RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: air force
CASE NUMBER:  PD0900042 		COMPONENT: active
BOARD DATE: 20090630		SEPARATION DATE: 20060920

________________________________________________________________

SUMMARY OF CASE:  This covered individual (CI) was an Air Force Senior Airman Information Management Journeyman medically separated in 2006 after three and a half years of active service.  She began experiencing heart palpitations in January 2006, was unable to tolerate physical exertion, and underwent an extensive cardiac evaluation.  She was unable to perform physical fitness training or testing and was not worldwide deployable so she was referred for a fitness evaluation. The Air Force Informal Physical Evaluation Board (PEB) found her unfit for continued service and she was separated with a 10% disability rating for 7099-7020 Cardiac septal aneurysm and mild mitral valve regurgitation (Ejection fraction 60-65%) using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.  The 10% rating was presumably based on her need for continuous medication.  An echocardiogram (ECHO) did show abnormalities including the mild intra-atrial septal aneurysm, mild mitral valve prolapse with mild regurgitation, and trace tricuspid valve regurgitation. A stress ECHO showed exertional tachycardia and the CI was able to exercise for a total of 12 minutes and achieve 12.8 METs without any ischemia or significant arrhythmia.  No comment on symptoms such as dyspnea, fatigue, dizziness, or syncope was available. A Holter monitor was noted by the cardiologist to have too much artifact to be read.  However, the Holter report noted no arrhythmia other than tachycardia.  The Air Force also determined that three other conditions were Category II (not currently compensable or ratable): 6522 Seasonal allergic rhinitis, 7615 Polycystic ovary disease, and 8199-8103 Benign essential tremor.  She had previously been referred to the PEB for the benign essential tremor and was found to be fit for duty. 

Using an evaluation done prior to separation from the Air Force, the Veterans Administration (VA) rated this disability as 7020 Cardiomyopathy with intra-atrial aneurysm at 30% based on an estimated appearance of symptoms at a  workload of 7 METs and mildly enlarged right ventricle noted on ECHO.  The right ventricle measured by the Air Force ECHO was 1.4cm in diastole and was 2.5cm on the VA ECHO. Informal consultation was obtained from a Navy cardiologist who stated this measurement is clinically insignificant.  The CI stated she could not tolerate any type of physical exertion and the VA physician felt the treadmill stress test was medically contraindicated.  The VA also rated 6522 Allergic rhinitis at 0% (this was later increased to 10%), 5299-5203 Left shoulder strain with scar, status-post arthroscopy at 10%, 5299-5215 Left wrist strain with scar, status-post ganglion cyst removal at 10%, 5237 Lumbar strain at 10%, 7399-7346 Gastroesophageal reflux disease at 10%, 9440 Adjustment disorder with anxiety and depression at 10%, 9905 Temporomandibular joint dysfunction at 10%, and 7828 Cystic acne at 0% for a combined total of 60% initially and then 70% when the rating for allergic rhinitis increased.  The CI contended that she did not get worse between the PEB and the VA examination and her rating from the Air Force should be the same as the rating from the VA.

________________________________________________________________

BOARD FINDINGS:  IAW DoDI 6040.44, the Board used the Veteran’s Affairs Schedule of Rating Disabilities (VASRD) as the most favorable basis for rating. Although the CI did not contend that the other conditions rated by the VA should also be rated, the Board examined these conditions and did not find any to be unfitting at the time of separation.  

After careful consideration of all available information, the Board concluded by simple majority that the CI’s unfitting condition is appropriately rated at 10% for 7099-7020 Cardiac septal aneurysm and mild mitral valve regurgitation (Ejection fraction 60-65%). This rating is based on the CI’s requirement for daily medication, estimated ability to perform greater than 10 METs without symptoms, and no evidence of cardiac hypertrophy or dilatation on electrocardiogram, ECHO, or X-ray.  The single voter for dissent recommended a 30% rating using the same code and a minority opinion is attached.

________________________________________________________________

RECOMMENDATION: The Board recommends that there be no recharacterization of the CI’s separation.

________________________________________________________________

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090117, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veteran's Affairs Treatment Record.

	 

Attachment:
Minority Opinion

MINORITY OPINION

SUBJECT:  xxxxxxxxxxxx, PHYSICAL DISABILITY BOARD OF REVIEW CASE NUMBER PD-2009-00042

The minority voter opined that covered individual (CI) met the VASRD criteria for 30% (7099-7020).  The majority of the Board reasoned that mild ventricular enlargement, proven by ECHO, was not cardiac dilation, as a cardiologist who saw only the ECHO summary report (without ECHO pictures or treatment records) said the right ventricle measurement (formally read out as mild enlargement) was ‘not clinically significant.’ ‘Clinical significance’ is not noted in the VASRD criteria for cardiac dilatation, nor would all cardiologists likely agree on a lower threshold of significance without the full clinical picture of the examinee.  Both the AF and VA cardiac ECHOs showed clear abnormalities in heart chamber size or configuration.  Although these exams differ, either can be contended to meet ‘evidence of cardiac dilation’ IAW the VASRD which justifies a 30% rating regardless of achievable symptom-free METs.  

Regarding achievable symptom-free METs; dyspnea, fatigue or dizziness at, or below, 7 METs would independently support the 30% rating. DoDI 1332.39 (E2, Atch1, Table 3) also allowed palpitations as a symptom end-point.  The absence of full records on the AF treadmill test, with a summary that did not comment on lack or presence of any non-ischemic symptoms decreased the probative value of that evaluation for rating purposes (similar to a back range of motion exam that neglected to mention pain onset limits).  There is only supposition to indicate that CI was symptom-free over 7 METs during the Treadmill exam.  Additionally, since the cardiologist noted the Holter monitor to have too much artifact to be read, the Holter  report of no arrhythmia other than tachycardia cannot be relied upon to exclude intermittent arrhythmia which may impact CI’s exertion limits, yet could be absent during a single treadmill test.  The NARSUM clearly stated CI ‘passed out twice during physical training’ with an abnormal holter monitor at the start of CI’s cardiology evaluation and continued symptoms on exertion at the time of PEB which was the basis for finding CI unfit.  Given the VA’s reasonable 30% rating rationale of diminished symptom free exertion (METs), interplay between CI’s cardiac disease and anxiety symptoms including palpitations, abnormal ECHOs, incomplete AF record of CI’s treadmill and Holter, and CI’s day-to-day exertional limitations, CI more nearly meets the criteria for the 30% rating.  

MINORITY RECOMMENDATION: The minority voter recommends that CI’s disposition be recharacterized as permanent retirement as of the date of her discharge.

Unfitting Condition	VASRD Code	Rating	
Cardiomyopathy with intra-atrial aneurysm 	7099-7020	30%	
Combined	30%	

________________________________________________________________

SAF/MRB
1535 Command Drive, Suite E-302
Andrews AFB, MD  20762-7002

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00042.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.