Citation Nr: 21000556 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 17-10 506 DATE: January 5, 2021 ORDER Entitlement to an initial rating greater than 30 percent from February 28, 2011, and 60 percent from September 3, 2019, for ischemic heart disease (IHD), status-post percutaneous coronary intervention and myocardial infarction, is denied. FINDINGS OF FACT 1. For the period prior to September 3, 2019, the Veteran’s service-connected IHD was not manifested by more than one episode of acute congestive heart failure in the past year, a workload of greater than 3 METs but not greater than 5 METs, or left ventricular dysfunction with an ejection fraction of 30 percent to 50 percent. 2. For the period from September 3, 2019, the Veteran’s service-connected IHD was not manifested by chronic congestive heart failure, workload of 3 METs or less, or left ventricular dysfunction with an ejection fraction of less than 30 percent. CONCLUSIONS OF LAW 1. For the period prior to September 3, 2019, the criteria for an initial rating greater than 30 percent for the service-connected IHD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.14, 4.104, Diagnostic Code 7006. 2. For the period from September 3, 2019, the criteria for an initial rating greater than 60 percent for the service-connected IHD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.10, 4.14, 4.104, Diagnostic Code 7006. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from July 1968 to June 1970. This matter comes before the Board of Veterans’ Appeals (Board) of a March 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board issued a decision denying an initial rating in excess of 30 percent for the service-connected IHD. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In September 2019, the Court vacated the November 2018 Board decision and remanded the issue for further consideration consistent with an August 2019 Joint Motion for Partial Remand (JMR) filed by counsel for the Veteran and the VA Secretary. The parties to the August 2019 JMR agreed that the Board erred in not ensuring that appropriate efforts were made to obtain private treatment records from the Capital Regional Medical Center that were identified in the Veteran’s VA treatment records and by not addressing whether a new VA examination was warranted given a statement accompanying the Veteran’s February 2014 notice of disagreement. The Board remanded the Veteran’s appeal for higher initial ratings for the service-connected IHD in July 2020 to obtain private treatment records, namely the May 2017 echocardiogram and a July 2017 bilateral carotid ultrasound report from the Capital Regional Medical Center identified in the August 2019 JMR. These records have since been associated with the Veteran’s claims file, and therefore the Board finds that its July 2020 remand directives were substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the Veteran was afforded a VA examination as to his service-connected IHD in September 2019. That examination provides the information necessary to render a full decision on the issue on appeal. Furthermore, the Veteran has not alleged that his service-connected IHD has increased in severity since the September 2019 VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time is not a basis for requiring a new examination). Rather, the Veteran contends only that higher ratings are warranted. As such, the Board finds that the examinations of record are adequate to adjudicate the Veteran’s increased rating claim and no further examination is necessary. Neither the Veteran nor his representative has raised any other issues with regard to the duty to notify or duty to assist as they pertain to the issue denied in this decision. 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 a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issue denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed).  Increased Rating Entitlement to initial ratings greater than 30 percent from February 28, 2011, and 60 percent from September 3, 2019, for ischemic heart disease (IHD), status-post percutaneous coronary intervention and myocardial infarction The Veteran seeks higher initial ratings for his service-connected IHD. The applicable rating period is from February 28, 2011, the effective date for the award of service connection for that disability, through the present. See 38 C.F.R. § 3.400. The Veteran’s service-connected IHD is rated pursuant to 38 C.F.R. § 4.104, Diagnostic Code (DC) 7006. Under DC 7006, a 10 percent rating is warranted where a workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. A 30 percent rating is warranted where a 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 dilation on electrocardiogram, echocardiogram, or X-ray. A 60 percent rating is warranted 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 results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent disability rating is warranted 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. A 100 percent disability rating is also warranted during and for three months following myocardial infarction, documented by laboratory tests. One metabolic equivalent (MET) 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. 38 C.F.R. § 4.104, Note (2). When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, 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. Id. For the purposes of a 60 percent rating, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of 30 to 50 percent. Otero-Castro v. Principi, 16 Vet. App. 375, 382 (2002). Additionally, the phrase “30 to 50 percent” means 30 percent through 50 percent. Id. at 380. Prior to September 3, 2019 For the period prior to September 3, 2019, the Veteran’s primary contention is that he is entitled to an increased disability rating for his service connected IHD, as his METs level is more comparable to 1-3 METs rather than 5-7 METs. See Handwritten Notations by Veteran on November 2012 IHD DBQ. Private treatment records dated in April 2011 showed that the Veteran complained of chest pain and it was noted that he had coronary artery disease status-post a previous right coronary artery stent. He indicated that his chest pain became more frequent, midsternal, associated with activity, and relieved with rest. A study revealed normal size left ventricle, normal wall thickness, and overall normal systolic function. The ejection fraction was between 50 percent and 55 percent. The medical professional specifically noted normal left ventricular systolic function with evidence of early left ventricular diastolic dysfunction normal right ventricular systolic function, mild tricuspid regurgitation and normal pulmonary artery pressure. A June 2012 private echocardiographic study revealed a normal size left ventricle without hypertrophy and overall normal left ventricular systolic function. Systolic ejection fraction was estimated to be 60 percent to 65 percent. The medical professional noted normal coronary arteriogram with widely patent right coronary stent, normal left ventriculogram, and no aortic or mitral valve abnormalities. Thereafter, private treatment records dated in July 2012 indicated that the Veteran was hospitalized due to sinus bradycardia, sick sinus syndrome (SSS), tachy, and brady. The Veteran reported that he had chest pain and dizziness. On physical examination, no murmurs were heard and there was no bruit in the carotid artery. The assessment was native coronary artery stenosis. Additional private treatment records dated in August 2012 noted that the Veteran had a recent diagnosis of SSS and indicated that he had tachybrady syndrome with a heart rate down to the 30s. The Veteran admitted to extreme fatigue, weakness, as well as dizziness. The medical professional noted that a recent echocardiogram also revealed a heart rate in the low 40s and as a result he was sent to this medical professional for insertion of a permanent pacemaker. On physical examination, the heart had regular rhythm and rate. The impression was sick sinus syndrome with symptomatic bradycardia. In addressing the Veteran’s contentions, per the November 2012 VA examination report, he has a history of myocardial infraction, but does not suffer from congestive heart failure (CHF). The lowest level of activity at which the Veteran reports symptoms is 5-7 METs resulting in dyspnea and fatigue. The Veteran had a 60-65 percent left ventricular ejection fraction (LVEF) reading. While the Veteran indicated that his METs level is more like 1-3 relative to the aforesaid VA examiner’s medical findings, the Board does not find any reason to deem the November 2012 VA examination (and the medical testing results therein), to be inadequate for purposes of rating the Veteran’s disability, nor does it find the Veteran competent to opine as to his METs level, as that determination requires precise medical testing. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Because the Veteran’s assessments as to METs level are not considered competent, they do not weigh against the probative value of the November 2012 VA examiner’s findings. Therefore, the Board accepts the November 2012 VA examiner’s assessment of 5-7 METs as an accurate and probative assessment of the Veteran’s METs level. In support of his claim, the Veteran submitted an August 2017 Cardiac Medical Source Statement which indicated that the Veteran suffers from chest pain, weakness, syncope, chronic fatigue, dizziness, and palpitations. Dr. J.B. indicated that relative to the Veteran’s angina, he suffers episodes of chest pain that typically occur several times a week, lasting about 10-15 minutes. Dr. J.B. indicated that the Veteran is incapable of even “low stress” work due to his co-morbid problems. Dr. J.B. also indicated that the Veteran had a normal echo. Ultimately, the Board finds the August 2017 Cardiac Medical Source Statement to not be probative in rating the Veteran’s service-connected IHD because it does not include medical testing results relative to METs or ejection fraction as contemplated by DC 7006. Per a private May 2017 echocardiogram, the Veteran had an LVEF estimated range of 65-70 percent, with no regional wall motion abnormalities. A private July 2017 carotid examination showed moderate plaque formation. The Board notes that the Veteran is not service-connected for an artery condition nor is there evidence of record that the same is a symptom of the Veteran’s service-connected IHD. In addressing the Veteran’s lay contentions that, due to his IHD, his METs level is more like 1-3 METs for this period on appeal, the Board also finds probative the September 2019 VA examiner’s findings that associate those levels not with the Veteran’s IHD, but rather with his non-service connected chronic obstructive pulmonary disease (COPD). Although the Veteran is competent to report his readily observable symptoms, he is not competent to opine as to his specific METs level or whether left ventricular dysfunction is present at a specific ejection fraction, as confirmation of these symptoms requires precise medical testing. Additionally, the Veteran is not competent to differentiate as to which of his conditions results in a specific METs level. The Board accepts the September 2019 VA examiner’s statement as probative in showing that although the Veteran’s overall capacity may be comparable to less than 5 to 7 METs, his service-connected IHD on its own and without consideration of the nonservice-connected COPD causes limited capacity comparable to 5 to 7 METs. Accordingly, in consideration of all the relevant evidence of record, the Board finds that the preponderance of the evidence weighs against finding that the Veteran’s service-connected IHD resulted in more than one episode of acute congestive heart failure, or a workload of greater than 3 METs but not greater than 5 METs, or an LVEF of 30 to 50 percent for the period prior to September 3, 2019. The Board therefore concludes that the Veteran’s service-connected IHD did not meet the criteria corresponding to an initial rating higher than 30 percent during that period. From September 3, 2019 For the period from September 3, 2019, the Veteran is in receipt of a 60 percent disability rating primarily based upon the September 2019 VA examination, which revealed a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope. Importantly, for purposes of rating the Veteran’s disability under DC 7006, the VA examiner did not find that the Veteran suffers from chronic congestive heart failure, LVEF of less than 30 percent, or a workload of three METs or less. As previously discussed, the VA examiner did find that the Veteran suffers from a workload of 3 METs or less; however, those testing results were attributed to the Veteran’s non-service-connected COPD condition, to include changes in symptomatology relative to that condition, rather than the Veteran’s service-connected IHD. The Veteran’s echocardiogram revealed an LVEF of 60 to 65 percent, with normal wall motion and thickness. Per an October 2019 Echo Report, the Veteran’s LVEF ranged from 60 to 65 percent. The attending physician noted that the Veteran had normal left ventricular systolic and diastolic function. Per an October 2019 Urgent Care Note, the Veteran had no edema, syncope, or palpitations. Objectively, the Veteran had normal heart sounds with regular rhythm with no murmurs, rubs, or gallops. Importantly, as supported by the September 2019 VA examiner’s findings, the attending physician ultimately determined that the Veteran was suffering from an exacerbation of his COPD condition and attributed the Veteran’s symptomatology of chest pain to his COPD. See also April 21, 2020 Pulmonary Consult (“…has had frequent exacerbations of COPD, most recently in February 2020”). In September 2020, his most recent echocardiogram was interpreted as showing normal left ventricle systolic function with grade 1 diastolic dysfunction, mild mitral regurgitation and mild-to-moderate tricuspid insufficiency with mild pulmonary hypertension. The attending physician noted that there had been no change in the LVEF as it is still within normal limits. Thus, for the period from September 3, 2019, the preponderance of the evidence, specifically the treatment records for this period on appeal, consistently reveal exacerbations of the Veteran’s non-service-connected COPD, rather than a worsening of his service-connected IHD. Accordingly, the Board assigns the most probative value to the September 2019 VA examiner’s findings as those findings are well supported by subsequent treatment records noting frequent exacerbations of the Veteran’s non-service-connected COPD condition. Those findings do not indicate that a rating in excess of 60 percent was warranted. The Board therefore finds that the criteria for higher initial ratings for the service-connected IHD have not been met. As the preponderance of the evidence is against the assignment of higher initial ratings, the doctrine of reasonable doubt is not for application, and the appeal must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). T. J. ANTHONY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.R. Fey, Associate 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.