RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00321
BRANCH OF SERVICE:  Army	BOARD DATE:  20141106
SEPARATION DATE:  20060321

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (88M/Motor Transportation Operator) medically separated for a heart condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The coronary artery disease (CAD) was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded seven other conditions (frequent ectopic ventricular ectopy, hypertension, dyslipidemia, plantar fascitis, intermittent right shoulder pain and high frequency hearing loss) that did not fall below retention standards to the PEB.  The Informal PEB (IPEB) adjudicated mild to moderate generalized coronary atherosclerosis as unfitting, rated at 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  There were no additional conditions for PEB adjudication.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 CAD condition is addressed below.  The not-unfitting ectopic ventricular ectopy, hypertension, dyslipidemia, plantar fasciitis, back pain, right shoulder pain and hearing loss were not contended hence are not within the DoDI 6040.44 defined purview of the Board.  These and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  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 and based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20060202	VA* - (2.4 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Coronary Artery Disease	7005	10%	Coronary Artery Disease…	7005	10%	20060531	
Other x 7 (Not in Scope)	Other x 13	
Combined:  10%	Combined:  50%	
*Derived from VA Rating Decision (VARD) dated 20070109 (most proximate to date of separation)

ANALYSIS SUMMARY:  

Coronary Artery Disease (CAD).  In April 2005, during completion of a routine over forty [years old] physical examination, the CI had an abnormal electrocardiography (EKG).  The EKG indicated evidence of a previous myocardial infarction (MI), but was without evidence of hypertrophy (enlarge heart).  Over the next several months, the CI was evaluated for MI and hypertension (high blood pressure).  On 11 July 2005, a follow-up EKG was noted to have premature ventricular contractions/complexes (PVCs), irregular heartbeats, but signs of cardiac hypertrophy were not evident; the CI reported chest tightness the previous night.  The treadmill exercise tolerance test (ETT) obtained on 19 July 2005, presented frequent PVCs while the ventricular myocardial perfusion studies (obtained also on the 19 July 2005), with a radioactive marker, demonstrated a defect consistent with a previous MI, without indication of hypertrophy and an ejection fraction (EF) of 47% (normal EF are between 50% and 65%).  The 24 hours Holter-monitor captured frequent PVCs.  The stress echocardiogram (ECHO) obtained on 5 August 2005 demonstrated an EF of 40%-50%, an exercise tolerance of 12.9 metabolic equivalents s (MET) and borderline left ventricular hypertrophy.  There were changes with the ECHO study that were consistent with ischemia ([cardiac] tissue death due to inadequate blood flow / lack of oxygen).  Subsequently, the CI underwent cardiac catheterization on 
9 August 2005 that demonstrated an EF of 60% and minimal to moderate plaque in the three primary coronary vessels.

At the MEB narrative summary (NARSUM) examination dated 5 October 2005 (approximately 5 months prior to separation), the CI reported angina (cardiac/coronary related chest pain) at rest while on his current CAD medication regimen, the ability to walked two miles 3 times a week and lifted 85 pounds tires at work; without chest pain.  He denied nausea, emesis, the use of nitroglycerin (blood vessel dilator), faint (feeling light-head-ness) nor fainting.  He also stated that he quit smoking weeks earlier.  At the MEB medical examination (DD Forms 2807 & 2808) dated 11 October 2005, the CI reported chest pain at the end of the day and palpitations while resting in bed.  Frequent PVCs and irregularity heart beat were noted on the cardiac examination, the examination overall was otherwise normal.

The VA Compensation and Pension (C&P) examination dated 31 May 2006 (approximately 2 months after separation), was not in evidence, but its’ information was detailed in the VA rating decision dated 9 January 2007.  The CI reported walking 30-60 minutes without chest pain and denied the use of nitroglycerine, angina, or shortness of breath.  At a second ETT on 19 July 2006, the CI was able to achieve 10.4 METS.

The Board directed its attention to its rating recommendation based on the above evidence.  Both the PEB and VA rated the cardiac condition at 10% under code 7005 (coronary artery disease) noting the achieved 12.9 METS.  The Board noted that both cardiac hypertrophy and decreased EF conditions were criteria for a higher rating.

Cardiac hypertrophy was first considered.  The ECHO study dated 5 August 2005 noted that there was signs of “borderline hypertrophy”, but the perfusion study obtained on 19 July 2005 was “without indication of hypertrophy, but EF of 47%”.  The Board considered the finding of borderline hypertrophy, which implies that the criteria for hypertrophy were not fully met and noted that the other ECHO study was normal.  Also CI’s EKGs in evidence did not demonstrate hypertrophy.  Therefore the Board determined that the evidence does not support the presence of cardiac hypertrophy.

The Board then examined the evidence for a decreased EF (indication of the left ventricle functionality capacity).  Two ECHO studies revealed low EF reading, the July 2005 study EF was 47% and Aug 2005 study revealed an EF of 40-50%, the latter value measurement was obtained by stress ECHO which also showed an exercise tolerance of 12.9 METS; these two values are not entirely consistent with historic doctrines that low EF readings would predict a low exercise tolerance, which was not the case on this test.  Also, the cardiac catheterization, considered to be the most accurate method of calculating an EF, showed an EF of 60% that is well within the normal range.  Nonetheless, Board determined that the evidence did not support the presence of an abnormal EF.  There were no reports of angina recorded in the examinations proximate to the CI’s separation (after a medication change), use nitroglycerine, faintness, or an exercise tolerance less than 10 METS.  The evidence does not support a rating higher than the 10% adjudicated by both the PEB and VA.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the CAD.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the cardiac condition and IAW VASRD §4.104 the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

					
XXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-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 XXXXXXXXXXXXXXX, AR20150004345 (PD201400321)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA