Citation Nr: A25035153 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 241020-483348 DATE: April 16, 2025 REMANDED Entitlement to an increased evaluation for coronary artery disease (CAD), greater than 30 percent from July 1, 2021, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from May 1964 to May 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a December 2022 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In the October 20, 2024, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on March 24, 2025. Therefore, the Board may only consider the evidence of record at the time of the December 2022 agency of original jurisdiction (AOJ) decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. However, because the Board is remanding the claim, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii). 1. Entitlement to an increased evaluation for CAD, greater than 30 percent, from July 1, 2021, is remanded. The Veteran is seeking a higher rating for CAD. The Veteran's condition is rated as 30 percent disabling from July 1, 2021. In August 2021 the Veteran filed a supplemental claim for service connection for CAD. In an August 2022 decision the AOJ noted a special review of the claim, and receipt of the August 2021 supplemental claim, and granted service connection for CAD with a 60 percent evaluation effective June 26, 2007; a 10 percent from December 8, 2008; a 60 percent is assigned from December 3, 2009; a 10 percent from March 17, 2010; a 60 percent is assigned from August 16, 2012; a 100 percent from February 27, 2020; and a 30 percent from July 1, 2021. In a December 2022 decision the RO noted receipt of the August 2021 supplemental claim and continued the 30 percent evaluation for CAD. The Veteran filed a request for Higher Level Review in December 2023, and in an April 2024 decision the 30 percent evaluation from July 1, 2021, was continued. The Veteran subsequently filed a notice of disagreement with the April 2024 decision. Therefore, the period on review dates from July 1, 2021. According to an August 2021 statement from Dr. P. G., of County Cardiology, the Veteran had been under treatment by County Cardiology Since September 2004 for ischemic heart disease. He had a history of multiple coronary stents placed for ischemia and was being monitored and worked up for a possible aortic valve replacement. In September 2021, a VA examiner reviewed the records and conducted an interview with the Veteran (without an in person or tele health examination) using the acceptable clinical evidence process. The Veteran was noted to be on continuous medication to manage this condition. There was no indication of congestive heart failure. An echocardiogram was performed in July 2021, which revealed cardiac hypertrophy and dilatation. The Veteran had a left ventricular ejection fraction of 55-60 percent. An exercise stress test was not performed. The interview-based METs test revealed breathlessness, fatigue, angina and dizziness, and a METs level of 3 to 5. The estimated interview based METs level due solely to the cardiac condition was different and was estimated to be between 5 and 7 METs. The examiner noted valvular heart disease contributes to the decreased METs level. In July 2022, the Veteran underwent a VA examination. He was diagnosed with atherosclerotic cardiovascular disease, unstable angina, arteriosclerotic heart disease, and valvular heart disease. He reported chest pain, dyspnea and fatigue. He had a total of 17 stents. The Veteran reported chest pain about every other month. He had mitral valve and tricuspid valve regurgitation, and aortic stenosis. There was no indication of an infectious heart condition or pericardial adhesions. On examination he had a regular heart rate of 16, and blood pressure 120/70. He had systolic and diastolic murmurs secondary to valve impairment. His peripheral pulses were normal. A July 2021 echocardiogram was reviewed, that revealed cardiac dilation and cardiac hypertrophy. A 2010 CT angiography revealed multiple vessel occlusion approaching 90%. An exercise stress test was not performed as it was not required as part of his treatment plan, and the test was not without significant risk. The interview based METs test revealed breathlessness, fatigue, angina and dizziness, and a METs level of 3 to 5. The estimated interview based METs level due solely to the cardiac condition was different and estimated to be between 5 and 7 METs. Functional impact was described as any work involving exertion, walking, or running, and he was only capable of doing sedentary work. The left ventricular ejection fraction (LVEF) was at 55% and was noted to be a more accurate finding regarding cardiovascular manifestations. In an August 2022 addendum opinion, the examiner indicated valvular heart disease and coronary artery disease commonly occur together because of shared risk actors but CAD does not cause valvular heart disease, and therefore the Veteran's valvular heart disease is less likely than not the result of his CAD. At the March 2025 Board hearing the Veteran noted a scan of his heart in 2021. He noted upon examination in July 2022, an estimate of his METs was made, however this was based on the 2021 examination findings, and not due to questioning. He reported being unable to conduct yard work such as weeding or utilize a power mower. He reported being unable to perform brisk walking up to 4 miles per hour. He reported being unable to stand or sit for a short period of time and being unable to drive. When walking he can only do so with the assistance of a walker, cane, or wheelchair. He noted even when not exerting himself he experienced angina, dizziness, fatigue, and breathlessness. The Veteran's spouse testified to assisting her husband with activities of daily living to include feeding, dressing, and hygiene. He reported not being asked questions pertinent to his cardiac health and symptoms at the 2022 examination. The Board finds a remand is necessary to correct a pre-decisional duty to assist errors, to include an examination. 38 C.F.R. § 20.802. The Board finds that a remand is necessary because though the Veteran underwent an examination in September 2021 and July 2022, on each occurrence an exercise stress test was not conducted, and sufficient explanation as to the estimated METs was not provided. The Veteran testified to experiencing more severe symptoms than what was reported at these examinations. He noted he was not posed the relevant questions as to the severity of his CAD symptoms. The July 2022 examiner noted an interview- based stress test was performed and provided an estimated METs of 3-5. The examiner indicated a different METs level solely due to his cardiac condition was estimated at 5 to 7, however, no justification or explanation for the difference in estimated METs was provided. Given the lack of clarity as to the estimated METs upon evaluation in July 2022, and the Veteran's indications that he was not sufficiently evaluated as to the severity of his condition, this constitutes a pre-decisional duty to assist error, and a remand is warranted to obtain an adequate opinion regarding the Veteran's METs level due solely to his service-connected CAD. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician, such as a cardiologist, to determine the current severity of CAD. Provide the Veteran's electronic claims file to the designated examiner for review. The reports of all indicated tests or studies, such as electrocardiogram, echocardiogram, or X-ray, must be included with the examination report. The examiner should identify the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops either by exercise testing or by estimation if exercise testing cannot be done for medical reasons. In the event the examiner finds different estimates for METs on account of CAD or other diagnosed conditions, an explanation is requested clarifying the examiner's reasoning. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Skiouris, Elena 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.