Citation Nr: 1817178	
Decision Date: 03/19/18    Archive Date: 03/30/18

DOCKET NO.  11-28 004	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in St. Petersburg, Florida


THE ISSUE

Entitlement to an initial rating in excess of 30 percent for coronary artery disease (CAD).


REPRESENTATION

Appellant represented by:	Disabled American Veterans


ATTORNEY FOR THE BOARD

A. Creegan, Associate Counsel






INTRODUCTION

The Veteran served on active duty in the U.S. Air Force from January 1966 to September 1969 and from April 1980 to July 1983 with additional service in the Air National Guard.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newington, Connecticut.

This case was previously before the Board in June 2017, at which time it was remanded for further development. There has been substantial compliance with the directives, and the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998).


FINDING OF FACT

The Veteran's CAD is manifested by dyspnea at 7-10 METs and an ejection fraction of 60 percent or greater. 


CONCLUSION OF LAW

The criteria for an initial rating in excess of 30 percent for CAD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 3.321, 4.7, 4.104, Diagnostic Code (DC) 7005 (2017).








REASONS AND BASES FOR FINDING AND CONCLUSION

I. Duty to Notify and Assist

In a March 2015 statement, the Veteran alleged that his 2014 VA examination was inadequate due to a lack of electrocardiogram, echocardiogram, and stress testing. This is addressed below. 

Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument).

II. Increased Ratings

Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.

Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. §§ 3.102, 4.3.

In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Since the Veteran timely appealed the rating initially assigned for his disability, the Board must 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 appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); 
Hart v. Mansfield, 21 Vet. App.  505 (2007). 

CAD

The Veteran contends that his initial 30 percent disability rating for CAD does not represent the severity of his condition.

DC 7005 provides ratings for arteriosclerotic heart disease (coronary artery disease), and requires documented coronary artery disease. A 10 percent rating is warranted for arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required. A 30 percent rating is warranted for arteriosclerotic heart disease resulting in 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. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in 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, is rated 100 percent disabling. 38 C.F.R. § 4.104, DC 7005.

For rating diseases of the heart, 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 rating, and a laboratory determination 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) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2.

The Veteran first noticed chest pain while walking in 2001.  In October 2001, the attending physician noted that imaging studies and arteriography showed 60 to 90 percent stenosis and a left ventricular ejection fraction of 45 percent.  The Veteran reported intermittent dyspnea and dizziness with exertion.  Following the placement of two stents, the physician noted zero percent residual stenosis. 

The Veteran was provided a VA examination in October 2010. He reported dyspnea on exertion when pushing heavy weights, but denied angina, dyspnea at rest, fatigue, dizziness or syncope. His clinically estimated METs score was 7-8. No estimated ejection fraction was provided; however, the examiner did note that in October 2001 the Veteran's pre-surgical ejection fraction was 45 percent. 

In November 2010, the Veteran underwent an echocardiogram that showed a left ventricular ejection fraction of 65 percent and no effusion, regurgitation, or valve abnormalities. 

The Veteran underwent another VA examination in September 2014. Due to a medical contraindication, no stress testing was conducted, and METs were estimated based on the Veteran's responses. The Veteran reported using an exercise bicycle three times per week for 30 minutes and cares for his lawn and a disabled child and denied shortness of breath, orthopnea, or swelling of the extremities.  The METs value estimated by the examiner was >7-10, with fatigue reported during activities such as climbing stairs quickly, moderate bicycling, sawing wood, and jogging. The examiner cited the November 2010 echocardiogram and testing that showed left ventricular ejection fraction was 65 percent. The Veteran contends the examination is inadequate due to the lack of testing. As noted above, 38 C.F.R. § 4.104, Note 2 provides that when stress testing is medically contraindicated, the METs value may be estimated and examples of activities provided. The decision to conduct testing is a medical one made by the examiner, and there is no indication that the examiner was not competent to make that decision or that any guidelines were not followed.  The examiner is also competent to determine whether an additional echocardiogram or other testing was required.  Therefore the Board finds the examination to be adequate.

Private treatment records dated in December 2014 indicate that the Veteran experiences osteoarthritis with low back and knee pain.  IN February 2015, a VA examiner assessed the status of the Veteran's diabetes mellitus and advised the Veteran to continue an exercise regimen.  

In February 2016 the Veteran was hospitalized for an episode of syncope with severe abdominal cramps. Although an echocardiogram showed ejection fractions estimated from 50 to 55 percent, a left heart catheterization (LHC) showed an ejection fraction of 60 percent.  The Veteran reported no cardiac complaints and was cleared for unrelated surgery. 

The Veteran received a VA examination in September 2017. The examiner noted the Veteran's reports of swollen ankles, occasional lightheadedness when getting up from reclining, and leg heaviness when riding exercise bike or mowing lawn. Again, the examiner stated that stress testing was medically contraindicated and provided an estimated METs value of >7-10 based on the Veteran's reported symptoms and physical activity level. The examiner also indicated that the Veteran's 2016 LHC test results were considered in the estimate. 

Based on the evidence of record, the Board concludes a rating in excess of 30 percent is not warranted at any point throughout the appeal period. The lowest METs level reported during the period was 7-8, and the lowest ejection fraction reported was 60 percent. To warrant a 60 percent rating, METs would need to be between 3-5 or the ejection fraction would need to be between 30-50 percent. The Board notes that the Veteran's ejection fraction in October 2001 was reported as 45 percent. However, all ejection fraction testing during the period on appeal showed an ejection fraction of 60 percent or more. Therefore, a rating in excess of 30 percent is not warranted.

All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against an increased rating in excess of 30 percent for the Veteran's service-connected CAD. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied.

Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record.  See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that 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

Entitlement to an initial rating in excess of 30 percent for coronary artery disease (CAD) is denied.




____________________________________________
J.W. FRANCIS
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs