RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02551
BRANCH OF SERVICE:  NAVY	SEPARATION DATE:  20080929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Storekeeper) medically separated for atrial fibrillation.  The atrial fibrillation condition could not be adequately rehabilitated to meet the physical requirements of his Rating.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  Atrial fibrillation was forwarded to the Physical Evaluation Board IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated atrial fibrillation as unfitting rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and then reduced the rating to 0% for noncompliance.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his condition by the VA and believes he should have received a higher rating from the Service.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB - Dated 20080731	VA* - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Paroxysmal Atrial Fibrillation	7010	0%	Atrial Fibrillation And Flutter	7010	10%	20090128	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  0%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20090326 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Atrial Fibrillation (AF).  The Service treatment record (STR) documented that the CI was started on a blood pressure medication (propranolol) twice daily for headache prophylaxis.  Adverse reactions associated with this medication include fatigue, dizziness, heart conduction disturbances, rebound tachycardia (abnormally rapid heart rate) with discontinuation, etc.  While underway on a submarine, he complained of his heart pounding, chest pain, and dizziness.  The CI stated “…he can’t keep track of time due to underway schedule [and] … is not really sure when he took meds.”  The CI thought the time between doses, for his twice a day propranolol, was greater than 24 hours.  The submarine independent duty corpsman noted tachycardia on exam.  The propranolol was discontinued because of the increased fatigue, lightheadedness and palpations.  Upon return to port, he was evaluated by his undersea medical officer (UMO).  The CI reported that since starting the propranolol, he had an increase in palpitations, which had been occurring for years.  The UMO documented “Pt reports that he has had these episodes for many years, however, he was always told not to worry about it.”  The palpitations usually lasted for several seconds and then resolved.  Episodes occurred both at rest and with exertion.  Palpitations were associated with mild chest pain, shortness of breath (SOB) and lightheadedness.  The CI denied syncope (loss of consciousness from insufficient blood flow to the brain).  The electrocardiogram (ECG) showed normal sinus rhythm ([NSR] normal heart rate and rhythm originating from sinoatrial node) with a right ventricular conduction delay.  The CI presented to the emergency room (ER) complaining of a pounding heart, chest discomfort and SOB.  The cardiac monitor and ECG showed AF (abnormal, irregular, and rapid heart rhythm where upper heart chambers [atria] generate electrical impulses chaotically) with a rapid heart rate of 115 beats per minutes.  Heart auscultation (listening with a stethoscope) revealed a tachycardic rate and an irregularly irregular rhythm.  The CI persisted in rapid AF with premature ventricular contractions.  He was given an intravenous antiarrhythmic medication (adenosine) to attempt pharmacologic cardioversion (restoration of sinus rhythm).  The CI was successfully cardioverted to NSR.  The CI was started on another blood pressure medication (diltiazem) daily and discharged.  

A cardiology evaluation documented two episodes of transient AF, lasting 1-2 hours, with symptoms of palpitations and episodes of dizziness.  The cause of the AF was unclear and the cardiologist opined it was most likely idiopathic (unknown cause or arises spontaneously).  The cardiologist ordered an echocardiogram (heart ultrasound) and exercise stress test with nuclear imaging.  The CI presented again to the ER complaining of intermittent left sided chest pain.  The cardiac monitor and ECG showed NSR.  Heart auscultation revealed a regular rate and rhythm.  A cardiology encounter recorded that the CI had undergone a fairly extensive cardiovascular evaluation.  The echocardiogram revealed preserved left ventricular systolic (contraction) function with no significant valvular abnormalities.  The stress test revealed preserved exercise capacity with no evidence of ischemia (heart muscle inadequate blood supply).  The diagnosis listed paroxysmal AF (self-terminating AF within 7 days) with repeated and regular episodes of palpitations.  The cardiologist prescribed a starting dose of an antiarrhythmic (flecainide) to reduce the frequency and severity of these episodes.  At the cardiology follow-up, the diltiazem was stopped and the flecainide dose was increased.  The electrophysiologist opined that the CI would be a good candidate for ablation (catheter destruction of tissues generating abnormal electrical impulses) given his age and normal heart structure.  He increased the flecainide dose and would consider ablation if the CI could not be controlled on a higher dose.  At the follow-up, the electrophysiologist documented that the CI continued to have self-limited episodes of AF.  These episodes had been further decreased in frequency with the increase in flecainide.  The examiner opined that an ablation procedure was a possibility, but that he would not subject the CI to an ablation with good control on flecainide.  The plan was to continue the flecainide at the current dose and to monitor the frequency of symptoms.  An internal medicine encounter documented the CI was without breakthrough episodes on the current dose of flecanide.  The CI presented to the ER complaining of intermittent 4/10 left sided chest pain and pressure with radiation to the left arm.  The cardiac monitor showed NSR and the rhythm remained unchanged throughout stay.  He experienced pain relief with supplemental oxygen and requested to leave.  The diagnoses listed unspecified chest pain and nonspecific gastritis.  The CI was given an antacid (Pepcid) and discharged.  At an internal medicine encounter the CI reported a self-limited episode AF in the preceding month.  It lasted 20 minutes, was associated with mild SOB, but with no chest pain.  Since starting flecainide, the CI had not had any episodes lasting longer than 20 minutes.  They were overall infrequent, occurred a few times a month, and typically only lasted a few minutes.  At the follow-up, the electrophysiologist documented that the CI continued to have paroxysmal AF with no known structural heart disease.  The intermittent episodes were short in duration and self-limited.  The examiner recommended continuing the current regimen of flecainide.  The electrophysiologist observed that AF episodes were often brought on by strenuous activity.  The examiner advised that the CI not participate in strenuous activity, or a strenuous daily exercise regimen, that could not be monitored from a cardiac perspective.  He recommended light symptom limited exercise.  

The narrative summary (NARSUM) by internal medicine recounted the history and interventions.  The CI reported his symptoms were often brought on, or exacerbated by, physical activity and exertion.  The cardiologist recommended that he avoid strenuous physical activity, including his PRT.  The CI complained of feeling more fatigue, and being unable to participate at a high level, while taking flecainide.  The NARSUM documented the CI “… states that his symptoms [AF] often occur due to the fact that he will intentionally miss doses of his flecainide in order to participate in physical activity and sports ….”  The examiner opined “By self-missing doses of his flecainide, however, he unintentionally brings about increased episodes of palpitations and atrial fibrillation, which have often required frequent emergency room visits in the past several months.”  His medications were flecainide 100 mg twice daily and aspirin 81 mg daily.  Cardiac auscultation revealed a regular rate and rhythm with normal heart sounds.  The diagnosis listed paroxysmal AF… “which has been well controlled with flecainide however; he has had difficulty adhering to this medication due to the likely side effect of fatigue.  As a result he has had multiple missed doses of this medication, resulting in exacerbations of his atrial fibrillation and subsequent emergency room visits.”  

The Compensation and Pension (C&P) exam, 4 months after separation, recounted the history and interventions.  The CI reported symptoms associated with episodes of AF were SOB, dizziness and fatigue.  He denied angina (chest pain from reduced blood flow to the heart muscle) and syncope or a history of rheumatic heart disease, heart attacks or heart surgery.  The CI reported no associated functional impairment.  His medications were flecainide 100 mg twice daily and atenolol 50 mg daily.  Cardiac auscultation revealed a regular rate and rhythm, normal heart sounds, and no pathologic heart sounds.  The ECG was within normal limits.  The diagnosis listed atrial fibrillation with flutter (arrhythmia which may be stable rhythm/bridge between atrial fibrillation and sinus rhythm).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the AF at 10%, reduced to 0% for noncompliance, coded 7010 (supraventricular arrhythmias [SVT, tachycardia]).  The VARD, citing the C&P exam 4 months after separation, rated the AF at 10%, coded 7010.  The VARD cited paroxysmal atrial fibrillation, one to four episodes per year documented by ECG or Holter monitor.  Review of the STR showed only one episode of paroxysmal atrial fibrillation documented by ECG or cardiac monitor.  The balance of the entries regarding ECGs and cardiac monitors showed NSR.  While the CI was intermittently symptomatic, episodes had decreased in response to titration (dose adjustment based upon response) of the antiarrhythmic medication.  With pharmacologic management, the episodes were short in duration and self-limited.  There was one documented episode of paroxysmal atrial fibrillation consistent with the 10% rating (one to four episodes per year, documented by ECG or Holter monitor).  There were not more than four episodes per year to support the 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the AF condition.  

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 AF condition, the Board unanimously recommends a disability rating of 10% coded 7010 IAW VASRD §4.71a.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Paroxysmal Atrial Fibrillation	7010	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 16 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 16 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 11 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 31 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 30 Nov 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 30 Nov 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 01 Dec 15 ICO  XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 04 Jan 16 ICO  XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (k) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 60 percent (increased from 20 percent) disability rating.

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 50 percent (increased from 10 percent) disability rating.

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 40 percent (increased from 10 percent) disability rating. 

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List effective date of discharge with a 30 percent (increased from 10 percent) disability rating. 

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 50 percent (increased from 20 percent) disability rating. 

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List effective date of discharge with a 30 percent (increased from 20 percent) disability rating. 

     j. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.  
       
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)