RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE:  PD1300191
BRANCH OF SERVICE:  ARMY		BOARD DATE:  20131126
SEPARATION DATE:  20030410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve Major (O-4) on extended active duty (92A 4T/Quartermaster General) medically separated for angina pectoris secondary to arteriosclerotic heart disease.  The CI presented with cardiac symptoms in September 2001 after physical training.  He subsequently underwent cardiac catheterization followed by angioplasty of a blocked coronary artery with stent placement.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P4 profile and placed on light duty.  He was referred for a Medical Evaluation Board (MEB) which then forwarded angina pectoris, Class II, with documented inferior ischemia on a nuclear stress test, hypertension and hypercholesterolemia conditions to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated the angina pectoris secondary to arteriosclerotic heart disease condition as unfitting, rated 10%.  The remaining conditions were determined to be not unfitting and were not rated.  The CI made no appeals and was medically separated.  Although the CI had over 15 years of active duty, and over 29 years of combined active, Guard, and reserve duty, there is no evidence he applied to be transferred to the retired reserve in order to receive a reserve retirement at age 60, although he was eligible.  The CI’s DD Form 214 indicates he accepted disability severance pay.

CI CONTENTIONS:  
A. The diagnosis of Angina Class II qualifies for a minimum of 30% disability.
B. The exercise stress test of 19 February 2003 is not valid and should be withdrawn from the evidence. 
C. The objective review of evidence was limited in scope.
D. The diagnosis of depression, secondary to CAD and its affect on my mental/emotional functionality was not addressed.
E. There are numerous omissions, clerical and medical administrative errors, and possible violation of Army Regulations.
The CI also submitted a 6-page memo with his application, as well as an additional memo dated 2 December 2013, continuing his contention remarks, which were considered by the Board in arriving at its recommendation.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting angina pectoris condition is addressed below; no additional conditions are within the Board’s defined DoDI 6040.44 purview.  The contention for inclusion of depression within the DoD disability rating is specifically outside the scope of this board as it was not addressed within either the MEB or PEB documents.  It, and any other conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

In accordance with DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  Provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the Veterans Affairs Schedule for Rating Disabilities (VASRD) in effect at the time of the adjudication.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20030312	VA - Service Treatment Records (STR)*	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Angina Pectoris Secondary to Arteriosclerotic Heart Disease	7005	10%	Myocardial Ischemia	7005	NSC	STR*	
Hypertension	Not Unfitting	No Corresponding VA Entry	
Hypercholesterolemia	Not Unfitting	No Corresponding VA Entry	
No Additional MEB/PEB Entries	Diabetes Mellitus	7913	NSC	STR*	
Combined:  10%	Combined:  N/A	
Derived from Original VA Rating Decision (VARD) of 20061116 (most proximate to date of separation [DOS]).
*No VA C&P Exam was done.  The VA used the STR to arrive at its conclusions.

ANALYSIS SUMMARY:  The treatment record was incomplete and efforts to locate the missing documents through the NPRC and the CI were unsuccessful.  Further attempts at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case.  It is not suspected that the missing evidence would significantly alter the Board’s recommendations.

Angina Pectoris Secondary to Arteriosclerotic Heart Disease Condition.  Due to symptoms of shortness of breath (SOB) and multiple cardiac risk factors, the CI underwent exercise stress testing on 12 September 2000, 4 months prior to entry into his last period of active duty.  The test was negative for symptoms or electrocardiographic changes.  He entered extended active duty on 31 January 2001 to work as a recruiter.  He was hospitalized on 28 September 2001 for new onset exertional chest pain (unstable angina) due to coronary artery disease.  A cardiology evaluation report dated 1 October 2001 recorded symptoms of chest pressure radiating to his right shoulder and jaw during exercise beginning the day prior to admission.  Medical evaluation determined he had not had a heart attack (no heart muscle damage).  Cardiac evaluation included a normal electrocardiogram and a normal echocardiogram showing “normal contractility, no regional wall motion abnormality” (normal heart wall motion and function).  Exercise stress testing demonstrated continued excellent exercise tolerance with normal electrocardiographic findings similar to the stress test a year prior to.  Nuclear cardiac imaging with exercise stress testing on 5 October 2001 demonstrated a possible abnormal area of heart blood flow (inferior wall of the left ventricle; but with normal heart function without dilation and with ejection fraction of 56%).  Medical treatment was initiated.  Due to symptoms, the CI underwent cardiac catheterization on 10 October 2001, disclosing significant coronary artery disease with severe blockage of the right coronary artery (99%; correlating with the nuclear scan) and some blockage of the left anterior descending artery (40%, but not considered severe enough to result in blocked blood flow or symptoms).  Post-catheterization cardiology notes indicate there was a left ventricular ejection fraction of 40% to 45% during the cardiac catheterization but without focal wall motion abnormality.  A 19 October 2001 cardiology follow up appointment noted “He has significant exertional angina. If he walks a quarter of a mile he becomes symptomatic with chest discomfort, diaphoresis and fatigue. This is relieved with rest and sublingual nitroglycerin.”  He subsequently underwent cardiac catheterization on 10 January 2002 to reopen the blocked right coronary artery with placement of a stent.  Following the procedure, his cardiologist recorded that functional capacity had doubled.  However repeat cardiac catheterization in March 2002 disclosed “mild stent re-stenosis” according to his cardiologist.  An abnormal ejection fraction was no longer listed in the cardiologist’s notes following placement of the stent. In a 10 April 2002 memo, the cardiologist estimated the CI’s functional status to be Class II to III angina (Class II is slight limitation in physical activity; Class III is marked limitation in physical activity).  The CI participated in a cardiac rehabilitation program that involved exercising up to 6 metabolic equivalents of tasks (METs) during Phase II of the program.  The final Phase II cardiac rehabilitation note, dated 31 May 2002, recorded that following the cardiac catheterization in March 2002, the CI had experienced 3 to 4 episodes of angina rated 2 to 4 on the 10 scale, resolving with rest alone except for one occasion when he used nitroglycerin (stable angina pattern).  He was progressed to Phase III of the program which advanced the exercise to moderate levels for 30 to 60 minutes four to 6 times per week; however, there is no documentation of participation.  Pharmacologic stress cardiac imaging in July 2002 showed no ischemia (blocked heart blood flow) and normal heart function (normal motion, ejection fraction 52%).  A chest X-ray and electrocardiogram on 30 July 2002 were within normal limits.  The MEB narrative summary (NARSUM) dated 22 October 2002 recorded the CI could not carry heavy baggage, and experienced symptoms with climbing hills or stairs, and walking “great distances,” consistent with Class II angina.  Another MEB NARSUM dated 28 October 2002 summarized the CI’s clinical history noted above and concluded his condition prevented military duties.  This document cited the cardiac catheterization report from October 2001, including the history of symptoms with walking a quarter mile, and stated “the patient continues with symptoms of class II-III angina pectoris despite maximal medical therapy and interventional therapy.”  The CI underwent exercise stress testing to assess functional capacity in the treated state (not for diagnosis) for the PEB on 19 February 2003, using the same standard protocol used in his prior exercise stress tests.  He exercised for 6 minutes and 40 seconds at which time he experienced chest pain and the test was stopped (40 seconds after the workload was increased over 7 METs).  According to the test report, the duration of exercise correlated with a functional capacity of 7.9 METS.  There were no abnormal EKG changes during exercise.  In addition, jaw tightness was noted at 3 minutes and 30 seconds into the test (30 seconds after workload was increased to the 7 MET level of intensity).

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the angina pectoris secondary to arteriosclerotic heart disease condition 10% utilizing code 7005, citing the stress test results attaining 7.9 METs.  Under VASRD diagnostic code 7005, atherosclerotic (coronary artery) heart disease, a 10% rating is supported when a workload greater than 7 METs but not greater than 10 METs results in symptoms of SOB, fatigue, angina, dizziness or syncope (on continuous medication).  The next higher rating of 30% is supported when those symptoms result with workload of greater than 5 METs but not greater than 7 METs.  The Board noted that the evidence of the treatment records and stress test indicate symptoms around the 7 MET level and discussed whether the preponderance of evidence more nearly approximated the 30% rating than the 10% rating based on the workload threshold for symptoms.  The CI experienced angina chest discomfort within 40 seconds of the work load exceeding 7 METs on the February 2003 stress test.  The jaw pain reported during the stress test suggested onset of angina type symptoms at or below 7 METs.  Jaw pain was reported as an angina associated symptom experienced by the CI at the time of initial evaluation in October 2001 and therefore was considered relevant.  The report of symptoms climbing hills also correlates with onset of symptoms at 7 METs (6.9 METs per standard references).  Therefore the Board concluded the evidence reasonably supported a conclusion that symptoms resulted at a workload of 7 METs and reasonably supported the 30% rating.  There was no evidence of heart failure or left ventricular dysfunction, or symptoms with workloads at or below 5 METs to support a rating higher than 30%.  The left ventricular ejection fraction at the time of the initial cardiac catheterization was unaccompanied by regional wall motion abnormalities and nuclear imaging following angioplasty of the blocked coronary artery was normal with regard to left ventricular wall motion and ejection fraction.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the angina pectoris secondary to arteriosclerotic heart disease.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  In the matter of the angina pectoris secondary to arteriosclerotic heart disease condition, the Board unanimously recommends a disability rating of 30%, coded 7005 IAW VASRD §4.104.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Angina Pectoris Secondary to Arteriosclerotic Heart Disease Condition 	7005	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130419, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXXXXXXXX, AR20140005230 (PD201300191)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl