Citation Nr: 22014196 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 16-61 723 DATE: March 11, 2022 ORDER Entitlement to an evaluation in excess of 10 percent for ischemic heart disease, status post myocardial infarction for the period of August 16, 2011, to February 1, 2017, is denied. Entitlement to an evaluation in excess of 30 percent for ischemic heart disease, status post myocardial infarction on or after February 2, 2017, is denied. FINDINGS OF FACT 1. Prior to February 2, 2017, the Veteran's service-connected ischemic heart disease, status post myocardial infarction, has not been manifested by cardiac hypertrophy, cardiac dilatation, congestive heart failure, or left ventricular dysfunction with an ejection fraction (LVEF). 2. Beginning February 2, 2017, the Veteran had evidence of hypertrophy on echocardiogram, but his service-connected ischemic heart disease was not manifested by cardiac dilatation, congestive heart failure, or LVEF. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent for ischemic heart disease, status post myocardial infarction prior to February 2, 2017, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7005. 2. The criteria for an evaluation in excess of 30 percent for coronary artery disease on or after February 2, 2017, have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.104, Diagnostic Code 7005. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) from a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In June 2021, the Board remanded the claim for additional development. That development has been completed, and the case has since been returned to the Board for appellate review. Law and Analysis Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist with regard to the issues decided herein. 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). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation 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. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 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. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial rating assigned, evaluation of the evidence since the effective date of the grant of service connection is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson, 12 Vet. App. at 126-27. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307, 37312 (Fed. Cir. Dec. 17, 2021) (benefit-of-the-doubt rule not for application when evidence persuasively favors one side or the other). The Veteran's ischemic heart disease, status post myocardial infarction, has been assigned a 10 percent rating from August 16, 2011, and a 30 percent rating from February 2, 2017, pursuant to 38 C.F.R. § 4.104, Diagnostic Code 7005. Diagnostic Code 7005 provides the following compensable rating criteria for arteriosclerotic heart disease (CAD). A 10 percent rating for workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. 38 C.F.R. § 4.104 (2020). A 30 percent rating for 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 rating 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; LVEF of 30 to 50 percent. Id. A 100 percent rating, the maximum available, for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; LVEF of less than 30 percent. Id. Effective November 14, 2021, VA revised the rating criteria for disabilities of the cardiovascular system. 86 FR 54089 (September 30, 2021), as corrected at 86 FR 62095 (November 9, 2021). Under the revised criteria, Diagnostic Code 7005 is evaluated using the General Rating Formula for Diseases of the Heart. Under this formula, a 10 percent rating is warranted when a workload of 7.1-10.0 METs results in heart failure symptoms; or continuous medication is required for control. A 30 percent rating is warranted when a workload of 5.1-7.0 METs results in heart failure symptoms; or evidence of cardiac hypertrophy or dilation confirmed by echocardiogram or equivalent (e.g. multigated acquisition scan or magnetic resonance imaging). A 60 percent rating is warranted when a workload of 3.1-5.0 METs results in heart failure symptoms. A 100 percent rating is warranted when a workload of 3.0 METs results in heart failure symptoms. 38 C.F.R. § 4.104. Heart failure symptoms include, but are not limited to, breathlessness, fatigue, angina, dizziness, arrhythmia, palpitations, or syncope. Id. at Note (3). The impact of medication may be considered under both the prior and amended criteria because the rating criteria in Diagnostic Code 7005 contemplate medication, specifically noted under the 10 percent rating criteria. See Jones v. Shinseki, 26 Vet. App. 56 (2012). Prior to February 2, 2017 In considering the evidence of record under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 10 percent for his service-connected ischemic heart disease status post myocardial infarction prior to February 2, 2017. The Veteran was afforded a VA examination in June 2014, where the examiner indicated that the Veteran experienced myocardial infarction in August 2005 and underwent percutaneous coronary intervention in September 2013. The examiner acknowledged that the Veteran's treatment plan included taking continuous medication for his condition. The examiner noted that the Veteran did not have congestive heart failure, cardiac hypertrophy, or dilatation. The Veteran's left ventricular ejection fraction (LVEF) was listed as being 55%. While the Veteran's METS level was reported as being at 4.5, the examiner explained that the Veteran's METs level was confounded by his other comorbid medical conditions, so his cardiac status was better indicated by his LVEF, which was normal. The Veteran was also afforded a VA examination in June 2016, where the examiner confirmed that the Veteran is noted to have a history of coronary artery disease status post stenting in 2005 and 2013 and that he requires continuous medication for this condition. The Veteran was not found to have congestive heart failure, cardiac arrhythmia, a heart valve condition, infectious heart conditions, or pericardial adhesions. The Veteran's heart rhythm, heart sounds, and peripheral edema were normal, and he was not found to have peripheral edema. Diagnostic testing revealed that there was no evidence of cardiac hypertrophy or cardiac dilatation. The Veteran's LVEF was listed as being 55%, which is normal. The examiner recounted the METs level testing conducted in June 2014, which revealed a METs score of 4.50, but noted that the test was terminated due to symptoms that are not related to the cardiac condition. The June 2016 VA examiner conducted an interview-based METs test, where the Veteran reported experiencing dyspnea and fatigue. The METs level was recorded as being >5-7, which has been found to be consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), and heavy yard work (digging). The examiner opined that the METs level limitation provided was not due solely to the Veteran's heart condition, and that the limitation in METs is due to multiple conditions and it was not possible to accurately estimate the percent of METs limitation attributable to each medical condition. The examiner concluded that, because of this, the Veteran's cardiac status is better indicated by his ejection fraction, which is normal. The Board also notes that a June 2016 VA primary care note states that the Veteran's dyspnea is "probably" related to cardiac issues but does not confirm this. The 30 percent criteria are not met under either the old or new criteria because, during this period, because the Veteran's METs level limitation provided was not due solely to the Veteran's heart condition. Further, the Veteran was not shown to have evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or x-ray. The Board also considered the Veteran's reported history of symptomatology. He is competent to report his symptoms and observations because this requires only personal knowledge as it comes through one's senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for a rating higher than that currently assigned for his service-connected disability on appeal have been met. Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, competent evidence concerning the nature and extent of the Veteran's ischemic heart disease, status post myocardial infraction, has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective reported worsened symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). Therefore, the Board finds that the evidence does not support the next higher schedular rating of 30 percent during this period. On or After February 2, 2017 In considering the evidence of record under the laws and regulations set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 30 percent for his service-connected ischemic heart disease status post myocardial infarction on or after February 2, 2017. The Veteran was most recently afforded a VA examination in October 2021. The examiner observed that continuous medication is required for control of the Veteran's heart condition. The Veteran was not found to have congestive heart failure, cardiac arrhythmia, or a heart valve condition. The Veteran also did not have any infectious cardiac conditions or pericardial adhesions. The Veteran's heart rhythm and heart sounds were normal, while his bilateral peripheral pulses were diminished. There was evidence of cardiac hypertrophy detected via echocardiogram on February 2, 2017. There was no evidence of cardiac dilatation. The echocardiogram dated February 2, 2017, demonstrated that the Veteran had a LVEF of 50%, which is normal, but his wall thickness was abnormal. At the October 2021 VA examination, exercise stress testing was not required as part of the Veteran's current treatment plan and the test was not without significant risk. Upon interview-based METs testing, the Veteran reported experiencing dyspnea, fatigue, and dizziness. The examiner concluded that the Veteran's METs level was best characterized as being between 1-3 METs, which has been found to be consistent with activities such as eating, dressing, taking a shower, and slow walking (2 mph) for 1-2 blocks. The examiner further concluded that the METs level was due solely to the Veteran's heart condition. The 60 percent criteria are not met under either the old or new criteria because, even though the Veteran has a workload between 1-3 METs, he has not had any episodes of acute congestive heart failure. The Board considered the Veteran's reported history of symptomatology. He is competent to report his symptoms and observations because this requires only personal knowledge as it comes through one's senses. Layno, 6 Vet. App. at 470. In this case, although the descriptions of his symptoms are competent and credible, they do not show that the criteria for a rating higher than that currently assigned for his service-connected disability on appeal have been met. Kahana, 24 Vet. App. 428. In this case, competent evidence concerning the nature and extent of the Veteran's ischemic heart disease, status post myocardial infraction, has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective reported worsened symptomatology. See Cartwright, 2 Vet. App. at 25. Therefore, the 30 percent evaluation from February 2, 2017, is appropriate as the evidence does not support a higher rating. J. CONNOLLY Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. DeVerter, 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.