RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03373
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060717

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Parking Enforcement, medically separated for “atypical chest pain” with a disability rating of 0%.  

CI CONTENTION:  “Please consider all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20060327	VARD - 20061204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atypical Chest Pain	7099-7005	0%	Atypical Chest Pain…	7099-7005	10%	20060525	
Hyperlipidemia	Cat II	No VA Placement	
Myocardial Bridge		No VA Placement	
Hypertension		Hypertension	7101	0%	20060525	
Depression	Cat III	Depressive Disorder	9434	10%	20060608	
Partner Relational Problem	Cat IV	No VA Placement	
Alcohol Dependence			
Personality Traits			
History of Polysubstance Dependence			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Atypical Chest Pain Condition.  According to Service treatment records (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the CI’s condition began in November 2004 after he complained of left sided chest pain (pounding sensation) occurring twice a day at rest approximately 16 months prior to referral for an MEB.  The CI achieved 10.1 metabolic equivalents [METS] (resting metabolic rate used to describe functional capacity or exercise tolerance) in an exercise stress test (EST) which was interpreted as “highly predictive of significant coronary disease.”  He complained of typical chest discomfort during the EST.  The MEB forwarded “congenital coronary artery anomaly” and “other chest pain” for PEB adjudication.  

An electrocardiogram (ECG) was normal.  The CI underwent cardiac catheterization which revealed normal coronary arteries without significant atherosclerotic disease.  A long area of intra-myocardial bridge (intramuscular [intra-myocardial] course of normally surface [epicardial] distributed major coronary artery) was noted in the mid left anterior descending (LAD) coronary artery.  The cardiologist opined that the chest pain/angina (chest pain from reduced blood flow to heart muscle) could be secondary to this intra-myocardial bridge.  The CI achieved 10.1 METS in a nuclear (Thallium) EST performed to assess cardiac perfusion.  No ischemic (heart muscle inadequate blood supply) ECG changes were noted, but the CI complained of fatigue during this study.  Nuclear medicine images demonstrated normal cardiac perfusion and no evidence of ischemia or infarction (tissue death from obstructed blood supply), which would have been expected if the myocardial bridge was hemodynamically significant.  Based on this study, the CI was felt not to have physiologically significant obstruction to flow in the LAD.  Because of persistent symptoms, the CI was treated empirically for presumed coronary artery spasm.  The physician opined “At this time it is unclear what the etiology of this patient's chest pain syndrome is.  He has no traditional coronary artery disease.  He does have an unusual finding of a myocardial bridge; however, this is not clinically felt to be the cause of the patient's symptoms.  It is not felt to be clinically significant based on physiologic testing including an exercise nuclear medicine stress test.  The patient is being treated for presumed vasospastic angina; however, if his symptoms do not improve with traditional therapy for this, he will be presumed to have a non-cardiac cause of his chest pain and other etiologies will need to be investigated.”  The treating physician discussed the case with interventional cardiology and the cardiothoracic surgeon and neither thought that invasive treatment (myocardial bridge stenting or single-vessel bypass) was warranted.  A workup for a gastrointestinal etiology was recommended.  An esophagogastroduodenoscopy ([EGD] upper gastrointestinal endoscope) was normal except for two small esophageal erosions and mild duodenitis (inflammation of the duodenum) consistent with a topical irritant.  An ambulatory esophageal pH procedure (assesses abnormal esophageal acid exposure or reflux) showed minimal prolongation of esophageal acid exposure with the only recorded symptom event not associated with a reflux episode.  An esophageal manometry procedure (measure esophagus pressures and motility) was normal.  

The MEB NARSUM examination on 9 February 2006, 5 months before separation, documented the CI had a congenital (inborn physical abnormality or disease) coronary artery anomaly (myocardial bridge).  He had frequent episodes of chest pain in spite of typical antianginal therapy.  He was tried on therapy for presumed coronary spasm, which also had essentially no effect on his symptom complex.  After all medication attempts were exhausted, interventional cardiology and cardiothoracic surgery felt that the literature did not support aggressive intervention with either stenting or bypass.  They recommended continued medical management and tobacco cessation (25-30 pack per year history).  In spite of medical management, the CI continued to have intermittent symptoms that were not related to exertion, and were not typical for usual angina.  The physical examination revealed no evidence of cardiac pathology.  There was no jugular venous distension, increased jugular venous pressure, or carotid artery bruits (vascular sound from turbulent blood flow).  The heart examination revealed a regular rate and rhythm, no murmurs, normal heart sounds, and a normal point of maximum impulse (PMI).  The lungs were clear to auscultation and percussion.  The extremities revealed no cyanosis (bluish discoloration due to insufficient oxygen) or edema (excess tissue fluid swelling) and normal pulses without bruits.  Serial ECGs had been normal.  The diagnoses listed atypical chest pain and myocardial bridge.  The examiner opined that his continued symptom complex was “possibly related to his coronary anomaly of a myocardial bridge.”  

The 25 May 2006 Compensation and Pension (C&P) evaluation, performed 2 months before separation, noted the CI’s condition had existed since birth.  He complained of intermittent symptoms of angina, shortness of breath, and fatigue.  Symptoms occurred up to 3 times per week and lasted 45 minutes.  The functional impairment listed “is hard do normal work during flare ups.”  The CI denied a history of congestive heart failure.  Because of the chronic nature, the CI required continuous treatment to control this condition.  The physical examination revealed no jugular venous distension.  “Examination of the heart does not reveal any evidence of congestive heart failure, cardiomegaly [enlarged heart] or cor pulmonale [right heart hypertrophy or dilatation/altered function from pulmonary hypertension].”  There was a normal (sinus) rhythm with no heart murmurs, gallops, heaves, or thrills.  The lung examination was normal with no abnormal breath sounds (rhonchi or rales).  The extremities revealed no cyanosis or edema and normal pulses.  The ECG was normal.  Chest diagnostic imaging (X-ray) showed an unremarkable heart.  The CI achieved 9.5 METs on treadmill stress testing.  The examiner documented for the CI’s claimed condition of heart condition/chest pain, a diagnosis was not possible because of limited findings to substantiate.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 7005 code (arteriosclerotic [atherosclerotic] heart disease [coronary artery disease, CAD]), citing atypical chest pain.  The VA assigned a 10% rating under an analogous 7005 code, based on the VA C&P examination 2 months before separation, citing symptoms of angina, shortness of breath, and fatigue and requiring continuous treatment.  The Board agreed that the subjective complaints of dyspnea, fatigue, angina and continuous medication required and workload of 9.5 METs were consistent with the 10% rating.  There was no evidence of cardiac hypertrophy or dilatation on electrocardiogram or X-ray or workload of 7 METs or less 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 atypical chest pain, analogously coded 7099-7005.  

Contended PEB Conditions:  The Board’s main charge is to assess the fairness of the PEB’s determination that the hyperlipidemia, myocardial bridge, hypertension, depression, partner relational problems, alcohol dependence, personality traits, history of polysubstance dependence, and nicotine dependence conditions were not unfitting.  
  
Hyperlipidemia, Myocardial Bridge, and Hypertension (Category II).  

Navy Category II conditions contribute to the unfitting condition.  While the hypertension was implicated in the limited duty (LIMDU) report, the hyperlipidemia and myocardial bridge were not.  The contended Category II conditions were not implicated in the nonmedical assessment (NMA) and were not judged to fail retention standards.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended Category II conditions and so no additional disability ratings are recommended.  

Depression (Category III).  

Navy Category III conditions are not separately unfitting and do not contribute to the unfitting condition.  While the depression was implicated in the LIMDU, it was not implicated in the NMA and was not judged to fail retention standards.  There was no performance based evidence from the record that this conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended Category III condition and so no additional disability rating is recommended.  

Partner Relational Problems, Alcohol Dependence, Personality Traits, History of Polysubstance Dependence, and Nicotine Dependence (Category IV).  

Navy Category IV conditions do not constitute a physical disabilities and are not subject to service compensation and therefore will not be addressed further in these proceedings.  

BOARD FINDINGS:  In the matter of the atypical chest pain condition, the Board unanimously recommends a disability rating of 10%, coded 7099-7005 IAW VASRD §4.71a.  In the matter of the contended hyperlipidemia, myocardial bridge, hypertension, depression, partner relational problems, alcohol dependence, personality traits, history of polysubstance dependence, and nicotine dependence conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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	PERMANENT RATING	
Atypical Chest Pain	7099-7005	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140627, 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 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX    
	(c) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 22 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 12 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 26 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

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

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

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

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

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

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

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