Citation Nr: 21075241 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 19-11 657 DATE: December 17, 2021 ORDER An evaluation of 60 percent, but no higher, for coronary artery disease (CAD), status post coronary artery bypass graft (CABG), effective March 1, 2016, is granted. FINDING OF FACT Throughout the period on appeal, the Veteran's coronary artery disease manifested as workload greater than 3 metabolic equivalents (METs) but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness or syncope. CONCLUSION OF LAW The criteria for a rating of 60 percent, but no higher, for coronary artery disease, status post coronary artery bypass graft, are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.100, 4.104, Diagnostic Code 7006. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August 1964 to July 1966. This appeal comes before the Board of Veterans' Appeals (Board) from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Unfortunately, the Veteran died during the pendency of this appeal. The appellant is the Veteran's surviving spouse. A February 2018 rating decision granted her service connection for the cause of the Veteran's death. As such, she is recognized as a proper substitution in this appeal. In October 2021, the appellant testified at a videoconference hearing from Wisconsin before the undersigned Veterans Law Judge sitting in the vicinity of the Central Office in Washington, D.C. A transcript of the hearing is available in the record. Entitlement to an increased evaluation for CAD, status post CABG from March 1, 2016. The appellant has assumed the Veteran's claim for an increased evaluation for CAD. The Veteran was assigned a temporary 100 percent evaluation from November 21, 2015 following a CABG procedure, and a 30 percent evaluation from March 1, 2016. The appellant argues that the Veteran's symptoms warranted an evaluation of 60 percent for his CAD rather than the assigned 30 percent. The Board agrees. 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 (rating schedule). 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1995). The Veteran's condition has been rated under 38 C.F.R. § 4.104, Diagnostic Code (DC) 7006, which is the DC used following a temporary 100 percent evaluation for a documented myocardial infarction. Under DC 7006, in pertinent part, a 30 percent evaluation is warranted when 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. A 60 percent evaluation is warranted for more than one episode of acute congestive heart failure in the past year, or; when workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; for left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The maximum evaluation of 100 percent is warranted for chronic congestive heart failure, or; when 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. See 38 C.F.R. § 4.104, DC 7006. 38 C.F.R. § 3.104 explains that one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 millimeters per kilogram of body weight per minute. 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. 38 C.F.R. § 4.104, Note (2). For the purposes of a 60 percent evaluation, 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. Additionally, for the purposes of a 100 percent evaluation, the rating criteria do not require a separate showing of left ventricular dysfunction in addition to an ejection fraction of less than 30 percent. See id. at 382. The Board also notes that the rating schedule for the cardiovascular system were amended, effective November 14, 2021. However, this amendment occurred after the March 2016 rating decision on appeal issued by the AOJ so the Board's appellate review will not consider the new criteria. If the Veteran desires to have the new criteria apply, then he is advised to file a supplemental claim, via a VA Form 20-0995, within a year of this decision. Next, the Board will turn to the pertinent lay and medical evidence of record in light of the relevant criteria set forth above. Following a CABG procedure after a myocardial infarction in November 2015, the Veteran was afforded a VA examination in February 2016 to evaluate his condition. The examiner documented that in November 2015, the Veteran's heart medication (Plavix) had been discontinued in anticipation of a prostate biopsy. However, during that discontinuation, the Veteran had a myocardial infarction while shoveling snow, resulting in the CABG procedure. The Veteran reported in February 2016 that recently he played golf with his wife, but that he used a golf cart. The Veteran could walk for 1 mile before having to stop due to back pain. The examiner indicated that exercise stress testing was not conducted as part of the Veteran's regular treatment plan, and due to risk, the examiner conducted an interview-based METs test instead. Based on the interview, the examiner wrote that the Veteran's METs level was 3-5 METs, consistent with his ability to perform activities such as light yard work like weeding, mowing the lawn with a power mower, or brisk walking, before experiencing symptoms attributable to a cardiac condition. The examiner also wrote that the Veteran was limited in his METs level due to multiple medical conditions and therefore it was not possible to accurately estimate the percent of METs limitation based solely on his cardiac condition; namely, the Veteran had reported his walking ability was limited because of back pain. Thus, the examiner wrote that left ventricle ejection fraction (LVEF) testing would be a more accurate evaluation of the Veteran's cardiovascular manifestations alone. The examiner documented the most recent LVEF testing from November 22, 2015, which was 55 percent at that time. See February 2016 Compensation and Pension Examination. The appellant testified to the Board in October 2021 that she believed the Veteran's condition in early 2016 was not accurately described in the VA examination. Following his surgery, the Veteran was unable to use the lawnmower or to vacuum the pool at their house. He could not rake the leaves or bring logs to the fireplace as he used to. She had observed him getting dizzy after their regular walks. She argued that the 60 percent evaluation under the rating schedule was more appropriate. See October 2021 Hearing Transcript. The appellant is competent to describe these observable symptoms shown by her husband, and the Board finds no reason to doubt her credibility in doing so. The Board observes the LVEF result documented during the VA examination was several months old, having been taken the day immediately following the Veteran's myocardial infarction. LVEF testing was not conducted as part of the VA examination, and none is shown in the Veteran's medical record at any time after November 2015. Thus, although the examiner indicated that LVEF testing would be a better representation of the Veteran's cardiovascular manifestations than the METs level estimate, the Board finds that the examiner's METs estimate tends to provide a better indication for the Veteran's cardiac disability in February 2016. The Veteran's condition immediately after his heart attack is not at issue. Indeed, as noted above, he had a temporary total rating from November 21, 2015 to March 1, 2016. Resolving reasonable doubt in the appellant's favor, the Board concludes that Veteran's heart condition in February 2016 is best shown in the record by the estimated 3-5 METs level during the VA examination. 38 C.F.R. §§ 4.3. Accordingly, a 60 percent evaluation is warranted from March 1, 2016, which is the day after the temporary 100 percent evaluation ended. 38 C.F.R. § 4.104. A higher evaluation of 100 percent is not warranted as the evidence, to include the 2016 VA examination report, does not show chronic congestive heart failure, or; when 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. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.