Citation Nr: 21063262 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 15-15 874 DATE: October 13, 2021 ORDER Entitlement to an evaluation greater than 30 percent for hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension is denied. REMANDED Entitlement to service connection for a sleep disorder, to include as secondary to service-connected disabilities is remanded. FINDING OF FACT The Veteran's hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension has not been manifested by 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. CONCLUSION OF LAW The criteria for an evaluation greater than 30 percent for hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7007. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Air Force from December 1989 to July 1993 and in the United States Navy from April 2003 to December 2003 and from December 2006 to December 2007. These matters are on appeal from April 2012 and May 2014 rating decisions. In August 2018, the Veteran testified before undersigned. A copy of the transcript is associated with the record. In March 2019 and March 2021, the Board remanded the appeal for additional evidentiary development. Entitlement to an evaluation greater than 30 percent for hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension. In October 2011, the Veteran filed a claim for an increased evaluation for his service-connected hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension. The Veteran's hypertensive heart disease with left ventricular hypertrophy is rated under Diagnostic Code 7007. 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 shovelling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. Diagnostic Code 7007 provides ratings for hypertensive heart disease. Hypertensive heart disease that results 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, is rated 30 percent disabling. Hypertensive heart disease that results 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. Hypertensive heart disease that results 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. In April 2014, the Veteran was afforded a VA heart examination. The VA examiner diagnosed hypertensive heart disease. The Veteran was employed as a firefighter. However, he experienced shortness of breath and dizziness that impacted his ability to work. The Veteran did not have congestive heart failure. An echocardiogram indicated that the Veteran's left ventricle ejection fraction was between 55 and 60 percent. There was evidence of cardiac hypertrophy. Interview-based METs testing indicated that the Veteran could perform between 7 and 10 METs of work. The VA examiner indicated that the Veteran's heart disability did not impact his ability to work because the Veteran was employed as a fireman. In August 2018, the Veteran testified that he had been hospitalized for rapid heartbeats. He also endorsed anxiety, dizziness, and fatigue that were associated with his heart condition. In February 2020, the Veteran was afforded another VA heart examination. The VA examiner diagnosed hypertensive heart disease with left ventricular hypertrophy. The Veteran did not have congestive heart failure. There was evidence of cardiac hypertrophy. The left ventricular ejection fraction was 60 percent. Interview based METs testing indicated that the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. Finally, the Veteran underwent his most recent VA heart examination in June 2020. The VA examiner confirmed the diagnosis of hypertensive heart disease. The Veteran did not have congestive heart failure. His left ventricular ejection fraction was between 60 and 65 percent. Stress testing was not conducted. The VA examiner explained that a stress test was not indicated with someone without cardiac symptoms. The Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. The VA examiner explained that the Veteran's heart disability had improved with the treatment of his hypertension. The Veteran's VA treatment records are silent for complaints of congestive heart failure and they do not disclose left ventricular ejection fractions less than 50 percent. There is no lay or medical evidence of record that the Veteran's hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension has been manifested by 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. Accordingly, the criteria for a 60 percent disability rating are not met or more closely approximated. The preponderance of the evidence is against the claim for a rating greater than 30 percent for hypertensive heart disease with left ventricular hypertrophy associated with essential hypertension. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Entitlement to service connection for a sleep disorder, to include as secondary to service-connected disabilities is remanded. In August 2021, the Veteran's representative asserted that his obstructive sleep apnea was proximately due to or aggravated by the service-connected posttraumatic stress disorder (PTSD). The representative cited medical literature to support this contention. There are no medical opinions of record that address the relationship between the Veteran's obstructive sleep apnea and his service-connected PTSD. Therefore, a remand is required to obtain an addendum opinion that addresses the etiological relationship between the Veteran's PTSD and his obstructive sleep apnea. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's obstructive sleep apnea is at least as likely as not proximately due to or aggravated beyond its natural progression by the service-connected PTSD. In rendering the opinion, the VA examiner is asked to address the literature cited in the August 2021 brief. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.R. Watkins, 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.