Citation Nr: 18154105
Decision Date: 11/29/18	Archive Date: 11/29/18

DOCKET NO. 16-54 071
DATE:	November 29, 2018
ORDER
A rating in excess of 30 percent for coronary artery disease is denied.
FINDING OF FACT
The Veteran’s coronary artery disease (CAD) has not been manifested by congestive heart failure, or a workload of 5 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or a left ventricular dysfunction with an ejection fraction of less than 55 percent.
CONCLUSION OF LAW
The criteria for a disability rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.104, Diagnostic Code 7005. 
REASONS AND BASES FOR FINDING AND CONCLUSION
The Veteran served on active duty from January 1966 to January 1968.  This matter is on appeal from a September 2014 rating decision.  
Increased Rating
By way of history, the Veteran’s coronary artery disease was granted and rated at 10 percent, effective March 26, 2008, by an August 2012 rating decision.  It was later increased to 30 percent by a September 2014 rating decision, effective, April 5, 2011. The Veteran timely filed a Notice of Disagreement in September 2014, asserting a disability rating of 100 percent was warranted.    
Under Diagnostic Code 7005, a 10 percent evaluation is warranted where there is a workload of greater than 7 METs but not greater than 10 METs resulting in dyspnea, fatigue, angina, dizziness or syncope; or, continuous medication required. A 30 percent evaluation is warranted where there is a workload of greater than 5 METs but not greater than 7 METs, where there is evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. A 60 percent evaluation is warranted where there is evidence of 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. Finally, a 100 percent evaluation is warranted where there is chronic congestive heart failure; or workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness or syncope; or, left ventricular dysfunction with an ejection fraction of less than 30 percent. 38 C.F.R. § 4.104, Diagnostic Code 7005.
One MET (metabolic equivalent) is defined as the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters 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 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).
A VA examination in September 2014 show that the Veteran’s left ventricular chamber size was normal. Mild concentric left ventricular hypertrophy was seen. There was normal left ventricular systolic function and the estimated ejection fracture is 55 to 60 percent. Diastolic parameters were consistent with mild or Grade 1 dysfunction (impaired relaxation).  There was mild mitral regurgitation and mild aortic stenosis. There was no indication of any myocardial infarction, congestive heart failure, cardiac arrhythmia, heart valve condition, infectious heart condition, or pericardial adhesion. The METs level was greater than 5-7, which is consistent with activities such as walking 1 flight of stairs, golfing (without cart), mowing lawn (push mower), heaving yard work (such as digging). In conclusion, the examiner opined that the Veteran’s condition was stable and had not worsened. Since his coronary artery bypass, the Veteran had been symptom free. While he did report some chest tightness, the sensation disappeared with continued walking. Because of this, the examiner could not state for certain that the Veteran’s chest tightness truly represented angina.  
November 2015 VA treatment records show regular rate and rhythm, Gr 2/6 systolic murmur at base. There was no peripheral edema.
Private treatment records dated October 2016 reported that the Veteran’s left ventriculography showed normal left ventricular systolic function with an estimated left ventricular ejection fraction of 68 percent and no mitral regurgitation. The physician noted that the Veteran underwent an exercise echocardiography in January 2009.  He achieved 12 minutes on a Bruce protocol. There were no significant EKG changes to indicate myocardial ischemia, or clinical signs or symptoms of myocardial ischemia. There was no echocardiographic evidence of ischemia.  The Veteran’s echocardiogram in April 2011 showed normal right ventricular systolic function. There was normal left ventricular systolic function with an estimated left ventricular ejection fraction of 60 to 65 percent. There was mild mitral insufficiency, mild aortic insufficiency, mild tricuspid regurgitation, and mild pulmonic insufficiency. On his most recent echocardiogram in August 2016, the Veteran was shown to have preserved left ventricular systolic function, with an estimated left and jugular ejection fraction of 65 percent. There was moderate aortic stenosis. There was mild tricuspid regurgitation. It was noted that the Veteran remained active and experienced very rare, very brief palpitations. He denied symptoms consistent with chest pressure, discomfort, dyspnea, exertional chest pressure and discomfort, lower extremity edema, near-syncope, orthopnea, paroxysmal nocturnal dyspnea, syncope, tachypnea, or TIA or stroke. 
In reviewing the medical evidence of record, the Board finds that a rating in excess of 30 percent is not warranted. There is no indication that the Veteran’s service connected coronary disease is manifested by a work load of between 3 and 5 METs.  His VA examination in 2014 reported no instances of myocardial infarction, congestive heart failure, cardiac arrhythmia, heart valve condition, infectious heart condition, or pericardial adhesion. At no point during the appeal period was the Veteran’s ejection fracture found to be less than 55 percent.  It was also noted in the Veteran’s private treatment records that he remained active and rarely experienced palpitations. Overall, the Veteran’s collective symptoms does not equate to a disability rating of 60 percent or greater. 
The Board has considered the Veteran’s contentions that a higher rating should be warranted because he had undergone seven surgeries on his heart, and was taking medication and regularly seeing a doctor.  However, as discussed above, VA regulations rate the Veteran’s heart disability on measurable functional limitation using metrics such as ejection fraction and METS.  While the Veteran is clearly taking medication for his heart, the Diagnostic Code provides a 10 percent rating when continuous medication is required.  However, the Veteran already receives a 30 percent rating.
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As described above, the evidence is against entitlement to a rating in excess of 30 percent and the claim is denied.
 
MATTHEW W. BLACKWELDER
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	N.Yeh, Associate Counsel 

For A Complete Guide To VA Disability Claims and to find out more about your potential VA disability case and how to obtain favorable VA Rating Decision! Visit: VA-Claims.org

For More Information on Veterans Disability Compensation Benefits! Visit: DisableVeteran.org ~ A Non-Profit Non Governmental Agency


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