BVA9500384 DOCKET NO. 92-03 264 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Entitlement to an increased rating for residuals of rheumatic heart disease, currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. R. Olson, Counsel INTRODUCTION The veteran's active military service extended from August 1946 to May 1949. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 1991 and subsequent rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. That decision continued a 10 percent rating for rheumatic heart disease that had been in effect since 1966. In November 1992, the Board remanded the case for examination of the veteran by specialists in respiratory disease, rheumatoid arthritis and rheumatic heart disease. Also, the RO was to adjudicate entitlement to service connection for any respiratory or joint disease found on examination. The requested examinations were completed. A February 1993 rating decision continued the 10 percent rating for rheumatic heart disease and denied service connection for joint and respiratory disease. The case was returned to the Board. The Board carefully searched the claims folder and found no indication that the veteran had been notified of the February 1993 rating decision denying service connection for joint and respiratory disease. In June 1993, the Board remanded the case so the RO could notify the veteran of its February 1993 rating decision. In July 1993, the RO notified the veteran that service connection for joint and respiratory disease had been denied. A reply or notice of disagreement was not received. In October 1994, the case was returned to the Board for appellate consideration. The Board now proceeds with its review of the appeal. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that the RO committed error in denying an increased rating for rheumatic heart disease. He argues that the residuals and complications of rheumatic heart disease have increased in severity and warrant a higher rating. 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 preponderance of the evidence supports a rating of 30 percent, and not in excess thereof, for the service-connected rheumatic heart disease. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. The veteran's service-connected rheumatic heart disease is manifested by 4 chamber heart enlargement, without severe dyspnea on exertion, elevated systolic blood pressure, or arrhythmias. 3. The veteran's disabilities do not present an exceptional or unusual disability picture rendering impractical the application of the regular schedular standards that would have warranted referral of the case to the Director of the Compensation and Pension Service. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, and not in excess thereof, for rheumatic heart disease, have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. Part 4, including § 4.7 and Code 7000 (1993). 2. Failure of the RO to consider or document its consideration of extraschedular ratings and the failure to refer the case to the Director of the Compensation and Pension Service is no more than harmless error. 38 C.F.R. § 3.321(b)(1) (1992). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). That is, he has presented a claim which is plausible. All relevant facts have been properly developed and no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). The service medical records show that the veteran was hospitalized in May 1949. Cardiovascular examination disclosed a blowing, systolic murmur, grade II, at the apex, which disappeared on standing. A chest x-ray was normal. The diagnosis was rheumatic cardiovascular disease, manifested by a previous history of Sydenham's chorea, pain in the knees, a grade II mitral systolic murmur and a grade II mitral diastolic murmur, both transmitted to the left axilla, and easy fatigue. VA provided a special cardiac examination in January 1950. The cardiac outline was normal. The was a normal sinus rhythm. After a period of rest, heart tones were noted to be of good quality. There was a loud systolic murmur best heard at the mitral and apical regions and the first sound was "quite impure" and changed after exercise. There was a very faint presystolic blowing murmur in the mitral area and numerous extrasystoles were noted. An electrocardiogram was interpreted as normal. The diagnosis was rheumatic heart disease, mitral stenosis and mitral insufficiency, Class I. A February 1950 rating decision granted service connection for rheumatic heart disease and assigned a 30 percent rating. The report of the January 1955 VA special heart examination shows that there was a loud blowing systolic murmur over the mitral valve and transmitted to the apex. There were no other abnormal sounds. The heart was not enlarged. Pulse was regular. The diagnosis was residuals of rheumatic heart disease. A January 1955 rating decision reduced the rating for rheumatic heart disease, inactive, to 10 percent. The report of VA hospitalization from January to March 1955 shows an elevated diastolic blood pressure. The veteran's heart was not enlarged. There was a grade III blowing systolic murmur at the mitral region and a presystolic rumble at the apex. Chest x-ray and electrocardiogram were normal. The final diagnosis was rheumatic valvulitis, inactive, with mitral stenosis and insufficiency, treated, unchanged. Similar diagnoses were rendered on hospitalization in August 1957, January 1958, August 1959, January and February 1960, and July and August 1960. During the hospitalization in October and November 1960, the veteran complained of shortness of breath on exertion. Heart sounds were regular and of good quality. A soft, systolic murmur, grade I, was heard at the apex. A presystolic murmur was heard on a post admission examination. The cardiac silhouette was not enlarged and the electrocardiogram was not diagnostic. The diagnosis was rheumatic heart disease (inactive), mitral stenosis and insufficiency, dyspnea on exertion and functional class II. On the basis of these findings and diagnosis, a November 1960 rating decision increased the evaluation for the service-connected rheumatic heart disease to 30 percent. A VA hospitalization in December 1960 described the mitral insufficiency as mild and the functional capacity as class II. The January 1961 VA hospitalization resulted in diagnoses which included rheumatic heart disease with mitral regurgitation, mild, functional class I. The March 1964 VA hospitalization concluded with a diagnosis of rheumatic heart disease with mitral insufficiency, cardiac functional capacity class II. The diagnosis on the April 1964 VA hospitalization was rheumatic heart disease, inactive, with mitral stenosis, minimal, probably class I. The veteran was examined at a VA outpatient clinic in January 1966. He had no complaints and seemed perfectly well. The only significant finding was an apical presystolic murmur. Blood pressure and heart rhythm and rate were normal. Based on the clinical findings, the RO reduced the rating for the rheumatic heart disease to 10 percent, in a February 1966 rating decision. VA clinical notes of 1988 and 1989 revealed respiratory complaints. Cardiovascular findings were essentially normal, except for elevated blood pressure readings. The veteran was admitted to a VA medical center in September 1989 for complaints of dyspnea and chronic fatigue. The cause was not determined although there were indications of reactive airway disease and bronchitis. The heart had a regular rhythm without murmurs or gallops. On VA hospitalization in September 1990, the veteran's heart had a regular rate and rhythm without murmurs, rubs or gallops. Testing and evaluation led to diagnoses of mild to moderate chronic obstructive pulmonary disease with reactive airway disease, mild depression, organic mood syndrome, and hypertension. The 1990 VA clinical notes contain normal and elevated blood pressure readings, as well as information pertaining to respiratory and orthopedic disabilities. A cardiac catheterization was performed in November 1991. Lung symptoms were noted. The heart had a regular rate and rhythm without murmurs, rubs or gallops. It was determined that there was no coronary artery disease. The veteran's joints were examined by a VA physician in January 1993. It was the doctor's medical opinion that the joint symptoms were related to degenerative disease of recent onset and were not residuals of rheumatic fever. Assessment by a VA respiratory specialist resulted in the medical opinion that the veteran had chronic obstructive lung disease, probably related to his long history of tobacco smoke. The doctor was of the opinion that the rheumatic heart disease would not affect the veteran's lungs. A chest x-ray was within normal limits. The report of the evaluation by a VA heart specialist, in January 1993, shows that the physician reviewed the record, including the report of the 1991 cardiac catheterization. That study was reported to reveal left ventricular hypertrophy and no functional abnormalities of any cardiac valve. On examination, the veteran's blood pressure was 140/98. His pulse was 98 and regular. The point of maximal impulse of the heart was displaced and increased in diameter and hyperdynamic. The first and second heart sounds were normal. There were no murmurs or bruits. An electrocardiogram was within normal limits with a normal sinus rhythm. An echocardiogram revealed 4 chamber enlargement, at least moderate left ventricular hypertrophy, normal left ventricular systolic function, and left ventricular diastolic dysfunction. There were no apparent valvular abnormalities, pericardial effusion, intracavitary masses or thrombi. It was the impression that the veteran had essential hypertension, obesity and previous cigarette smoking. The physician was of the opinion that the veteran was in the New York Heart Association Functional Class I. The doctor was of the opinion that the debilitating shortness of breath was due to his chronic obstructive pulmonary disease and could not be explained by the cardiac findings. Service-connected disabilities are rated in accordance with a schedule of ratings which are based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1993). Prior to further discussion, it should be noted that while some of the veteran's symptoms have been attributed to respiratory disease and degenerative arthritis, the RO has denied service connection for chronic obstructive pulmonary disease and degenerative joint disease, but no appeal was filed by the veteran. The service connected rheumatic heart disease is currently rated as 10 percent disabling under diagnostic code 7000. That rating will be assigned following established active rheumatic heart disease if there is an identifiable valvular lesion or slight dyspnea, if any, and the heart is not enlarged. The next higher rating, 30 percent, requires a diastolic murmur with characteristic EKG manifestations or a definitely enlarged heart. The next higher rating, 60 percent requires that the heart be definitely enlarged, severe dyspnea on exertion, elevation of systolic blood pressure, or such arrhythmias as paroxysmal auricular fibrillation or flutter or paroxysmal tachycardia; with more than light manual labor precluded. 38 C.F.R. Part 4, Code 7000 (1993). The current 10 percent rating requires that there be no enlargement of the heart. However, the 1993 echocardiogram disclosed enlargement involving all 4 heart chambers, as well as at least moderate left ventricular hypertrophy, and left ventricular diastolic dysfunction. These abnormalities approximate, but do not exceed the enlargement contemplated for the next higher rating, 30 percent. 38 C.F.R. § 4.7 (1993). The evidence does not show the other manifestations which would support a 30 percent rating, such as a diastolic murmur or definite electrocardiogram manifestations. The examination findings show that the requirements for the next higher rating, 60 percent, are not present. While there is enlargement on the echocardiogram, the heart enlargement is no so significant as to be noted on x-ray studies. Dyspnea on exertion is not a manifestation of the service-connected rheumatic heart disease. Systolic blood pressure is not elevated. There is no arrhythmia. The medical opinions indicate that the veteran is in functional class I, which does not preclude manual labor. Consequently, while the disability approximates the criteria for a 30 rating, it does not exceed those criteria or approximate the criteria required for a higher rating. This case does not present an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (1993). Any failure by the RO to refer the case to the Director of the Compensation and Pension Service for extraschedular consideration was harmless error. ORDER An increased rating of 30 percent, and not in excess thereof, is granted for rheumatic heart disease, subject to the law and regulations governing the payment of monetary awards. JOAQUIN AGUAYO-PERELES 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.