Citation Nr: 19106923 Decision Date: 01/29/19 Archive Date: 01/29/19 DOCKET NO. 16-49 932A DATE: January 29, 2019 ORDER Entitlement to an initial evaluation of 30 percent for coronary artery disease (CAD) is granted for the entire period on appeal. Entitlement to a rating greater than 30 percent for CAD is denied. FINDING OF FACT For the entire period on appeal, the Veteran’s CAD has been manifested by symptoms of dyspnea, fatigue, angina, dizziness, and evidence of cardiac hypertrophy on electrocardiogram. CONCLUSIONS OF LAW 1. Resolving all doubt in favor of the Veteran, for the entire period on appeal, the criteria for a disability rating of 30 percent for coronary artery disease have been met. 38 U.S.C. §§ 1155, 5103 (2012); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2017). 2. The criteria for a rating in excess of 30 percent disability rating for CAD have not been met at any time during the appeal period. 38 U.S.C. §§ 1155, 5103 (2012); 38 C.F.R. § 4.104, Diagnostic Code 7005 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August 1968 to March 1970. During his period of service, the Veteran earned the National Defense Service Medal, Armed Forces Expeditionary Medal (Korea), and Sharpshooter (M-14) Badge. Disability ratings are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. If, as here, there is disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). See also AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original rating remains in controversy when less than the maximum available benefit is awarded); Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, staged ratings for the disability on appeal have already been assigned; accordingly, the Board will discuss the propriety of the ratings assigned at each stage. In this case, the Veteran’s service-connected CAD was assigned a 30 percent rating from August 31, 2010 to December 16, 2011; a 10 percent rating from December 16, 2011 to November 14, 2012; a 30 percent rating from November 14, 2012 to May 2, 2014; and a 10 percent rating from May 2, 2014, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides that a 10 percent rating is warranted for documented CAD resulting in workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or a requirement of continuous medication. 38 C.F.R. § 4.104, Diagnostic Code 7005. A 30 percent rating is warranted for documented CAD resulting in workload of greater than 5 METs but not greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Id. A 60 percent rating is warranted for documented CAD resulting in more than one episode of congestive heart failure in the past year, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Id. A 100 percent rating is warranted for documented CAD resulting in 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. Id. The Veteran appeared for a VA echocardiogram in October 2010. The examiner noted that the Veteran’s left ventricular systolic function was normal. Left ventricular ejection fraction (LVEF) was 50 to 55 percent. The left ventricular wall motion was normal and the left ventricle was grossly normal size. The examiner further noted mild concentric left ventricular hypertrophy. The Veteran appeared for a VA diabetes mellitus examination in November 2010. The examiner noted a history of coronary artery disease. The Veteran’s treatment consisted of taking 40 mg of Zocor nightly. The Veteran reported occasional chest pain. He stated that he tried to walk 12 blocks, four times a week. He indicated that he would sometimes get chest pain after walking seven blocks, at which time he would stop and rest before going further. Upon examination, the Veteran’s heart had a regular rate and rhythm. There was no evidence of murmurs, clicks, rubs, or extra sounds. The Veteran appeared for a VA echocardiogram in December 2011. The Veteran’s left ventricular function was normal. LVEF was 55 to 60 percent. The left ventricular size, and wall thickness was normal. The Veteran appeared for another VA echocardiogram in November 2012. LVEF was 55 to 60 percent. The left ventricular function and size was normal. Left ventricular wall thickness indicated mild concentric left ventricular hypertrophy. The Veteran appeared for a VA myocardial perfusion rest and stress single photon emission computed tomography (SPECT) in November 2012. Imaging demonstrated a LVEF of 61 percent with proximal septal hypokinesis of unknown etiology. Exercise metabolic equivalent of tasks (METs) testing demonstrated the level of activity that the Veteran could perform was 8.30 METs. There was no evidence of chest pain or ST changes. In November 2012, the Veteran appeared for a VA heart conditions examination. Upon examination, the Veteran’s heart rhythm was regular and heart sounds were normal. The examiner noted that the Veteran’s November 2012 echocardiogram showed evidence of cardiac hypertrophy. Diagnostic testing included an echocardiogram, which indicated a LVEF of 60 percent. Wall motion was normal. Wall thickness was described as abnormal, indicating mild concentric left ventricular hypertrophy. Exercise stress and interview-based METs testing demonstrated the level of activity that the Veteran could perform was between 7 to 10 METs. The Veteran reported symptoms of dyspnea and angina during testing. The Veteran appeared for another VA heart conditions examination in May 2014. Upon examination, the Veteran’s heart rhythm was regular and heart sounds were normal. An echocardiogram conducted in conjunction with the examination showed a LVEF of 60 to 65 percent. Wall motion and thickness was normal. Interview-based METs testing demonstrated the level of activity that the Veteran could perform was between 7 to 10 METs. The Veteran reported symptoms of dyspnea during testing. The examiner noted that the Veteran’s non-service connected lumbar spine disease and deconditioning contributed to limiting the METs level. As such, the examiner opined that the LVEF percentage was more than likely a better estimation of METs than the interview-based METs test. The Veteran most recently appeared for a VA heart conditions examination in January 2017. The Veteran reported angina, dyspnea on exertion, increasing fatigability, and dizziness. The Veteran underwent an echocardiogram in conjunction with the examination, which was noted to be normal and not significantly changed when compared to the March 2014 echocardiogram. The examiner noted that continuous medication was required for control of the Veteran’s heart condition, to include aspirin and simvastatin. Interview-based METs testing demonstrated the level of activity that the Veteran could perform was between 3 to 5 METs. The Veteran reported symptoms of dyspnea, fatigue, angina, and dizziness during testing. The examiner opined that the main difference in the Veteran’s cardiac health since his last VA examination in May 2014 was a decrease in stamina with easy fatigability and dizziness. There was no increase in the Veteran’s cardiac medications and he had not sustained or developed a myocardial infarction or congestive heart failure. His chest pain was also stable. An addendum opinion was provided in December 2017. Upon further review of the Veteran’s overall condition and factoring the impact of his cerebrovascular accident (CVA) and deconditioning, the examiner opined that it was not possible to provide an estimated METs score without resorting to speculation. Therefore, the examiner indicated that the Veteran’s LVEF rendered a more accurate finding regarding cardiovascular function as it related to the Veteran’s CAD. Based on this evidence, the Board finds that a 30 percent, uniform rating for the Veteran’s CAD is warranted for the periods on appeal. Echocardiogram imaging showed evidence of cardiac hypertrophy upon examination in November and December 2012. The Veteran have reported symptoms of dyspnea, fatigue, angina, and dizziness. Thus, rather than assigning staged ratings based on results from individual VA examinations, the Board will afford the Veteran the full benefit-of-the-doubt and find that the totality of the evidence favors the assignment of a 30 percent rating for CAD throughout the appeal period. However, the Board also finds that a rating higher than 30 percent is not warranted. The preponderance of the evidence demonstrates that the Veteran has not been shown to have congestive heart failure, or workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope, or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. See 38 C.F.R. § 4.104, DC 7005. The Board notes that interview-based METs testing demonstrated METs levels between 3 to 5, with symptoms of dyspnea, fatigue, angina, and dizziness during testing at the time of the January 2017 VA examination. However, in a December 2017 addendum opinion, the examiner indicated that the Veteran’s LVEF rendered a more accurate finding regarding cardiovascular function, as METs testing factored in residuals of CVA and deconditioning. The Board notes that the Veteran’s LVEF scores have remained above 50 percent throughout the appeals period. (Continued on the next page)   Accordingly, as the Veteran’s disability picture more closely approximates the picture contemplated by the 30 percent rating for the period on appeal, an initial 30 percent rating, but no higher, is granted for CAD. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim of entitlement to an increased rating in excess of that granted herein, that doctrine is not applicable. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). A. S. CARACCIOLO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Joseph, Associate Counsel