant abnormalities that warranted a cardiac diagnosis, and the examiner reported that there was no new diagnosis. The record reflects that the RO has assigned a 0 percent disability rating for the service-connected supraventricular arrhythmia, retroactive to April 2001. The Board notes, however, that there are objective findings in the record that delineate distinct time periods in which the Veteran's service-connected cardiac disability manifested symptoms which warrant different evaluations; thus, the assignment of staged ratings is appropriate. See Fenderson v. West, supra. The Board also notes that, in light of the METs testing results noted on the VA examinations in March 2012 and in August 2017, and the fact that in August 2017 the VA examiner attributed these findings to the Veteran's arrhythmia, these findings are most appropriately considered under DC 7011. Pursuant to DC 7011, a 10 percent rating is assigned for a workload of greater than 7 METs but not greater than 10 METs, which results in dyspnea, fatigue, angina, dizziness, or syncope, or continuous medication required. A 30 percent rating is assigned when a workload of 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 assigned 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 assigned for chronic congestive heart failure; or 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. 38 C.F.R. § 4.104, DC 7011. One MET (metabolic equivalent) 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). Accordingly, the Board finds that that review of the record on appeal shows that the criteria for a 10 percent rating, pursuant to DC 7010, have been met or approximated, as VA treatment records and VA examinations have shown that the Veteran's supraventricular arrhythmia has manifested one to four episodes per year of supraventricular tachycardia, which were initially reported by the Veteran and later documented with a Holter monitor. Further, on the VA examination dated March 2, 2012, it was noted that METs testing revealed a workload of greater than 5 METs but not greater than 7 METs, resulted in dyspnea, fatigue, angina, dizziness, and syncope. Thus, these findings meet the criteria for a 30 percent rating under DC 7011, effective from March 2, 2012. Prior to March 2, 2012, however, the criteria for a rating in excess of 10 percent have not been met as there was no report or documented finding that the Veteran's episodes of supraventricular tachycardia occurred more than 4 times per year. Additionally, effective from March 2, 2012, the criteria for a rating in excess of 30 percent have not been met as the Veteran's supraventricular arrhythmia with chest pain was not manifested by a workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea, fatigue, angina, dizziness, and syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. On the August 25, 2017 VA examination, the Veteran's supraventricular arrhythmia with chest pain was also characterized as ventricular arrhythmia, and was found to be productive of a workload of greater than 3 METs but not greater than 5 METs, resulting in dyspnea and fatigue. Effective from August 25, 2017, the criteria for a 60 percent rating, pursuant to DC 7011, have been met. However, at no time effective from August 25, 2017 has the record shown any report or finding of congestive heart failure, workload of 3 METs or less resulting in symptoms, or left ventricular dysfunction with an ejection fraction of less than 30 percent. Thus, effective from August 25, 2017, the criteria for a rating in excess of 60 percent rating, pursuant to DC 7011, have not been met. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Prior to March 2, 2012, an initial 10 percent rating for the Veteran's supraventricular arrhythmia with chest pain is granted, subject to the laws and regulations governing the payment of monetary benefits. Effective from March 2, 2102 and until August 24, 2017, a 30 percent rating for the Veteran's supraventricular arrhythmia with chest pain is granted, subject to the laws and regulations governing the payment of monetary benefits. Effective from August 25, 2017, a 60 percent for the Veteran's supraventricular arrhythmia with chest pain is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs