Citation Nr: 1828968 Decision Date: 05/18/18 Archive Date: 05/23/18 DOCKET NO. 13-19 606 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial rating in excess of 60 percent for ischemic heart disease. REPRESENTATION Appellant represented by: Amy R. Fochler, Attorney ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel INTRODUCTION The Veteran had active military service from November 1966 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2011 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. This case was previously before the Board in June 2017, at which time the issue on appeal was remanded for additional development. The case has now been returned to the Board for further appellate action. In his May 2013 substantive appeal, the Veteran requested a Board hearing. However, in a June 2015 correspondence from the Veteran's representative, the Board hearing request was withdrawn. In a February 2017 rating decision, the Veteran was assigned a 60 percent rating for his ischemic heart disease, effective the date of service connection. That does not represent a full grant of the benefit sought on appeal. However, the Board has limited its consideration accordingly. FINDINGS OF FACT 1. METs workload findings are not a sufficient basis to determine the severity of the Veteran's service-connected heart disability as he has co-morbid chronic obstructive pulmonary disease, which contributes to his decreased METs workload; and, left ventricular ejection fraction findings have been found to most accurately represent the severity of the Veteran's service-connected heart disability. 2. The Veteran's left ventricular ejection fraction has been shown to be, at worst, 39 percent. CONCLUSION OF LAW The criteria for an initial rating in excess of 60 percent for ischemic heart disease have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran asserts that he should have a higher initial rating for his ischemic heart disease as his symptoms are worse than those contemplated by the currently assigned rating. In October 2015, the Veteran was afforded a VA examination. In the VA examination report, it was noted that an in-person examination was not performed, rather a telephone interview examination was conducted. At that time, it was noted that the Veteran took continuous medication for control of his heart disability, to include aspirin, Lasix, Nitroglycerin, Metoprolol, Rosuvastatin, and Isosorbide Mononitrate. The Veteran did not have a history of myocardial infarction (MI) and did not have congestive heart failure (CHF). There was no arrhythmia, valve conditions, infectious heart conditions, or pericardial adhesions. The Veteran did not have a history of surgical procedures or hospitalizations for his heart disability. There was no evidence of cardiac hypertrophy or cardiac dilatation. The examiner cited to a November 2013 echocardiogram, which showed a left ventricular ejection fraction (LVEF) of 60 - 65 percent. Exercise stress testing was not performed. Interview-based METs testing revealed the Veteran to have a METs workload of 1-3 with dyspnea and fatigue. The examiner noted that the Veteran's reduced METs workload was the result of multiple medical conditions, including his heart disability, but that it was not possible to accurately estimate the METs limitation attributable to each disability. The examiner noted that the Veteran's LVEF was not indicative of his current cardiac disability picture than the subjective METs level given the Veteran's co-morbidity of chronic obstructive pulmonary disease (COPD). In January 2017, the Veteran was afforded another VA examination. However, at that time, the examiner noted that an in-person or telehealth examination of the Veteran was not completed and all the medical findings provided were based on a review the record. The examiner noted that the Veteran required continuous medication for control of his heart disability and was currently prescribed Lisinopril, Isosorbide Mononitrate, Ranolazine, Metoprolol Succinate, Furosemide, and Aspirin. The Veteran had no history of MI, CHF, arrhythmia, heart valve condition, infectious heart condition, or pericardial adhesions. The Veteran had not had any surgical procedures or hospitalizations for his heart disability. It was noted that a March 2016 echocardiogram showed a LVEF of 50 to 55 percent, basal and mid inferior wall akinesias, and mild left ventricular hypertrophy. It was noted that a May 2016 nuclear stress test revealed regional wall motion abnormalities correlating to the inferior and inferolateral walls with an overall LVEF of 39 percent. Cardiac stress testing was not performed. Interview-based METs testing showed the Veteran to have a METs workload of 1-3 with dyspnea and fatigue. The examiner again noted that the Veteran's reduced METs workload was the result of multiple medical conditions, including his heart disability, but that it was not possible to accurately estimate the METs limitation attributable to each disability. However, the examiner also noted that the Veteran's LVEF of 39 percent from his May 2016 nuclear stress test would be more accurate than the 50-55 percent shown at the time of his March 2016 echocardiogram. Further, the examiner noted that the Veteran's LVEF of 39 percent would be most indicative of his current ischemic heart disease than his estimated METs workload as his estimated METs were influenced by his co-morbid COPD. In April 2017, the Veteran was afforded an in-person VA examination. At that time, the examiner noted that the Veteran continued to take the previously noted prescribed medication for control of his heart disability. The Veteran was noted to have a silent MI that was not treated acutely in 2010. However, he had no history of CHF, arrhythmia, heart valve conditions, infectious heart conditions, or pericardial adhesions. The Veteran had not had any surgical procedures or hospitalizations for treatment of his heart disability. Upon physical examination, the Veteran's heart rhythm was regular, his point of maximal impact was not palpable, heart sounds were normal. There was no jugular-venous distention, auscultation of the lungs revealed left base rhonchi, peripheral pulses were diminished, and there was evidence of lower extremity edema. A March 2016 echocardiogram was noted to reveal cardiac hypertrophy, cardiac dilatation, and a LVEF of 50-55 percent. Exercise stress testing was not performed. Interview-based METs testing showed the Veteran to have a METs workload of 1-3 with dyspnea, fatigue, and angina. The examiner again noted that the Veteran's reduced METs workload was the result of multiple medical conditions, including his heart disability, but that it was not possible to accurately estimate the METs limitation attributable to each disability. The examiner reiterated that the Veteran's LVEF of 39 percent shown by May 2016 nuclear stress testing would be most indicative of his current ischemic heart disease than his estimated METs workload as his estimated METs were influenced by his co-morbid COPD. In a July 2017 clarifying VA opinion, at the request of a Board remand, the examiner indicated the Veteran was not offered a physical stress test because his COPD prevented him from being able to perform the physical activity. A review of the record shows that the Veteran receives treatment for various disabilities, to include his heart disability, at the VA Medical Center and from private providers. However, a review of the evidence of record does not show that the Veteran has reported symptoms of his heart disability that are worse than those which have been described in the various VA examination reports of record. The Board finds that the Veteran is not entitled to an initial rating in excess of 60 percent for his heart disability. In this regard, the Veteran has consistently been shown to have a LVEF of more than 30 percent for the entire period on appeal. In fact, the Veteran's LVEF has been found to be, at worst, 39 percent. In so finding, the Board acknowledges that the Veteran has been found to have a METs workload of less than 3 METs, which would typically warrant assignment of a 100 percent rating for his ischemic heart disease. However, it has been noted that the Veteran's METs workload was diminished by not just his heart disability, but also his co-morbid COPD. Further, the Board acknowledges that the examiners have also indicated that it is not possible to determine the METs workload resulting from the Veteran's heart disability without regard to his COPD. However, the examiners have very clearly found that the best representation of the severity of the Veteran's heart disability alone would be his LVEF, which as noted, has been in excess of 30 percent for the entire period on appeal. Given the medical findings in that regard, it would be inappropriate to rely on the Veteran's METs workload for assignment of a higher rating as that METs workload represents diminished capacity resulting from a nonservice-connected disability. Therefore, the Board finds that an initial rating in excess of 60 percent is not warranted. 38 C.F.R. § 4.104, Diagnostic Code 7005 (2017). Consideration has been given to assigning staged ratings. However, at no time during the period in question has the disability warranted a higher schedular rating than that assigned. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to an initial rating in excess of 60 percent is not warranted. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 60 percent for ischemic heart disease is denied. ____________________________________________ Kristin Haddock Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs