Citation Nr: 0000305 Decision Date: 01/06/00 Archive Date: 01/11/00 DOCKET NO. 95-06 435 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUE Entitlement to an increase in a 60 percent rating for coronary artery disease, status post coronary artery bypass grafting, with hypertension. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. T. Jones, Counsel INTRODUCTION The veteran served on active duty from January 1960 to December 1963 and from March 1964 to August 1981. This matter initially came to the Board of Veterans' Appeals (Board) from a September 1994 decision by the VA RO that denied an increase in a 30 percent rating for service- connected coronary artery disease, status post coronary artery bypass grafting, with hypertension. The Board remanded the case in October 1997. In June 1998 the RO increased the rating for the service-connected heart disease to 60 percent. (The RO also granted a total compensation rating based on individual unemployability, due to the effects of all service-connected disabilities.) The appeal for an increased rating for the service-connected heart disease continued, and the Board remanded the case again in November 1998. The case was returned to the Board in August 1999. FINDINGS OF FACT The veteran's service-connected heart disorder (coronary artery disease, status post coronary artery bypass grafting, with hypertension) is manifested by a history of repeated angina attacks but no congestive heart failure or angina on moderate exertion; it precludes more than light manual labor but does not preclude more than sedentary employment; it results in a METs level of 4; it does not produce left ventricular dysfunction; and hypertension is controlled with medication. CONCLUSION OF LAW The criteria for a rating in excess of 60 percent for the veteran's service-connected heart disease have not been met. 38 U.S.C.A. §§ 1155 (West 1991); 38 C.F.R. § 4.104, Diagnostic Codes 7005, 7017, 7101 (1997 and 1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION I Background The veteran served on active duty from January 1960 to December 1963 and from March 1964 to August 1981. During service he had hypertension, which was controlled with medications. In 1982 the RO granted service connection for hypertension, rated 0 percent disabling. On a VA heart examination in January 1992, it was noted that the veteran had a history of treatment for tachy arrhythmias which were first noted in the mid-1980s. It was reported that he had undergone medical management and cardioversions. He also had a long history of hypertension and diet- controlled diabetes mellitus. The examination report notes that the veteran had no cardiac symptoms between tachy arrhythmias and no mention was made of coronary artery disease or hypertension. The diagnoses were multiple episodes of tachycardia arrhythmia secondary to Wolf- Parkinson-White Syndrome; and radio frequency catheter ablation therapy in September 1991, more recently requiring rapid atrial pacing, and subsequent cardioversion, and currently on medical management. In April 1992 the RO denied service connection for supraventricular tachycardia caused by a congenital accessory pathway. In June 1993 the RO granted an increased rating of 10 percent for hypertension, and continued the denial of service connection for supraventricular tachycardia. VA and private medical records show treatment for heart problems in 1993, including treatment for palpitations during a VA admission in June 1993. The veteran was admitted to a private hospital in August 1993 for coronary artery bypass grafting for coronary artery disease. It was noted that his cardiac history started in 1985 with a history of tachycardia treated with medications. The tachycardia returned in 1989 and he had a catheterization ablation. He developed atrial fibrillation in February 1993, and had excision of his pathway and had normal sinus rhythm since. Around that time he had chest pain on exertion and a positive stress test. During the present admission, he underwent 1-vessel coronary artery bypass grafting, but developed some complications and had 2 cardioversions for atrial fibrillation and had treatment for respiratory complications. The second cardioversion was successful and he remained in normal sinus rhythm before his discharge in September 1993. Numerous later medical records show continued treatment for heart problems, primarily atrial flutter, in 1993 and 1994. On an August 1994 VA cardiovascular examination, it was noted that the veteran had had multiple hospitalizations for evaluation of recurrent atrial flutter. He had been cardioverted numerous times and had an atrial overdrive pacing to bring him out of his flutter. It was reported that that he was medications to reduce the incidence of atrial fibrillation. It was noted that he also had a history of Wolf-Parkinson-White Syndrome, for which he had had a catheter ablation of the aberrant pathway. Examination showed he was well developed, well nourished, and in no apparent distress. His blood pressure was 120/70. The assessments were coronary artery disease, status post coronary artery by-pass grafting one year ago with no further episodes of chest pain or shortness of breath, and recurrent atrial flutter. The examiner said that the atrial flutter was a debilitating problem requiring numerous hospitalizations. It was reported that the veteran worked as an air-conditioning repairman on ladders and roofs, which was absolutely contraindicated in a patient who is chronically anti-coagulated. Therefore he had been ordered by his doctor not to work. The other diagnoses noted by the examiner were diabetes mellitus controlled by diet and hypertension controlled by his current regimen. In September 1994 the RO established service connection for coronary artery disease, status post coronary artery bypass grafting, which was rated with the previously service- connected hypertension. A 30 percent rating was assigned for the heart condition. In a December 1994 statement, the veteran's private physician, James Wells, M.D., stated the veteran's heart condition was classified as Class II under the New York Heart Association's standards. The veteran testified at a hearing at the RO in December 1994. He related that his private doctor and a VA examiner both told him that he should not continue in his occupation as a air-conditioning repairman or engaged in heavy labor while he was on Coumadin therapy because of the possibility of an injury. He said he was continuing at his job. He said he exercised a lot by walking, but stopped if got shortness of breath. He said he had side effects of dizziness from his cardiac medications. In May 1995 the hearing officer at the RO granted a temporary 100 percent rating for coronary artery bypass grafting from August 1993 through October 1994 (a temporary total convalescent rating, followed by a 1-year schedular rating for bypass surgery), with a 30 percent rating thereafter. The veteran was hospitalized for treatment of atrial flutter in October 1995. Other medical records show VA and private treatment for cardiovascular and other ailments in 1995 and 1996. In a June 1996 statement, the veteran's employer said that the veteran's doctors had recommended that that he quit working because of heart, back, and neck problems. He added that the veteran's job as a refrigeration mechanic involved climbing on top of buildings, heavy lifting, and working in hot and cold environments. Private treatment records in 1997 show the veteran was seen by Dr. Wells for his cardiac condition. During a January 1997 admission, the veteran complained of angina symptoms but a cardiolite heart scan was negative. The records show the veteran was evaluated for his atrial flutter in June 1997. It was noted that, angiographically, his coronary artery disease was stable. The final diagnoses included recurrent atrial flutter, coronary artery disease, and hypertension. The veteran was admitted to a private hospital in August 1997 with complaints of recurrent fluttering of his heart with short bursts of palpitations. Vital signs were stable except for a blood pressure of 155/105. Following evaluation, the doctor concluded that the veteran had a possible recurrent paroxysmal atrial flutter with a possible emboli episode. The final diagnoses were left facial weakness, possibly related to accelerated hypertension; recurrent arrhythmia; history of Wolf-Parkinson-White Syndrome; three previous transcatheter ablations of intra-cardiac electrical pathways; coronary artery disease with previous coronary artery bypass grafting; and hypertensive cardiovascular disease. Clinical treatment records from Dr. Wells from August to November 1997 show the veteran continued to receive treatment for cardiac symptoms. In October 1997 he denied anginal-type pain. In November 1997, it was noted that he did not a great deal of energy and had some mild shortness of breath. He had not had any chest pain and no sustained dysrhythmias. On a January 1998 VA cardiovascular examination, it was reported that the veteran had to retire from his job as refrigeration engineer because he could not do the fairly heavy labor involved. His principal current complaint was lack of energy. He also reported relatively mild dyspnea and occasional chest tightness associated with dyspnea. He reported intermittent palpitations and occasional mild orthostatic dizziness. He reported that he was aware of acceleration of his heart rate when he walked around his yard. On examination, it was noted that his blood pressures were 138/96, 134/84, and 129/80. The heart was not enlarged to percussion. It was reported that that a January 1998 EKG showed left atrial enlargement and non-specific T-wave abnormality. The diagnoses were coronary artery disease status post single vessel coronary artery bypass grafting; hypertension, controlled on current medications; and history of atrial flutter, status post ablation procedure. The examiner commented that the veteran was functional Class III, although the source of his limitation was not related to his coronary artery disease. It was noted that some of his exertional symptoms could be due to extensive anti- hypertensive drug regimen, additional treatment was directed toward persistent arrhythmia, and the status of his atrial fibrillation was not well defined. In June 1998 the RO increased the rating for the service- connected heart disease to 60 percent. Based on all of the veteran's service connected disabilities, the RO also granted a total compensation rating based on individual unemployability. The veteran's other service-connected disorders are gouty arthritis (rated 20 percent), diabetes mellitus (10 percent), and restrictive lung disease (0 percent). The veteran was admitted to a private hospital in June 1998 after he developed compressive chest pain the night prior to admission. EKGs showed nothing specific. It was reported that that he had moderate exertional dyspnea, but that he denied paroxysmal nocturnal dyspnea, orthopnea, and leg edema. On an April 1999 VA cardiovascular examination, the veteran reported that he had arrhythmia with exertion, so he did not exert himself much. He reported that he could walk less than 100 yards because he would develop chest pain, shortness of breath, and arrhythmia. The veteran reported that he very labile blood pressure, and that it had been as high as 200/130. On examination it was noted that his blood pressure was 160/78. The heart had a regular rate and rhythm. The examiner reported that a treadmill stress test in March 1999 was stopped at 14 seconds into stage 2 of the Bruce protocol because of dyspnea and chest pain. A stress EKG showed occasional premature atrial contractions and an accelerated junctional rhythm, but no ST-segment evidence of ischemia. The resting EKG, prior to the stress test, showed 1st degree arteriovenous block and left atrial enlargement. The assessments were supraventricular tachycardia with the exertional capacity evident on the treadmill stress test of 4 METS; and coronary artery disease, status post one-vessel bypass with evidence of discomfort on the stress test, but no ST-segment evidence of ischemia. In an addendum to the examination report, the doctor noted that a June 1998 Holter monitor showed atrial fibrillation, and a January 1999 Persantine stress test showed no evidence of ischemia. In a June 1999 addendum to the examination report, the VA doctor noted that the veteran's claim file had been reviewed, that the maximal exercise capacity on the March 1999 exercise stress test was 4 METS, and that the only arrhythmia was a junctional tachycardia at 110 beats per minute. The doctor said that this corresponded to a functional Class III heart condition. II. Analysis The veteran seeks an increase in a 60 percent rating for his service-connected heart disease. His claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a), in that it is plausible. Relevant evidence has been properly developed, and no further assistance to the veteran is required to comply with the duty to assist. Id. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. During the course of this appeal, the rating criteria for cardiovascular disorders were changed effective January 12, 1998. The Board has considered both the old and new rating criteria. Karnas v. Derwinski, 1 Vet.App. 308 (1991). A 60 percent evaluation is the highest rating for hypertension under either the old or new rating criteria. 38 C.F.R. § 4.104, Diagnostic Code 7101 (1997 and 1999). The veteran's service-connected hypertension, which is controlled by medication, is rated as part of his service-connected coronary artery disease, status post coronary artery bypass grafting. Under the old rating criteria, a 100 percent rating is assigned for one year after coronary artery bypass surgery (the veteran has received such temporary total rating), and thereafter residuals are to be rated under the provisions for arteriosclerotic heart disease, with a minimum 30 percent rating. 38 C.F.R. § 4.104, Diagnostic Code 7017 (1997) (in effect prior to January 12, 1998). Under the old rating criteria, arteriosclerotic heart disease following a typical coronary occlusion or thrombosis, or with a history of substantiated anginal attack, where ordinary manual labor is feasible, is rated 30 percent disabling. When there is a history of substantiated repeated anginal attacks and more than light manual labor is not feasible, a 60 percent rating is assigned. Arteriosclerotic heart disease with chronic residual findings of congestive heart failure or angina on moderate exertion or more than sedentary employment precluded, is rated 100 percent disabling. 38 C.F.R. § 4.104, Diagnostic Code 7005 (1997) (in effect prior to January 12, 1998). Under the new rating criteria, residuals of coronary artery bypass surgery are rated 100 percent for 3 months after hospital admission for surgery. Thereafter, the condition is rated 30 percent when a workload of greater than 5 METs (metabolic equivalent units) 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. The condition is rated 60 percent when there is 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; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. The condition is rated 100 percent when there is chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, a 100 percent rating is assigned. 38 C.F.R. § 4.104, Diagnostic Code 7017 (1999) (effective January 12, 1998). In this case the veteran's predominant heart problems are related to his supraventricular tachycardia; service connection for this condition has been denied by RO, and manifestations of the non-service-connected disorder are not considered in rating his service-connected coronary artery disease, status post coronary artery bypass grafting, with hypertension. 38 C.F.R. § 4.14. Considering the old rating criteria, the recent medical evidence does not show that the veteran has chest pain that is specifically noted to be anginal, and recent exercise stress tests have not shown evidence of ischemia. The medical evidence of record does not suggest that the veteran has symptoms, attributable to coronary artery disease or hypertension, that would warrant a rating in excess of 60 percent. Specifically, congestive heart failure, angina on moderate exertion, and preclusion of more than sedentary employment are not demonstrated. The veteran's last job involved strenuous physical labor, and he left it partly due to his service-connected heart condition. A total compensation rating based on individual unemployability has been assigned based on the effects of all service-connected disabilities. While the service-connected heart disease may prohibit more than light manual labor (as required for a 60 percent rating), it alone does not preclude more than sedentary employment (as required for a 100 percent rating). Considering the new rating criteria, the recent stress test showed that the veteran could perform a workload of 4 METS, and the doctor pointed out that most of the impairment was not due to the service-connected coronary artery disease. Moreover, the evidence does not suggest that the veteran has congestive heart failure due to his service-connected cardiac condition, or that there is left ventricular dysfunction. Medical evidence demonstrates that the service-connected heart condition is no more than 60 percent disabling under the new criteria. The preponderance of the evidence is against the veteran's claim for an increased rating for his service-connected heart disease. Thus, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). ORDER An increased rating for coronary artery disease, status post coronary artery bypass grafting, with hypertension, is denied. L. W. TOBIN Member, Board of Veterans' Appeals