BVA9500271 DOCKET NO. 91-56 654 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to a disability rating higher than 60 percent for hypertensive vascular disease. REPRESENTATION Appellant represented by: Military Order of the Purple Heart WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. J. Kunz, Associate Counsel INTRODUCTION The veteran served on active duty from July 1956 to July 1957, from August 1960 to August 1962, and from August 1978 to October 1983. This appeal originally arose from a March 1989 rating decision of the San Francisco, California, regional office (RO). The veteran has since relocated, and his filed has been transferred to the Phoenix, Arizona, RO. In the March 1989 rating decision, the RO denied an increased rating for hypertension. The veteran's claim to an increased rating had been received by the Department of Veterans Affairs (VA) on October 28, 1988. In September 1991, the Board of Veterans' Appeals (Board) denied the veteran's appeal from the 1989 rating decision, issuing a decision denying entitlement to a disability rating greater than 10 percent for hypertensive vascular disease. The veteran appealed the Board's decision to the United States Court of Veterans Appeals (Court). In December 1992, the Court issued a decision that affirmed the Board's decision with respect to the rating assigned the hypertension under Diagnostic Code 7101, and remanded for readjudication in consideration of the possible application of other Diagnostic Codes, specifically Diagnostic Codes 7007 and 7100, with reasons and bases for the Board's determinations as to the applicability of those Diagnostic Codes. The Court also indicated that, on remand, the appellant could request additional medical testing. [citation redacted]. In July 1993, the Board remanded the case to the RO for further development by the RO. The RO further developed the case, obtaining additional medical records post-dating the Board's 1991 decision and according the veteran further medical evaluation. In August 1994, following review of the additional medical information obtained, the RO assigned a 60 percent disability rating, under Diagnostic Codes 7007 and 7005, for arteriosclerotic coronary artery heart disease with hypertension, effective October 28, 1988, The RO then returned the case to the Board for further appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran essentially contends that an increased disability rating is warranted for his hypertension and heart disease. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the veteran's arteriosclerotic coronary artery heart disease with hypertension is no more than 60 percent disabling. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the veteran's appeal has been obtained by the originating agency. 2. The veteran has essential hypertension and arteriosclerotic coronary artery heart disease. 3. The limitation of the veteran's functional capacity due to his cardiovascular condition has been classified as Functional Class III, characterized by marked limitation of physical activity, with comfort at rest, but with less than ordinary activity causing fatigue, palpitation, or dyspnea. 4. Neither an exceptional nor an unusual disability picture has been presented so as to render impractical the application of the regular schedular standards. CONCLUSION OF LAW The criteria for a disability rating in excess of 60 percent for arteriosclerotic coronary artery heart disease with hypertension have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.7, 4.10, 4.14, Part 4, Codes 7005, 7007, 7100, 7101 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board notes that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107 (West 1991). A well grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). We are also satisfied that all relevant facts have been properly developed so that further assistance to the veteran is not required. 38 U.S.C.A. § 5107 (West 1991). Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). Separate rating codes identify the various disabilities. 38 C.F.R. Part 4 (1994). In determining the current level of impairment, the disability must be considered in the context of the whole recorded history, including service medical records. 38 C.F.R. § 4.2 (1994). An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (1994). The veteran, who is a retired ophthalmologist, has service- connected hypertension. He has asserted that testing has revealed cardiovascular disability that is characterized both by hypertension and by conditions that affect his heart. He initially described the heart disorder, which he related to his hypertension, as cardiomegaly. Development of the evidence relevant to this appeal has included gathering records of medical treatment and testing of the veteran, and conducting examinations and tests with regard to the veteran's cardiovascular condition. Treatment records indicate that the veteran has been on medication for hypertension since the 1980s. A January 1989 VA examination report noted that with medication the veteran's blood pressure was well controlled, and generally measured 130/80 to 140/90. In an August 1989 hearing at the San Francisco RO, the veteran testified that a physician who had treated him in the years following his last period of military service found that the veteran's blood pressure had been only under borderline control. The veteran testified that an echocardiogram had revealed cardiomegaly, which the veteran understood placed him at greater risk for myocardial infarction. He also testified that he experienced shortness of breath on exertion. The claims file contains extensive reports of cardiovascular examinations, treatment and testing of the veteran. The report of a March 1991 chest x-ray showed that the cardiac size was within normal limits. A thallium scan was performed at a VA Medical Center (VAMC) in March 1992. The examiner reported: Areas of infarction are seen anterolaterally in the apical region, along with the septum, and posteriorly. Some reversible ischemia is revealed along the septum and anterior wall as well. No frank vascular congestion is seen during stress. The veteran underwent VA examination and testing in April 1994. The examining physician prepared a report dated in April and May 1994. He indicated that he had reviewed the veteran's claims file and VA clinical records, noting a 1992 thallium treadmill study and a 1992 echocardiogram which showed reversible ischemia. On examination in April 1994, the veteran reported that he played "doubles" tennis for exercise. His blood pressure was read at 130/90 in the right arm and 140/94 in the left. Chest x-rays showed borderline cardiomegaly. A MUGA scan was reported to be a normal study, showing an ejection fraction of 68 percent with normal cardiac wall motion. An echocardiogram showed concentric left ventricular hypertrophy with normal wall motion and contractility, mild aortic insufficiency, and trivial mitral regurgitation. The electrocardiograms were described as unchanged since 1983. The examiner provided the following assessment: 1. Essential hypertension - controlled. 2. Arteriosclerotic heart disease without angina but with EKG and thallium treadmill studies positive for myocardial ischemia but without clear-cut evidence of myocardial infarction. Functional class III. 3. Mild aortic insufficiency, trivial mitral insufficiency, etiology probably rheumatic heart disease. These valvular insufficiencies are hemodynamically insignificant. Functional Class III refers to the classification, by the New York Heart Association, of heart disease patients into four classes of functional capacity. Functional Class III indicates marked limitation of physical activity. The individual is comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Functional Class IV refers to a level where the individual is unable to carry on any physical activity without discomfort. The symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. See Marcus A. Krupp, M.D., and Milton J. Chatton, M.D., Current Medical Diagnosis & Treatment, 164 (1980) The veteran's cardiovascular disability has been characterized in part as arteriosclerotic heart disease. Arteriosclerotic heart disease is rated under Diagnostic Code 7005, as follows: During and for 6 months following acute illness from coronary occlusion or thrombosis, with circulatory shock, etc....... 100 After 6 months, with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded....... 100 Following typical history of acute coronary occlusion or thrombosis as above, or with history of substantiated repeated anginal attacks, more than light manual labor not feasible....... 60 Following typical coronary occlusion or thrombosis, or with history of substantiated anginal attack, ordinary manual labor feasible...... 30 38 C.F.R. Part 4, Code 7005 (1994). In its 1994 rating decision, the RO rated the veteran's heart condition as related to his service-connected hypertension. It is appropriate, and in accord with the Court's Order, to consider the veteran's condition in light of Diagnostic Code 7007, relating to hypertensive heart disease. That Code provides the following ratings: With definite signs of congestive failure, more than sedentary employment precluded....... 100 With marked enlargement of the heart, confirmed by roentgenogram, or the apex beat beyond midclavicular line, sustained diastolic hypertension, diastolic 120 or more, which may later have been reduced, dyspnea on exertion, more than light manual labor is precluded....... 60 With definite enlargement of the heart, sustained diastolic hypertension of 100 or more, moderate dyspnea on exertion..... 30 38 C.F.R. Part 4, Code 7007 (1994). Because the veteran has been found to have both arteriosclerosis and hypertension, the provisions in the Rating Schedule for rating arteriosclerosis in general, (Diagnostic Code 7100) and essential hypertension (Diagnostic Code 7101), are also relevant to a determination of the appropriate rating for the veteran's cardiovascular disability. Diagnostic Code 7100 rates general arteriosclerosis as follows: With slight weakening of bodily vigor....... 20 Without symptoms or renal, cardiac, or cerebral complications.... 0 Note: Rate the arteriosclerotic complications, such as renal, cardiac, or cerebral, under the appropriate schedule. 38 C.F.R. Part 4, Code 7100 (1994). Diagnostic Code 7101 provides the following ratings for hypertensive vascular disease (essential arterial hypertension): Diastolic pressure predominantly 130 or more and severe symptoms....... 60 Diastolic pressure predominantly 120 or more and moderately severe symptoms....... 40 Diastolic pressure predominantly 110 or more with definite symptoms....... 20 Diastolic pressure predominantly 100 or more....... 10 Note 1: For the 40 percent and 60 percent ratings under code 7101, there should be careful attention to diagnosis and repeated blood pressure readings. Note 2: When continuous medication is shown necessary for control of hypertension with a history of diastolic blood pressure predominantly 100 or more, a minimum rating of 10 percent will be assigned. 38 C.F.R. Part 4, Code 7101 (1994). As the veteran's arteriosclerosis has been found to have cardiac complications, in the form of arteriosclerotic heart disease, it is appropriate that his arteriosclerosis be considered under Diagnostic Code 7005. See 38 C.F.R. Part 4, Code 7100, Note (1994). The veteran's hypertension has been controlled by medication for several years. The records do not document diastolic pressure of predominantly 100 or more, although it is not clear what the veteran's blood pressure would be without medication. The veteran's hypertensive heart disease, however, warrants a higher disability rating under Diagnostic Code 7007 than that which would be warranted under Diagnostic Code 7101 for the veteran's hypertension alone. Medical records with regard to the veteran's arteriosclerotic heart disease do not indicate that the veteran has residuals of congestive heart failure, angina, coronary occlusion, or thrombosis which would entitle him to a 100 percent disability evaluation under Diagnostic Code 7005. The effect of his heart disease on his ability to engage in ordinary activities, however, has been classified by a VA physician as Functional Class III, and he has been found to have shortness of breath and fatigue upon exertion. The veteran reports that he is able to engage in tennis playing to some extent. These findings are most consistent with the characterization pertaining to the 60 percent rating under Diagnostic Code 7005 that more than light manual labor is not feasible. As the record does not show that the veteran would be precluded from more than sedentary employment, the criteria for a 100 percent rating under Diagnostic Code 7005 are not met. 38 C.F.R. Part 4, Code 7005 (1994). With respect to Diagnostic Code 7007, chest x-rays have shown only borderline enlargement of the heart, suggesting that a rating of no more than 30 percent is warranted. We note, however, that the criteria of dyspnea on exertion, and preclusion of more than light manual labor, listed under the 60 percent rating, are consistent with the Functional Class III profile. 38 C.F.R. Part 4, Code 7007 (1994). Recognizing that the evaluation of the same manifestations of a given disability under different diagnoses is to be avoided, we will evaluate the various cardiovascular symptoms as manifestations of one disability. 38 C.F.R. § 4.14 (1994). As the veteran's Functional Class III profile is best represented by a 60 percent rating under Diagnostic Codes 7005 and 7007, a 60 percent rating is warranted. 38 C.F.R. Part 4, Codes 7005, 7007 (1994). An exceptional or unusual disability picture has not been presented in this case such as would warrant an extra-schedular evaluation under 38 C.F.R. § 3.321(b) (1993). Specifically, there has been no demonstration of marked interference with employment or frequent periods of hospitalization so as to render impractical the application of the regular schedular criteria. ORDER A disability rating in excess of 60 percent for arteriosclerotic coronary artery heart disease with hypertension is not warranted. BETTINA S. CALLAWAY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.