RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00098
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030624

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Recruiter, medically separated for “antiphospholipid antibody syndrome” with a disability rating of 0%.

CI CONTENTION:  The VA rated his heart condition higher.  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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 panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel 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 - 20030624	VARD - 20040702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Antiphospholipid Antibody Syndrome	7199-7121	0%	Coronary Artery Disease	7005	30%	20030819	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Antiphospholipid Antibody Syndrome.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was found to have the antiphospholipid antibody syndrome (an autoimmune hypercoagulable condition) after having a myocardial infarction (MI) (heart attack) on 31 August 2001.  Initial treatment with aspirin, heparin and Retavase (reteplase, a thrombolytic agent to dissolve blood clots).  Subsequently, the CI underwent cardiac catheterization which documented compromised flow and thrombus (blood clot) in the left anterior descending and left circumflex arteries.  Angiojet therapy removed most of the clot, but did not remedy the poor blood flow.  Complete heart block and bradycardia were treated with a temporary pacemaker and placement of intra-aortic balloon counterpulsation (mechanical circulatory support), beta-blockers, antiarrhythmic medication and IV Integrilin (eptifibatide to prevent blood clots).  

Laboratory testing was consistent with the presence of lupus anticoagulant, an inducer of a hypercoagulable state. Treatment with Coumadin (warfarin, an anticoagulant) was instituted and the CI stabilized and was discharged with the diagnoses of an acute anterior MI, complicated by cardiogenic shock, resolved, complete heart block, resolved, ventricular dysrhythmias, resolved, pericarditis, a hypercoagulable state, and cigarette abuse.  Post-hospitalization medications included Lasix (furosemide, a diuretic), captopril (an ACE inhibitor), atorvastatin (to treat hyperlipidemia), and digoxin (an antiarrhythmic agent), and Coumadin, the dose of which was based upon his international normalized ratio (INR) coagulation status.  

An electrocardiogram on 20 September 2001 revealed sinus bradycardia (54 BPM) with right superior axis deviation, and an anteroseptal infarct with inferolateral ischemia.  On 22 October 2001 the reported he was able to exercise on a treadmill for 9 minutes without pain. An echocardiogram on 2 November 2001 reveal very minimal mitral regurgitation, a normal left atrial size, trace aortic regurgitation, a slightly enlarged left ventricle with an ejection fraction of approximately 60%, and no pericardial effusion.  A P3 profile was issued on 11 July 2002 for s/p heart attack, complicated and hypercoagulable state with maximum work time limitations and no assignment away from definitive medical care or assignment with risk of significant trauma, head injury, fall, or other cause of bleeding.  The commander’s statement dated 17 July 2002 noted his heart attack and physical condition limited his maximum duty day.

The 9 September 2002 MEB NARSUM examination, 10 months prior to separation, noted complaints of some palpitations with “heart racing” and lightheadedness at the times of stress s/p myocardial infraction.  Physical examination showed a well-developed, well-nourished man, alert and oriented in no acute distress.  Cardiac evaluation revealed a regular rate and rhythm, normal S1 and S2 sounds, and an intermittent S3 with no murmurs.  The examiner noted lifetime Coumadin/anticoagulation was needed and his diagnoses were “s/p extensive and complicated myocardial infarction with current Class I symptoms, no evidence of ongoing ischemia, residual cardiomyopathy, LVEF (left ventricular ejection fraction) approx. 54%, wall motion abnormalities” and “hypercoagulable state/antiphospholipid antibody syndrome, probable cause of myocardial infarction.”  The examiner noted the CI required lifelong medical treatment to include Coumadin or equivalent medication with a target INR 3.0-4.0, a beta-blocker, an ACE-inhibitor, and continued treatment of dyslipidemia, and he was to refrain from using tobacco or exposure to second hand smoke.

The 9 September 2002 MEB NARSUM Addendum, noted the CI had a myocardial infarction on 30 August 2001 and while admitted had antiphospholipid antibody syndrome diagnosed, based on a positive Russell’s viper venom time (RVVT) screening test and a positive confirmatory hexagonal lipid test.  The remainder of the CI’s hypercoagulation work up was negative (factor V Leiden, prothrombin gene mutation 20210, protein S and C deficiency, and anti-thrombin III deficiency).  The hematologist noted that the antiphospholipid antibody syndrome was known to cause arterial thrombosis in the absence of an inciting factor, such as trauma or prolonged stasis.  The thrombosis of a coronary vessel was extremely uncommon, but was still the likely responsible factor for the CI’s myocardial infarction.  Physical examination on 24 October 2002 revealed the CI not to be in acute distress with a blood pressure of 142/81, pulse 66 beats per minute, respirations 20 per minutes, weight of 234 pounds, and height of 69 inches.  He had normal heart sounds without S3 or S4 sounds and normal breath sounds.  There was no edema of the extremities.  The INR was 2.18, and the lipids were elevated.

The 12 February 2003 MEB NARSUM examination, 4 months prior to separation, noted a cardiac ultrasound on 12 February 2003 revealed a top normal left ventricular size with preserved LVSF (left ventricular systolic function) globally, distal anterior anterolateral hypokinesis (diminished or abnormally slow movement) and apical akinesis (localized lack of wall motion).  Global ejection fraction with a wall motion abnormality estimated 50-60% with trace tricuspid regurgitation and pulmonic insufficiency, borderline left ventricular hypertrophy, and mild left ventricular relaxation abnormality.     A graded exercise test using the Bruce protocol to 9 minutes revealed shortness of breath, but no chest pain with an estimated 10 METS (metabolic equivalent), which is the energy cost of standing quietly at rest.  A resting MUGA (multigated acquisition scan) on 12 February 2003 showed an akinetic distal apex of the left ventricle with the calculated left ventricular ejection fraction of 54% (normal 50-75%).  The examiner revised the diagnosis to “s/p extensive and complicated myocardial infarction with current Class I symptoms, no evidence of ongoing ischemia, some residual cardiomyopathy, LVEF (left ventricular ejection fraction) approx. 54%, wall motion abnormalities as described, and S4 [sound] on examination.”  Complete blood count results dated 28 March 2003 revealed the CI’s hemoglobin was 17.1 g/dL (normal 14.5-16.5) and hematocrit 49.3% (normal 43-49); however, prior results were within normal limits as were hepatic and renal laboratory results. 

At the 19 August 2003 VA Compensation and Pension (C&P) General evaluation, performed 2 months after separation, the CI reported a history of an anterior septal wall MI and cardiogenic shock and a syndrome of hypercoagulation on chronic Coumadin.  Based on a MUGA scan in February 2003 where the ejection fraction was 54% and apical dyskinesia, “he was rated 6 METS of cardiac output, which is within the normal range.”  He had serial EKGs done and no chest pain complaints.  Physical examination showed his weight was 239 pounds with an ideal weight of 154 to 166.  His blood pressure was 130/80 sitting and pulse was 58 and regular.  He had no ecchymosis and no prolonged bleeding evidence at all.  His lungs were clear in all fields with normal peripheral pulses and no cyanosis, clubbing or edema noted.  There were no murmurs.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the antiphospholipid antibody syndrome condition 0%, coded 7199-7121 (post-phlebitic syndrome of any etiology), citing a “hypercoagulation condition which is the probable cause of an acute myocardial infarction”  and “this analogous code as this is the closest to a post-phlebitic condition with the thrombosis occurring in the coronary artery.”  

The VA rated the lupus anticoagulant condition not service connected, coded 7541 (renal involvement in diabetes mellitus, sickle cell anemia, systemic lupus erythematosus, vasculitis, or other systemic disease processes), citing the CI had a congenital condition that the disability existed prior to service and was not permanently aggravated by service.  The VA rated the s/p coronary artery disease with myocardial infarction and angioplasty condition 30%, coded 7005, citing a rating of 6 METS of cardiac output during a recent VA examination.

The PEB combined the antiphospholipid antibody syndrome and the acute myocardial infarction, which was caused by the hypercoagulable condition as a single unfitting condition coded 7199-7121 and rated 0%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

The evidence for the antiphospholipid antibody syndrome and s/p myocardial infarction conditions was presented together above.  In this case, each condition was profiled and implicated in the NARSUM and commander’s statement.  Members agreed that each condition is separately unfitting and that a separate code and rating is applicable for each condition.  Members noted that the PEB indicated the CI had more than 8 years of active duty, which was confirmed on his DD Form 214; therefore, a rating for the antiphospholipid antibody syndrome is permissible despite its presumptive congenital origin, which was not proved to be genetic in the CI’s case.  

Members discussed the VASRD codes applied by both the PEB and the VA for the condition, which is not specifically listed in VASRD.  The PEB used 7199-7121 (post-phlebitic syndrome of any etiology), which actually refers to veins rather than arteries and rating options relate to the extremities especially at 10% and 20%.  However, the CI’s thromboses were in the coronary arteries.  Furthermore, he was required to take Coumadin or another anticoagulation medication for life.  Therefore, use of an analogous code 6899-6817 (pulmonary vascular disease) is a not unreasonable alternative coding option since it also addresses anticoagulant therapy.  However, after the acute myocardial infarction despite persistence of the antiphospholipid antibody, treatment with Coumadin prevented development of any further thrombosis proximate to separation.  Therefore, to apply a 60% rating for “chronic pulmonary thromboembolism requiring anticoagulant therapy, or; following inferior vena cava surgery without evidence of pulmonary hypertension or right ventricular dysfunction” seems to be a high rating since the CI had only one, albeit quite serious, thrombotic event, although he will continue to need lifetime anticoagulation, but he was clinically otherwise asymptomatic since he had no further thrombotic episodes, which is more compatible with a 0% rating (asymptomatic, following resolution of pulmonary thromboembolism).  Code 7115 (thrombo-angiitis obliterans (Buerger’s Disease)) refers to vascular inflammation of the lower extremities related to smoking and is associated with claudication (pain) when walking, which would be analogous to cardiac angina, which the CI did not have thereby making the use of code 7115 inapplicable.  Therefore, members determined that a rating higher than the 0% assigned by the PEB could not be obtained.

Members then discussed a rating for the s/p myocardial infarction using code 7006 (myocardial infarction) or code 7005 (arteriosclerotic heart disease (coronary artery disease)), which represents the site of the thrombosis.  An exercise test using the Bruce protocol generated approximately 10 METS in both October 2001 and again in February 2003 that warrants a 10% rating; however, the VA reported the CI had an ejection fraction of 54% and apical dyskinesia and was rated at 6 METS, but there was no primary documentation in the record to confirm it although it was based on the MUGA scan in February 2003, the copy of which in the STR did not address METS.  However, the NARSUM addendum noted borderline left ventricular hypertrophy and mild left ventricular relaxation abnormality, which falls short of the defined left ventricular hypertrophy threshold by an echocardiogram of a 30% rating that requires “evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray.”  A higher rating of 60% requires “left ventricular dysfunction with an ejection fraction of 30 to 50 percent.”  However, while the MEB referred the CI to the PEB with a 45% ejection fraction, a subsequent study revealed an ejection fraction of 54%.  Therefore, the CI’s condition did not rise to either a 30% or 60% rating at the time of separation.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the antiphospholipid antibody syndrome condition, coded 7199-7121 and a disability rating of 10% for the s/p myocardial infarction condition, coded 7005.  

BOARD FINDINGS:  In the matter of the antiphospholipid antibody syndrome condition, the panel unanimously recommends a disability rating of 0%, coded 7199-7121 IAW VASRD §4.104.  In the matter of the s/p myocardial infarction condition, the panel unanimously recommends a disability rating of 10%, coded 7005 IAW VASRD §4.104.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Antiphospholipid Antibody Syndrome	7199-7121	0%	
S/P Myocardial Infarction	7005	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160216, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014055, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure