Citation Nr: 19178024 Decision Date: 10/10/19 Archive Date: 10/10/19 DOCKET NO. 14-27 083 DATE: October 10, 2019 REMANDED Entitlement to an initial rating in excess of 30 percent prior to June 8, 2011, for cardiovascular disease is remanded. Entitlement to a rating in excess of 60 percent since June 8, 2011, for cardiovascular disease is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1964 to December 1967; he died in December 2015. At the time of his death, the Veteran had a pending appeal for the issue of entitlement to an initial rating in excess of 30 percent for his cardiovascular disease. In February 2018, substitution of the appellant for the Veteran was granted. Accordingly, the appellant has been substituted as the claimant for the purposes of all claims that were pending at the date of the Veteran’s death. 38 U.S.C. § 5121A. The appellant is appealing the original assignment of a disability evaluation following an award of service connection for cardiovascular disease. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran’s cardiovascular disease was rated as 30 percent disabling from June 21, 2000, to June 7, 2011, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005, for workload of greater than 5 metabolic equivalents but not greater than 7 metabolic equivalents resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. 38 C.F.R. § 4.104. A 60 percent rating was assigned starting June 8, 2011, for 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, resulting in dyspnea, fatigue, angina, dizziness or syncope, or; 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. A 100 percent evaluation is also warranted for 3 months following hospital admission for coronary bypass surgery. Private treatment records indicate that the Veteran had a mild myocardial infarction in May 1997. He was found to have a 77 blockage of his left anterior descending artery (LAD) and underwent percutaneous transluminal coronary angioplasty (PTCA) and implantation of a stent in the anterior descending artery. In October 1999, chest x-ray showed no evidence of frank congestive heart failure. In July 2001, the Veteran presented with recurrent angina post angioplasty. He underwent cardiac catheterization and was noted to have moderate coronary atherosclerosis though generally with good coronary blood flow. The Veteran began having bouts of congestive heart failure beginning in November 2006 which was noted to be congestive heart failure decompensation/acute congestive heart failure exacerbation. U.S. National Library of Medicine, National Institutes of Health, Texas Heart Institute Journal notes, Acute decompensated heart failure [(ADHF)] can be defined as the sudden or gradual onset of the signs or symptoms of heart failure requiring unplanned office visits, emergency room visits, or hospitalization. Regardless of the underlying precipitant of the exacerbation, pulmonary and systemic congestion due to increased left- and right-heart filling pressures is a nearly universal finding in ADHF. … Most patients admitted to the hospital with ADHF have a worsening of chronic HF, although 15% to 20% of ADHF hospitalizations represent new diagnoses of HF. … Patients with a new diagnosis of HF are much more likely to present with pulmonary edema or cardiogenic shock, while decompensation of chronic HF usually presents with other signs of congestion and fluid retention, such as weight gain, exertional dyspnea, or orthopnea. … In this case, in November 2006, the Veteran was seen for difficulty breathing that had been ongoing for 24 hours. Physical examination showed 1+ pedal edema without cyanosis in the extremities. Thus, although the February 2010 VA examiner noted a history of acute cardiac illness of congestive heart failure in 2007, it appears that the Veteran may have had at that time chronic congestive heart failure. The Board finds that an additional opinion is required for a VA examiner to clarify, based on review of the record, whether the Veteran had chronic congestive heart failure at any time during the applicable time periods. Such also includes the examiner commenting on whether any medications the Veteran took prevented worse cardiac symptoms, to include keeping congestive heart failure at bay. In Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), the Court held that “[a]bsent a clear statement [in the diagnostic code] setting out whether or how the Board should address the effects of medication ... the Board may not deny entitlement to a higher disability rating on the basis of relief provided by medication.” Per 38 C.F.R. § 4.114, Diagnostic Code 7005, there is not an explicit statement indicating how the Board should treat the ameliorative effects of medication on the Veteran’s coronary artery disease. Thus, pursuant to Jones, the Board may not deny entitlement to a higher disability rating based on the fact that the Veteran’s use of medication lessened his symptoms. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician, preferably a cardiologist, as to the severity of the Veteran’s service-connected cardiovascular disease with regard to each of the following: a) whether cardiovascular disease resulted in chronic congestive heart failure at any time from June 2000 until the Veteran’s death in December 2015; b) whether cardiovascular disease would have resulted in chronic congestive heart failure absent his use of medication any time from June 2000 until the Veteran’s death in December 2015. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Olson, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.