Citation Nr: 21010441 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 15-41 094 DATE: February 24, 2021 ORDER Entitlement to an initial disability rating in excess of 10 percent for premature atrial contractions (also known as “supraventricular beats”), residuals of acute pericarditis, is denied. REMANDED Entitlement to service connection for obstructive sleep apnea, as secondary to service-connected heart condition, is remanded. FINDING OF FACT The Veteran’s disability has been manifested by lone atrial fibrillation but not by paroxysmal atrial fibrillation or other supraventricular tachycardia exceeding four episodes per year. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 10 percent for premature atrial contractions have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.104, Diagnostic Code (DC) 7010. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1958 to March 1963. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from April 2014 and February 2016 rating decisions issued by the Department of Veteran Affairs (VA) Regional Office (RO), which granted service connection for premature atrial contractions, assigning a 10 percent disability rating, effective March 14, 2012, and denied entitlement to service connection for obstructive sleep apnea. This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2) and 38 C.F.R. § 20.900(c). In April 2019, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Board videoconference hearing. A copy of the transcript has been associated with the claims file. In March 2020, the Board remanded the claims on appeal for further development. Substantial compliance has been obtained with respect to the Veteran’s claim for an increased rating. Entitlement to a higher initial rating for premature atrial contractions Disability ratings are determined by applying the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings is permissible. See Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Veteran is seeking an initial rating in excess of 10 percent for his service-connected premature atrial contractions. The Veteran’s service-connected premature atrial contractions is rated under 38 C.F.R. § 4.104, DC 7010, pertaining to supraventricular arrhythmias. A 10 percent rating is assigned for permanent atrial fibrillation (lone atrial fibrillation) or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A 30 percent rating is assigned for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. Turning to the relevant evidence of record, September 2012 private treatment records note that the Veteran has complained of chest pain and had woken up with sharp pain in the left side of his chest that lasted about ten minutes. During this episode, he reported no sensation of dyspnea, diaphoresis, or nausea. The pain had gradually improved and he reported that his chest discomfort was not worsened by activities such as walking, shopping, carrying groceries, and yard work. The Veteran underwent VA examination in April 2013. The examiner noted the diagnosed heart condition- acute pericarditis with tamponade, which was remote and resolved. The Veteran reported that he has had an irregular heart beat since discharge from service, and stated he had intermittent sharp chest pains in the neck area. The examiner stated that continuous medication was not required to control the Veteran’s heart condition. The Veteran did not have myocardial infarction, congestive heart failure, arrhythmia, or a heart valve condition. The Veteran also did not require treatment for an active infection, and he did not have a syphilitic aortic aneurysm. The examiner remarked that the Veteran did not have pericardial adhesions, or any procedures or hospitalizations for treatment of his heart condition. Upon examination, testing revealed a heart rate of 80, with regular rhythm, normal heart sounds, and no jugular-venous distension. Auscultation of the lungs was clear, peripheral pulses were normal, with no peripheral edema. Blood pressure was 148/86. The examiner commented that the Veteran had regular rhythm but with a single, premature beat and that premature ventricular contractions (PVC) was likely. Diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. Echocardiogram results revealed left ventricular ejection fraction (LVEF) greater than 55 percent, with normal wall motion and wall thickness. The Veteran’s METs exercise stress test was negative, with his METs level at 10; METs level limitation was not solely due to his heart condition, and the examiner estimated that no percentage of METs level limitation was solely due to his heart condition. February 2014 private treatment records report that the Veteran’s wife, who is a nurse, reported that his pulse revealed “skipping beats.” The Veteran reported chest pain, described as sharp, lasting about 15 to 20 minutes, which did not radiate. His activity was not limited by his chest pain, and he shoveled snow that morning without any issues. He reported dizziness and lightheadedness when standing. In October 2015, the Veteran underwent VA examination. The examiner noted diagnoses of acute pericarditis with tamponade, which was remote and resolved as well as premature atrial contractions, residuals of acute pericarditis. The Veteran’s heart conditions were not within the generally accepted medical definition of ischemic heart disease (IHD). Continuous medication for control of the Veteran’s heart condition was required, and the Veteran was taking metoprolol. The Veteran did not have myocardial infarction or congestive heart failure. However, he had a cardiac arrhythmia, described as non-sustained paroxysmal atrial contractions, with zero episodes reported in the past 12 months as documented by EKG and Holter monitor. The Veteran did not have a heart valve condition, infectious heart conditions, pericardial adhesions, or any procedures or hospitalizations for the treatment of his heart conditions. Upon examination, testing revealed a heart rate of 60, with regular rhythm and no jugular-venous distension. His heart sound was abnormal, specified as Gr2-3/6 sys murmur at LSB. Auscultation of the lungs was clear, peripheral pulses were normal, with trace peripheral edema, bilaterally in his lower extremities. Blood pressure was 130/60. Diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. EKG revealed normal sinus rhythm with nonsustained PAC’s, and inferior Q waves were noted. Echocardiogram results revealed LVEF greater than 55 percent, with normal wall motion and wall thickness. MUGA revealed normal LVEF greater than 55 percent. Interview-based METs test was conducted, revealing symptoms of fatigue, dyspnea, chest episodes, and diaphoresis. The Veteran’s cardiologist had noted that these symptoms are “random events not related to activity” and were “not due to a cardiac condition.” Other notes indicated that these episodes were due to Meniere’s disease. The METs level was reported as greater than 5-7, which has been found to be consistent with activities such as walking one flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). The examiner commented that the limitation in METs level is due to multiple medical conditions including the heart condition(s) and it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. As rationale, the examiner stated that “it is very difficult to assess the effect of his multiple conditions: advanced age, chronic knee pain with bilat arthroplasty. According to his cardiologist his heart function is at normal levels.” Pursuant to the March 2020 Board remand, the Veteran underwent VA examination in December 2020. The examiner noted the Veteran’s premature atrial contractions, residual of acute pericarditis. The Veteran’s heart condition was not within the generally accepted medical definition of IHD. Continuous medication for control of the Veteran’s heart condition was not required. The Veteran did not have myocardial infarction, congestive heart failure, or a cardiac arrhythmia. The Veteran also did not have a heart valve condition, infectious heart conditions, pericardial adhesions, or any procedures or hospitalizations for the treatment of his heart condition. Upon examination, testing revealed a heart rate of 59, with regular rhythm and no jugular-venous distension and his heart sound was normal. Auscultation of the lungs was clear, peripheral pulses were normal, with no peripheral edema. His reported blood pressure was 152/82, 153/79, and 146/78. Diagnostic testing revealed no evidence of cardiac hypertrophy or cardiac dilation. EKG and chest x-rays were normal. Echocardiogram results revealed LVEF greater than 55 percent, with normal wall motion and wall thickness. Interview-based METs test was conducted, and the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. The examiner remarked that there was no change in diagnosis of his premature atrial contractions, residual of acute pericarditis, which he stated was quiescent. After review of the evidence of record, the Board finds that the totality of the evidence weighs against a rating in excess of 10 percent for the Veteran’s service-connected premature atrial contractions. The Veteran’s private treatment records as well as the VA examination reports do not indicate a period when the Veteran had paroxysmal atrial fibrillation episodes, or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor. The Board has also considered the Veteran’s testimony that his heart condition has worsened in severity over the past few years. Unfortunately, these reports do not warrant a higher rating for the Veteran’s disability on appeal. In claims for a higher rating it is the current level of disability that is of primary concern. See Francisco, 7 Vet. App. at 58 (1994). While the Board has considered the Veteran’s statements, the weight of the evidence is against a finding that he has suffered more than four episodes of premature atrial contractions, as residual of acute pericarditis during the appeal period. Further, the Board notes evidence showing that the Veteran has been limited by his heart condition, to include shortness of breath, but these limitations in part are the reason for his current disability rating. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Accordingly, the Board finds that an initial rating in excess of 10 percent for his service-connected premature atrial contractions, residuals of acute pericarditis is not warranted. REASONS FOR REMAND In the March 2020 remand, the Board noted the Veteran’s testimony that his sleep apnea is related to his service-connected heart condition. Pursuant to the Board directives, VA examination was obtained in December 2020. The examiner opined that it was less likely than not that the Veteran’s sleep apnea was proximately due to or the result of his service-connected premature atrial contractions, residuals of acute pericarditis. As rationale, he stated that “neither premature atrial contractions or pericarditis are established primary etiologies of sleep apnea in the medical literature.” However, the examiner did not address whether the Veteran’s sleep apnea was aggravated by the heart condition. The Board’s remand directive specifically instructed the examiner to opine whether the Veteran’s sleep apnea was “aggravated beyond its natural progression by service-connected disability, to include premature atrial contraction.” A medical opinion that does not specifically address aggravation is generally inadequate to decide a secondary service connection claim. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013). As such, the Board finds that substantial compliance with the March 2020 remand directives has not been achieved. See Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, a VA addendum opinion should be obtained with complete rationale as to whether the Veteran’s sleep apnea is caused or aggravated by his service-connected premature atrial contractions. The examiner must also consider the Veteran’s April 2019 Board hearing testimony The matter is REMANDED for the following action: 1. Send the Veteran’s claims file to an appropriate medical professional to obtain an addendum opinion regarding the etiology of his obstructive sleep apnea. The Veteran’s entire electronic claims file must be made accessible to the designated professional for review. A detailed rationale for any opinion expressed should be provided. The examiner must also consider the Veteran’s lay statements, to include the April 2019 Board hearing testimony. 2. The examiner must opine whether the Veteran’s sleep apnea is at least as likely as not (1) proximately due to service-connected heart disability, to include premature atrial contractions, or (2) aggravated beyond its natural progression by service-connected heart disability, to include premature atrial contractions. 3. After completing the above, and any other development as may be indicated, the Veteran’s claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Kovacs, 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.