Citation Nr: 21011806 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-37 145 DATE: March 2, 2021 ORDER Entitlement to a rating greater than 30 percent for service-connected coronary artery disease (CAD) is denied. FINDING OF FACT Throughout the appeal period, the Veteran’s CAD has not more nearly approximated 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 a rating greater than 30 percent for service-connected coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.7, 4.104, Diagnostic Code (DC) 7005. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from July 1965 to July 1967. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) in which the RO denied a rating greater than 10 percent for the Veteran’s service-connected CAD. The Veteran disagreed with that decision and in a May 2017 rating decision, the RO increased the Veteran’s CAD rating to 30 percent, effective October 24, 2014, the date that the Veteran’s claim for increased was received; a statement of the case addressing entitlement to an rating greater than 30 percent was issued that same month and the Veteran subsequently perfected an appeal to the Board. The matter was then before the Board in September 2019, at which time it was remanded for further development. Upon completion of that development, the agency of original jurisdiction (AOJ) issued a supplemental statement of the case (SSOC) in September 2020 in which it continued to deny a rating greater than 30 percent. The matter was thereafter returned to the Board for further appellate consideration. 1. Entitlement to a rating in excess of 30 percent for service-connected coronary artery disease is denied. The Veteran asserts that his CAD is more disabling than currently rated, and that it has been more disabling than currently rated for the entire period on appeal. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. If two disability ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. §§ 3.102, 4.3. In general, when 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). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The must then weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the “authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence”). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. In this matter, the Veteran’s CAD is currently evaluated as 30 percent disabling under 38 C.F.R. § 4.104, DC 7005, which pertains to arteriosclerotic heart disease (coronary artery disease) and requires documented coronary artery disease. Under DC 7005, CAD resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or when continuous medication is required, is rated 10 percent disabling. 38 C.F.R. § 4.104, DC 7005. CAD resulting 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. Id. CAD resulting 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. Id. Lastly, CAD resulting 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. Id. 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. 38 C.F.R. § 4.104, Note (2). Turning to the evidence of record, in August 2014 the Veteran underwent an echocardiogram stress test. The test indicated CAD, dyspnea on exertion, and mitral valve insufficiency. It was noted that “with stress, the patient completed 1 minute 17 seconds of Bruce protocol. Peak workload achieved equivalent to 3.3. METs. Exercise discontinued due to shortness of breath and dizziness. Peak heart rate was 120 beats per minute, 80% of the maximum predicted heart rate. Maximum obtained blood pressure 142/60.” See e.g., August 2014 Echocardiogram Stress Test Details Report. The Veteran was afforded a VA examination on October 2014; for reasons discussed in the Board’s September 2019 remand, the report of that examination is in adequate to rely upon for adjudication purposes and will not be discussed further herein. The Veteran submitted an ischemic heart disease (IHD) Disability Benefits Questionnaire dated October 2014 completed by a private physician. The physician diagnosed the Veteran as having CAD. The examiner noted that the Veteran performed at 4.0 METs on a September 2014 exercise test and in August 2013 his left ventricular ejection fraction (LVEF) was at 56 percent. It was noted that the Veteran’s treatment plan included taking continuous medication, however, the Veteran was not noted to have congestive heart failure. The examiner noted that there was evidence of cardiac hypertrophy/dilatation. Finally, the examiner noted that the Veteran’s IHD does not impact his ability to work. In January 2015, the Veteran underwent a VA examination at which time he was diagnosed with CAD and supraventricular arrhythmia. After examining the Veteran and reviewing the VA claims file, the examiner opined that in his medical judgment the plaquing seen on CT coronary angiography had not caused any clinical issues. Upon a review of the Veteran’s medical history, the examiner noted that the Veteran had a syncopal episode in August 2013. At that time, an “echocardiogram showed svt” and the Vetean was put on Metoprolol. The Veteran complained of tightness in his neck and some vision changes, however it was noted that those symptoms were non-specific and “not typically symptoms of svt.” The Veteran also complained of shortness of breath, chest pains, and dizziness, all of which were attributed to panic attacks. The examiner noted that, with the Veteran’s normal stress tests and EF, the CAD had a zero effect on the Veteran’s METs score. The examiner noted that since the Veteran had other limiting conditions, he would have to resort to speculation as to what the Veteran’s METs score would be, based upon his CAD alone. It was noted that the Veteran underwent an exercise stress test in August 2014 and scored >3-5 METs. This level has been shown to be consistent with activities such as light yard work (weeding), mowing the lawn (power mower), and brisk walking (4 mph). At this METs level, the Veteran experienced symptoms such as dyspnea and dizziness. An echocardiogram was performed in August 2013 and showed the left ventricular ejection fraction (LVEF) to be at 56 percent. The Veteran was afforded another VA Examination in November 2017 at which time the examiner confirmed a diagnosis of CAD, atherosclerotic cardiovascular disease, supraventricular arrhythmia, and valvular heart disease. Although the VA examiner examined the Veteran, he indicated that no records were reviewed, to include the results of the August 2014 exercise stress test. The examiner indicated that the etiology of the atherosclerotic cardiovascular disease and the valvular heart disease was likely multifactorial with contributing factors including diabetes, hypertension, hyperlipidemia, as well as ischemic heart disease. The etiology of the supraventricular arrhythmia was also likely multifactorial with contributing factors including diabetes, hypertension, and hyperlipidemia as well as valvular heart disease. Finally, the examiner noted that the etiology of the Veteran’s CAD was likely multifactorial with contributing factors including diabetes, hypertension, and hyperlipidemia. The examiner went on to note that the diagnosis of CAD reflected the presence of ischemic heart disease. The Veteran’s CAD required continuous medication for control. There was no documentation of myocardial infarction or congestive heart failure. Echocardiogram was not performed. An EKG performed in October 2017 showed a sinus rhythm with left axis deviation and ventricular rate of 69. An exercise stress test was not performed. An interview based METs test performed in October 2017 showed that the Veteran experienced symptoms of dyspnea and dizziness during activity. METs level was measured at >5-7 METs consistent with activities such as walking one flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). The examiner noted that the METs level provided is due solely to the heart condition the Veteran is claiming in the diagnosis section. The examiner opined that the Veteran’s CAD does impact his ability to work because the claimant can experience chest pain, shortness of breath, and dizziness upon exertion, and these symptoms limit the claimant’s ability to complete tasks requiring physical exertion. The Veteran underwent a chest x-ray in October 2017, at which time it was noted that atherosclerosis was seen along the aortic arch. See e.g., October 2017 Radiology Report. At the time of a VA examination for respiratory conditions dated March 2018, the Veteran reported that he gets short of breath when climbing stairs and performing activities such as walking and mowing the lawn. See e.g., March 2018 Compensation and Pension Examination. In September 2018, the Veteran was seen by his primary care physician at which time he denied experiencing chest pain, shortness of breath, palpitations, orthopnea, PND, and lower extremity edema. Past medical history was positive for “plaque in LAD-both calcified and non-calcified; normal nuclear stress test on 08/15/07.” It was noted that the Veteran’s CAD was stable on Metoprolol, Losartan, and Asa. See e.g., September 2018 Primary Care Attending Note. In a VA treatment record dated in March 2019, the Veteran denied experiencing chest pain, leg swelling or palpitations, orthopnea, PND, leg pains or cramps. It was noted that the Veteran “saw his cardiologist two weeks ago and his condition was stable.” See e.g., March 2019 Primary Care Attending Note. In June 2020, the Veteran underwent another VA examination at which time the examiner confirmed a diagnosis of CAD, supraventricular arrhythmia, and valvular heart disease. The examiner’s findings were based on a review of all available records along with a telephone interview with the Veteran. The examiner noted that the etiology of the Veteran’s supraventricular tachycardia and valvular heart disease were likely multifactorial, to include hypertension, CAD, and Diabetes. The Veteran’s CAD required continuous medication for control. There was no documentation of myocardial infarction or congestive heart failure. An echocardiogram was performed in August 2020 and showed a left ventricular ejection fraction of 55 percent. An EKG performed in August 2020 showed a left anterior fascicular block. An interview based METs test performed in June 2020 showed that the Veteran experienced symptoms of dyspnea during activity. METs level was measured at >5-7 METs consistent with activities such as walking one flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). The examiner noted that the METs level provided is due solely to the heart condition the Veteran is claiming in the diagnosis section. The examiner opined that the Veteran’s CAD does impact his ability to work because his cardiac condition limits his capacity for occupations that require strenuous activities such as heavy lifting, pushing, and pulling. It was noted that this capacity for sedentary activities is not limited by his cardiac conditions. The examiner opined that the along with the Veteran’s CAD (a form of ischemic heart disease), the Veteran’s valvular heart disease and supraventricular tachycardia are also caused by his history of hypertension and diabetes. “Both hypertension and diabetes are potent risk factors for the development of cardiac conditions.” In addition, the examiner noted that all of the Veteran’s functional limitations were a result of his collective cardiac conditions. The VA examiner concluded that “It is not possible to delineate what proportion of the Veteran’s functional status is due to his CAD alone excluding the contributions from his valvular heart disease and supraventricular tachycardia because the Veteran’s cardiac conditions are too closely related to each other.” See e.g., June 2020 Compensation and Pension Examination. Critically, the evidence of record does not demonstrate that the Veteran has exhibited symptoms of acute congestive heart failure, or, a workload of greater than 3 METs but not greater than 5 METs; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent. Rather, VA medical examination shows that his METs level has been between 5 and 7 and no left ventricular dysfunction with ejection fraction of 30 to 50 percent is present. Indeed, the evidence of record is negative for any indication that the Veteran has experienced congestive heart failure at any point during the period on appeal. It is not contended otherwise. Thus, the Veteran’s CAD symptoms more nearly approximate the level of disability contemplated by the 30 percent rating under DC 7005. As delineated above, the clinical evidence contains some ambiguity as to whether the Veteran’s other cardiac symptoms, including METs level limitations, are due to his service-connected coronary artery disease. However, the June 2020 examiner attributes them all as being caused by service-connected disabilities. Where it is not possible to distinguish the symptoms of a service-connected disability from non-service-connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Affording the Veteran the benefit of the doubt, the Board will consider all of the Veteran’s cardiac symptomatology as attributable to his service-connected CAD, regardless of how it has been characterized by the clinicians. The Board acknowledges the Veteran believes that his CAD is entitled to a higher evaluation. To this end, although the Veteran is competent to provide testimony to establish the occurrence of medical symptoms, he is not medically qualified to prove a matter requiring medical expertise. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The severity of this condition is a medical, not lay, determination, and outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran’s complaints of dyspnea, dizziness, shortness of breath, and chest pains are certainly relevant and probative medical evidence. However, in order to rate the severity of CAD, medical testing is required to determine to what extent symptoms express in conditions of stress or exercise. Absent a recent myocardial infarction or chronic congestive heart failure, both of which would warrant 100 percent evaluations, the Board can only rely on the metrics provided in the rating schedule. While the Veteran may believe his CAD is worse during this time, the medical evidence of record does not support this assertion. (Continued on the next page)   Thus, the preponderance of the evidence shows that a rating in excess of 30 percent for service-connected CAD is not warranted during the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). KRISTIN E. NEILSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.D. Hobbs, 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.